Using Your Provider Manual
1
Provider Manual
General Services
pages 7-59
Provider Services
Provider website
Appointment Access
Credentialing and re-credentialing
Contracting
Customer Care
Enrollment
Cultural Competency
Care Management
Family and Community Development (Outreach) Services
Claims and Billing
CMS 1500
UB04
2
Provider Manual
Enrollee Benefits and Authorizations
pages 60-86
Benefits and Pharmacy List
Care Management Services
Utilization Management
Authorization Guidelines
Medical Necessity Criteria
Appeals Process
Fair Hearing Process
OB/GYN
Behavioral Health
Care Management Services
Utilization Management
Authorization Guidelines
Medical Necessity Criteria
Appeals Process
Fair Hearing Process
OB/GYN
Behavioral Health
3
Provider Manual
Clinical Practice Standards
pages 87-104
Primary Care and specialty services
HealthCheck (formerly EPSDT)
Supplemental Security Income (SSI) program
Individuals with Disabilities Education Act (IDEA)
Adult Care
Vaccines
Dental
Clinical Practice Guidelines
Advance Directives
Mandatory Reporting
Clinical conditions
4
Provider Manual
Regulatory Standards
pages 138-142
Corporate Compliance
Fraud, Waste and Abuse
Audit and Oversight Activity
Provider Responsibilities
Appendix A – Forms
pages 143-157
Behavioral Health Home Services Referral From
Disclosure of Ownership
Home Health Care Referral Form
Mental Health Screening Tool
OB Gobal Authorization and PsychoSocial Form
Outpatient Treatment Report (Sample)
Provider Interest Form
Unusual Incident Report
DC Medicaid Universal Referral Form
Appendix B – Acronyms
pages 158-159
5
About Us
Health Services for Children with Special Needs (HSCSN) is a unique
health plan that provides innovative care management services and
benefits to pediatric and young adults (ages 0-26) receiving Medicaid
and Supplemental Security Income (SSI) in Washington, DC.
Each enrollee is assigned a care manager - a nurse, social worker or
other qualified professional - throughout their entire enrollment. The
HSCSN Care Manager provides coordination of care, ongoing support
and collaboration with the primary care medical home and other
specialty providers in order to successfully meet the physical, mental,
behavioral and developmental service needs of each enrollee.
HSCSN is a subsidiary of The HSC Foundation, along with The HSC
Pediatric Center, and HSC Home Care.
6
Department of Health Care Finance
(DHCF)
The mission of the Department of Health Care Finance is to
improve health outcomes by providing access to
comprehensive, cost-effective and quality healthcare services
for residents of the District of Columbia.
7
DHCF – Summary of Services
DHCF, an agency created in FY 2009, that provides health care
services to low-income children, adults, the elderly and persons
with disabilities.
Over 200,000 District of Columbia residents (nearly one third
of all residents) receive health care services through DHCF’s
Medicaid Managed Care contracts and Alliance and Fee-forservice programs.
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Verifying Enrollee Eligibility
Providers should verify an enrollee’s plan membership and eligibility
prior to providing any service except a service in response to an
Emergency Medical Condition. Providers are responsible for providing
immediate services for an enrollee’s Emergency Medical condition in
accordance with the provider’s license and scope of practice.
Verification of an enrollee’s health plan membership is not required for
requests for emergency medical assistance.
If you need assistance with verifying an enrollee’s eligibility please
contact the Customer Care Department at 202-467-2737 or 866-WER4Kiz or 1-866-937-4549.
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Access Standards
•
Enrollees with appointments who arrive by their scheduled appointment time shall not
routinely be made to wait more than forty-five (45) minutes from their scheduled
appointment time to see a PCP.
•
PCPs shall offer new Enrollees an initial appointment within forty-five (45) days of their
date of enrollment with the PCP or within thirty (30) days of request, whichever is sooner
•
PCP’s must accommodate the need for evening and weekend appointments
•
Providers place of business must comply with the regulations outlined in the American
Disabilities Act (ADA)
•
Providers office must be culturally competent and not discriminate against any enrollee
based on cultural or religious background
•
Enrollees shall have access to services for the assessment and stabilization of psychiatric
crises on a twenty-four (24) hour basis, seven (7) days a week, including weekends and
holidays.
•
Enrollees shall have access to twenty-four (24) hour access to Urgent Care and Emergency
Care seven (7) days a week, including weekends and holidays. Urgent Care will be provided
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directly by enrollee’s PCP or HSCSN would provide other arrangements.
Access Standards
•
Health Check/ initial EPSDT screens shall be offered to new Enrollees within sixty (60) days
of the Enrollee’s enrollment date with HSCSN or at an earlier time if an earlier exam is
needed to comply with the periodicity schedule
•
Health Check / initial screen shall be completed within three (3) months (90 days) of the
Enrollee’s enrollment date, unless provider determines that the new Enrollee is up-to-date
with the EPSDT periodicity schedule.
•
All Health Check / EPSDT screens, laboratory tests, and immunizations shall take place
within twenty (20) days of their scheduled due dates for children under the age of two (2)
and within thirty (30) days of their due dates for children over the age of two (2). Periodic
EPSDT screening examinations shall take place within thirty (30) days of a request.
•
IDEA multidisciplinary assessments for infants and toddlers at risk of disability shall be
completed within thirty (30) days of request, and any needed treatment shall begin within
fifteen (15) days of the completed assessment
•
Enrollees have the right to second opinions if he/she refuses or disagrees with a
recommended Plan of Treatment (POT).
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Cultural Competency
Understanding Cultural Competency
Healthcare providers are expected to obtain cultural background information on a patient, to help them
better understand the patient’s needs and apply the knowledge in the course of their care to that patient.
HSCSN providers are required and expected to intimately acquaint themselves with the cultural essence of
a child with special needs; so as to assist in the management and care of the child.
Assessing Cultural Competence:
There are some unique indicators that have been determined for Special Needs Children. These key
indicators are very important in assessing cultural competency for special need children and include:
 Physical disability
 Mental disability
 Family background
 Language
 Diet and nutrition
 Race and ethnicity
 Cultural Beliefs
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Cultural Competency
Domain areas in assessment of Cultural Competence by a Healthcare provider, as defined in HRSA (Health
Resources and Services Administration) findings are as follows:
Organizational Values: An organization's perspective and attitudes with respect to the worth and importance of cultural
competence and its commitment to provide culturally competent care.
Governance: The goal-setting, policy-making, and other oversight vehicles an organization uses to help ensure the delivery of
culturally competent care.
Planning and Monitoring/Evaluation: The mechanisms and processes used for: a) long- and short-term policy,
programmatic, and operational cultural competence planning that is informed by external and internal consumers; and b) the
systems and activities needed to proactively track and assess an organization's level of cultural competence.
Communication: The exchange of information between the organization/providers and the clients/population, and internally
among staff, in ways that promote cultural competence.
Staff Development: An organization's efforts to ensure staff and other service providers have the requisite attitudes,
knowledge and skills for delivering culturally competent services.
Organizational Infrastructure: The organizational resources required to deliver or facilitate delivery of culturally
competent services.
Services/Interventions: An organization's delivery or facilitation of clinical, public-health, and health related services in a
culturally competent manner.
*Excerpt from; Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence
Assessment Profile. http://www.hrsa.gov/culturalcompetence/indicators/
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Care Coordination
Care Coordination is a series of activities provided by HSCSN Care Managers to assist
enrollees in gaining access to necessary services (medical, behavioral and others),
coordinate preventative and specialty services and facilitate communication and
coordination in the medical home. Care coordination is individualized, empowering,
comprehensive, and outcome-focused.
What are the Care Manager’s role and responsibilities?
•
•
•
•
•
•
•
•
•
•
•
•
•
Develop a relationship with and support the enrollee and/or caregiver
Develop relationships with physicians and providers servicing enrollees
Communicate with enrollee, caregiver, treating physician(s) and providers
Assist the family with identifying their medical needs
Facilitate access and coordinating services for the enrollee (identify provider, schedule appointments, coordinate
transportation)
Develop and monitor the care coordination plan
Educate enrollees and families on HSCSN benefits, resources and processes
Identify and coordinate enrollee/caregiver education needs (classes, literature, referrals)
Support the relationship between the enrollee and their providers
Connect the enrollee/caregiver with resources
Make referrals to educational advocates and attend educational meetings (with permission of enrollee/caregiver)
Assist the provider with obtaining home evaluations and/or social work assessments
Assist the provider and family to address overutilization and underutilization of services and noncompliance
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Care Coordination
Working with the Care Manager – what is the role of the Provider?
•
Comply with EDSDT and adult preventive care requirements and guidelines
•
Collaborate in development of the Care Coordination Plan (review, edit, sign,
and return)
•
Follow the HSCSN Referral Guidelines for services requiring preauthorization
•
Ensure that referrals for home care, durable medical equipment and medical
supplies are complete and that services are monitored as indicated
•
Communicate with the HSCSN Care Manager about concerns (risks,
noncompliance, overutilization, underutilization, health education needs, etc.)
and progress
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General Claims
HSCSN will process all claims through an automated system. Our goal is to pay providers
for covered services within 30 days of receipt of each completed clean claim form. Your tax
identification number is your provider ID. Please include it and the NPI on every claim to
help expedite payment.
Professional providers and Home Health Agencies are required to submit for payment of
covered services on the Centers for Medicare and Medicaid Services (CMS)-1500 Health
Insurance Claim Form and Home Health Agencies. Hospitals are required to submit for
payment of covered services on the CMS UB04. These forms are available from CMS at
http://www.cms.hhs.gov/CMSForms.
Providers have the option of submitting claims electronically through EMDEON or via mail.
HSCSN’s payor ID is 37290. Claims should be mailed to:
HSCSN
PO Box 29055
Washington, DC 20017
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General Claims
Timely Processing of Claims
In accordance with D.C. Code § 31-3132, HSCSN shall accept Network and non-Network
Provider initial Claims for Covered Services no later than one hundred and eighty (180)
days from the date of service.
Health Care Acquired Conditions
The Patient Protection and Affordable Care Act of 2010 include provisions prohibiting
Federal Financial Participation (FFP) to States for payments for health care acquired
conditions (HCACs) and other provider preventable conditions or Never Events.
HSCSN shall no longer reimburse providers for procedures relating to the following health
care acquired conditions when any of the following conditions are not present upon
admission in any inpatient setting, but subsequently acquired in that setting.
Appeals
Claim payments or denials can be appealed in writing within 90 days of the denial or
payment.
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General Claims
Electronic Billing
Providers now have the opportunity to submit claims electronically and check your claims
through a system called claims status link. HSCSN encourages you to sign up by visiting the
HSCSN website and follow the link: www.Emdeon.com/PAYERLISTS/payerlists.php
HSCSN PAYOR ID 37290
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General Claims
Coordination of Benefits
Health Services for Children with Special Needs, Inc. (HSCSN), is always the payer of
last resort when the enrollee has another insurance coverage. As a provider, you must
always submit your claims to the other insurance company first. Once you receive
an explanation of payment from them, you should file the claim with HSCSN. You
must attach a copy of the explanation of payment from the other carrier or a copy
of the letter of denial. HSCSN will coordinate the payment with the other carrier’s
payment. HSCSN will pay up to the amount that is contracted. The provider will not
receive payment for more than the charge or contracted amount when combining
the payments of both payers.
HSCSN’s Provider Manual, Pages 24-59, has further information on Claims.
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Authorizations
These services – DO NOT – require authorization:
•Specialty office visits (except behavioral health)
•Primary care visits
•Well woman care (including Depoprovera shots)
•Vision services (including eye glasses)
•Labs and Radiology (including X-Rays, sonograms, MRIs, CT and PET Scans)
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Authorizations
Required Authorizations for Medical/Surgical
•Early
Intervention Services
•Rehabilitative therapies (physical, speech, occupational)
•OB Global services and services associated with pregnancy
•Home health (nursing, personal care aide and rehab therapies) and hospice care
•Durable Medical Equipment and Assistive Technology
•Supplies and Nutritional supplements
•Anesthesia for dental procedures
•Elective medical admissions (including feeding programs)
•Facility admissions - Sub-acute, Rehab, Transitional and Long Term Care
•Elective surgery (including plastic surgery), outpatient and inpatient
•Home Modification
21
Authorizations
Required Authorizations for Behavioral
•Psychiatric
and Neuropsychiatric evaluations
•Psychological testing and evaluations
•Psychotherapy, Counseling and Applied Behavioral Analysis (ABA)
•Psychotropic medication management visits
•Intensive Outpatient Programs and Day Rehabilitative services
•Partial hospitalization programs
•Sub-acute admission
•Substance Abuse treatment (inpatient and outpatient)
•Residential Treatment Facility
•Intermediate Care Facility for Mental Retardation (ICF-MR)
•
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Authorizations
Home Health Services- Medical
Home health services (Skilled Nursing) must be ordered by a physician. The ordering
provider must submit a completed HSCSN Home Care Referral Form prior to service
initiation. The form will improve and expedite referrals, reviews and authorizations. The
completed HSCSN Home Care referral form can be faxed to 202-721-7190. The care
requested must be appropriate to the home setting and to the enrollee’s needs. The request
will be reviewed every 60 days within the Home Health Unit for medical necessity. The
requesting provider must review and sign the plan of care from the home care agency every
60 days to ensure that services are appropriate and continue to be medically necessary.
For Personal Care Aides – HSCSN requires an in-home assessment of the enrollee’s
personal care needs by an RN prior to the initial authorization of services and a minimum
of every 6 months for ongoing services.
Please call HSCSN at 202-467-2737 and request to speak with the Home Health Review
Nurse if you need assistance.
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Authorizations
Home Health Services- Behavioral
The goal of our behavioral health home care service is to work with enrollees, their families
and community providers to treat challenging behaviors that interfere with a youth's
successful functioning at home and in the community. In-home services are delivered by a
trained Behavior Specialist and a supervising licensed behavioral health professional.
The HSCSN Behavioral Health Home Services Referral Form must be submitted for all
home-based behavioral health service requests. The form will improve and expedite
referrals, reviews and authorizations. It is important that the provider supply all relevant
clinical history. The completed HSCSN Behavioral Health Home Services Referral form can
be faxed to 202-721-7190. The requests are reviewed by the Home Health Unit and referred
to an independent licensed social worker to conduct an assessment and provide
recommendations for services. Behavioral health home services are authorized based on
the recommendation. The services will be reassessed every 6 months within the Home
Health Unit for continued medical necessity.
Please call HSCSN at 202-467-2737 and request to speak with the Home Health Review
Nurse if you need assistance.
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Authorizations
Durable Medical Equipment (DME), Orthotics, Prosthetics and Assistive Technology
The documentation required for the authorization is dependent on the type of equipment requested. The following
are standard requirements:
Physician
Order for the Service
Certificate of Medical Necessity (CMN) or Physician Letter
A pended authorization is generated after receipt of the CMN and the physician order. Delivery confirmation
receipt from the vendor is required before an authorization can be approved. Please fax receipt to the DME Review
Nurse within 24 hours of delivery (or next business day if after hours) at 202-467-0978. Receipt should
include the following information:
Signature
of person taking possession of equipment at time of delivery;
Delivery date;
Documentation of education conducted; and
Brand name, model number, quantity, serial/identification number(s) of equipment delivered
HSCSN verifies all new and replacement durable medical equipment, prosthetics, orthotics, and assistive
technology delivered to the enrollees in the home.
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Authorizations
Inpatient Admissions
Non-emergent (elective) medical/surgical inpatient admissions and outpatient surgical procedures
must receive prior authorization from the UM Department. The PCP or specialist should contact
the UM Department at least 3 business days prior to the scheduled admission or procedure to
obtain authorization.
All emergent/urgent inpatient admissions must be reported to the UM Department within 24
hours of the admission. Please fax admission information to 202-635-5590. The following
information is needed for the admission:
Enrollee Name
ID Number
Admitting Physician
Hospital Name and Address
Admission Date
Diagnosis and clinical information
Name and Telephone Number of Contact Person

If notification is not received within 24 hours of the admission, the day’s prior to notification will
be denied unless there are documented extenuating circumstances.
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Medical Necessity Guidelines
A service is Medically Necessary for an individual if a physician or other treating health Provider, exercising
prudent clinical judgment, would provide or order the service for a patient for the purpose of evaluating,
diagnosing or treating illness, injury, disease, physical or mental health conditions, or their symptoms, and
that is:
In
accordance with the generally accepted standards of medical practice
Clinically
appropriate, in terms of type, frequency, extent, site and duration
considered
effective for the patient’s illness, injury, disease, or physical or mental health
condition
Not
primarily for the convenience of the individual, Care giver, treating physician, or other
treating healthcare provider
More
cost effective than an alternative service or sequence of services, and at least as likely
to produce equivalent therapeutic or diagnostic results with respect to the diagnosis or
treatment of that individual’s illness, injury, disease or physical or mental health condition.
Refer to HSCSN’s Provider Manual for more detail regarding medical necessity criteria.
Pages 83-86.
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Appealing a Clinical Decision
Provider Rights to Appeal a Clinical Denial Decision
Providers have the right to:
Discuss denial decisions with the licensed clinical reviewer
Speak with the physician reviewer who issued the denial (or designee)
Obtain an explanation of appeals process, including timeframes for appeal decision
Appeal decision by submitting written comments, documents or any relevant information
To File an Appeal
There are two ways to file an Appeal:
Telephone the Utilization Review Line at 202 721-7162 Mon. – Friday 8:30am – 5:00pm
Health Services for Children with Special Needs, Inc.
1101 Vermont Avenue, NW - Suite 1200
Washington, DC 20005
Attn: Utilization Management Department - Appeals
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Outpatient Mental Health Services
Authorizations for medication management and therapy services (individual, group, family)
are provided by the enrollee’s Care Manager in accordance with the table below.
Type of service requested
Benefit
Medication Management
Plan allows 16
visits/year
Initial Authorization
Requirement
Submit initial treatment
plan
Individual, Group and
Family Therapy
Plan allows 90 visits/six
months
Submit initial treatment
plan
Continued Authorization
Requirement
Updated treatment plan or
submitted treatment report
- required every 12 months
Updated treatment plan or
submitted treatment report
– required every 6 months
The behavioral health treatment plan or outpatient treatment report must be received by
the Care Manager within 30 days of initiating services and every six (6) to twelve (12)
months for continued authorization, depending on the authorized service (see table).
HSCSN does not accept psychotherapy notes.
See HSCSN’s Provider Manual – Pages 76-79 for further information.
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HealthCheck/EPSDT Participation
Medicaid's Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) Program is a preventive primary health care program for eligible
low-income children and teens ages birth to 21. EPSDT emphasizes preventive
care, especially screening services, to promote good health and identify and
treat problems early and effectively.
EPSDT is a joint federal-state partnership program administered by the Centers
for Medicare & Medicaid Services (CMS). The program has two operational
components:
Assuring the availability and accessibility of required health care
resources
Helping Medicaid recipients and their parents or guardians to effectively
use these resources
CMS, state Medicaid agencies, and EPSDT providers have a shared obligation to
ensure comprehensive pediatric preventive care for eligible children and teens,
and to support their families in accessing the health services available through
EPSDT.
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HealthCheck/EPSDT Participation
The DC Department of Health Care Finance (DHCF) in partnership with
Georgetown University has developed the free, online HealthCheck Provider Education
System.
Please take a minute to REGISTER at http://dchealthcheck.net to review the
curriculum. Your registration ensures that your training is recorded by DHCF. This is
necessary so that you get credit for fulfilling the training obligations required to be a
Medicaid provider. Please note that this training will fulfill your obligations for all Medicaid
Managed Care Organizations (MCOs) with which you are paneled:
Chartered Health Plan
Health Services for Children with Special Needs
UHC Community Health Plan (Unison)
In addition, you will receive 5 CME’s upon completion of the curriculum.
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Blood Lead Screening
All Medicaid eligible children are to receive blood lead
screening by ages 12 months and 24 months of age to be in
compliance with the requirements of 42 U.S.C. § 1396d (r) (1)
(B) (iv) and the CMS State Medicaid Manual, section 5123.2D.
This testing is reported annually as part of the CMS Form 416
report on Health Check services.
Blood lead screenings are also required for those children
greater than 24 months (2 years) of age, up to 72 months (6
Years) of age, for whom blood lead screenings cannot be
documented.
32
Individuals with Disabilities
Education Act (IDEA)
Individuals with Disabilities Education Act (IDEA): Federal law governing the rights of
infants and toddlers to receive early intervention (Part C) and the educational rights of
school-age children and youth with education-related disabilities (Part B).
The early intervention system is designed to serve children from birth through three years
of age (36 months) who are DC residents. In order for the child to receive services he/she
must be found eligible. Children are eligible if they were born with a disability or health
condition that affects their development or are functioning at half their age (greater than
50% delay) in one or more areas of performance such as:
Physical development
Cognitive development
Communication, language & speech development
Social/emotional development
Adaptive/self-help skills
Early intervention may include speech, physical, occupational and family therapists,
developmental educators, assistive technology, nursing.
Infants and Toddlers with Disabilities (ITDD) of the Department of Health and the MCO’s
coordinate the needed services.
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Level of Care Criteria
The medical and behavioral criteria approved for the use by HSCSN for clinical
determinations is InterQual Level of Care Criteria. HSCSN is licensed to utilize
the criteria by McKesson Health Solutions, LLC. All InterQual criteria sets are
based on two major clinical components:
1) Severity of Illness
2) Intensity of Service
The sets are sub-grouped by body system, clinical findings, imaging findings,
laboratory findings and daily treatment protocols.
See HSCSN’s Provider Manual, Pages 83-84, for further information.
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Clinical Guidelines
HSCSN encourages the use of evidence-based Clinical Practice Guidelines to
ensure that the best and most current quality of care is provided to enrollees.
HSCSN reviews all Clinical Guidelines every two years.
For a list of all clinical practice guidelines adopted and approved by HSCSN’s
Quality Council can be found on the Provider Resources page on the HSCSN
Website @ www.hscsn-net.org.
The Clinical Guidelines may also be found in your HSCSN Provider Manual on
pages 102-103.
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Healthcare Effectiveness Data and
Information Set (HEDIS®)
HEDIS is a program designed and Managed by the National
Committee on Quality Assurance (NCQA). The program is designed
to measure a set of quality indicators and then be able to make
comparisons across the nation based on plan type. HSCSN posts our
results on our website and in our Provider Newsletter annually. You
as a provider may also receive information throughout the year on
your personal provider status with these measures as well as our
overall health plan status. These are tools to help us partner to
improve outcomes with the care delivery system for our enrollees.
For complete information see Pages 111-114 of the HSCSN Provider Manual.
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HEDIS®
What can HSCSN’s network physicians do?
Diabetes Care
Educate on the importance of eye exams, lipid control, blood pressure control, foot
exams, and serum glucose control. Tight management of diabetic enrollees to assist in
meeting HEDIS goals is recommended. The goals for good Diabetic Management are:
Lipid control = LDL-C < 100mg/dL
HbA1C = < 7% good control, < 8% control, > 9% poor control
BP = < 130/80 good control, < 140/90 poor control
Annual medical attention for nephropathy
1.
2.
3.
4.
5.
Refer enrollees to ophthalmologists/optometrists at least every two years.
Encourage enrollees to have ordered labs drawn.
Contact HSCSN Care Management when enrollees cancel appointments.
Ensure that diabetic patients receive a comprehensive examination annually.
Code information on your claims to document care delivery
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HEDIS®
What can HSCSN’s network physicians do?
Monitoring of BMI and associated components of good health
In order to target Obesity and malnutrition and begin interventions as early as possible for
both of these conditions it is accepted that monitoring of BMI and tracking what percentile
and enrollee falls in is the most reliable way to date of determining where an enrollee is in
the growth cycle. HEDIS also looks for documented discussions surrounding nutrition and
exercise between the physician and caregiver or enrollee. Coding can also be used for all of
these measures to document your care
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HEDIS®
What can HSCSN’s network physicians do?
Childhood Immunizations
HEDIS looks at the Immunizations recommended by the CDC as an area of comparison for
quality care. The Childhood immunization measure most specifically counts recommended
immunizations that have been given PRIOR to the child’s second birthday. Immunizations
that have been recommended to be given prior to 24 months of age that are given after the
child’s second birthday are considered non-compliant.
Rotavirus administration is low, this may be because you must document if you are giving
the two doses or three dose vaccines. If there is no documentation it is assumed the three
dose vaccine was used and one dose was missed.
Rates of administration of the Influenza vaccine have been low in the last few years. This is
a CDC recommendation that influenza vaccines be administered to children under two
annually.
Call the HSCSN care manager to be your partner in getting enrollees in to get their
immunizations in the recommended time frame.
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HEDIS®
What can HSCSN’s network physicians do?
Timeliness of Prenatal Care and of Postpartum Care
1.
2.
3.
4.
5.
6.
7.
Schedule/provide initial prenatal care as soon as pregnancy is confirmed.
Remind expectant enrollees to make appointments for prenatal care and postpartum
care
Educate enrollees about the importance of prenatal and postpartum care.
Contact HSCSN Care Management when enrollees cancel/fail to show up for scheduled
visits.
Alert HSCSN Care Management to any needs for outreach
Provide postpartum visits between 21 and 56 days after delivery
Global billing is a tool for your office to use for ease of billing purposes but you may
submit documentation of visits/care delivery by submitting the CPT II (Table 4) codes
to document individual visits not captured in the global billing. Codes should be used
with a zero charge as individual visit payments are already included in the global
payment.
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Fraud, Waste and Abuse
Fraud - means an intentional deception or misrepresentation by a person with
the knowledge that the deception could result in some unauthorized benefit to
himself or to some other person. It includes any act that constitutes fraud under
applicable Federal or State law.
Waste - means the over-utilization of services not caused by criminally
negligent actions; waste involves the misuse of resources.
Abuse - means provider practices that are inconsistent with sound fiscal,
business, or medical practices, and that result in an unnecessary cost to the
Medicaid program, or in reimbursement for services medically unnecessary or
that fail to meet professionally recognized standards for health care. It also
includes beneficiary practices that result in unnecessary cost to the Medicaid
program
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Fraud, Waste and Abuse
What is your role concerning the FCA?
You are essential to your organization’s compliance with the FCA.
The codes your office/facility attaches to diagnoses and procedures, the documentation you
keep for each patient, the bills you file –even the dates you record when procedures occur
are subject to the FCA. Therefore, your work must be clear, accurate and in compliance with
all rules and regulations.
Safeguard your organization by ensuring:
You document orders in the patient’s medical record;
Services are deemed medically necessary based on patient’s needs;
Medical necessity is documented in the patient’s medical record;
All billing, coding, and reimbursement rules are followed;
Services not rendered, are credited to the patient’s account;
Accountability for your actions and acting with integrity in all circumstances.
You do not retain Medicaid funds that were improperly paid
42
Reporting Requirements
By law, providers must report all occurrences of sexually transmitted diseases,
communicable diseases, vaccine preventable diseases, immunizations administered,
lead levels and developmental delay in infants and children to the following
organizations:
Sexually Transmitted Diseases, Communicable Diseases
Department of Health (202) 727-6408
Immunizations, Dept. of Health (Vaccine for Children)
(202) 576-7130
Lead Levels, DC Lead Registry (202) 535-1398
Developmental Delay – DC Early Intervention
(202) 727-3665 or visit www.strongstartdc.com
43
Health Insurance Portability and
Accountability Act (HIPAA)
The goals of the privacy standards are to protect the confidentiality of individually
identifiable information obtained, restricts how it can be used and disclosed and to protect
individual rights.
Access to Enrollee Records
Permitted Uses and Disclosures:
HSCSN may request Protected Health Information (PHI) for:
a) Treatment, payment or healthcare operations,
b) The healthcare operations of another covered entity or healthcare provider, if each entity has or
had a relationship with the individual who is the subject of the PHI being requested, and the
disclosure is:
i.
For a purpose listed in the definition of healthcare operations; or
ii.
For the purposes of healthcare fraud and abuse detection or compliance.
c) Another covered entity that participates in an organized healthcare arrangement with The HSC
System for any healthcare operation activities of the organized health care arrangement.
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Always….
Remember to always refer to your Provider Manual
Contract your Provider Service Representative with any questions or concerns
Refer to your important numbers (Page 5) of your Provider Manual
Notify us of any changes in your practice:
•Provider resigned
•New provider on staff
•Change of address
Read your voucher, post your payment and review the reason code description
in a timely manner.
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Questions???
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