Amerigroup mmp appeals

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Member Missed Appointments Second Medical or Surgical Opinion Access and Availability Access and Availability Standards Table Continuity of Care Covering Physicians Plan-specific Termination Criteria Incentives and Payment Arrangements Laws Regarding Federal Funds Prohibition Against Discrimination Provider Panel — Closing a Panel Provider Panel — Transferring and Terminating Members Reporting Obligations Cultural Competency Member Eligibility Role of the Enrollment Broker Summary of the Benefits Tables Formulary Exceptions Pharmacy Transition Policy Personal Attendant Wage Requirements Electronic Visit Verification Adaptive Aids and Medical Supplies Dental Services Cognitive Rehabilitation Therapy Employment Assistance Supported Employment Financial Management Services Support Consultation Service Coordination Discharge Planning Claim Adjudication and Reimbursement Provider Complaints Provider Payment Appeals Covered Behavioral Health Services Primary and Specialty Services Behavioral Health Care Provider Responsibilities Care Continuity and Coordination Guidelines Emergency Behavioral Health Services Urgent Behavioral Services Precertification and Referrals for Behavioral Health Performance Standards and Compliance Physician — Patient Communications Provider Participation Decisions: Appeals Process Notification to Members of Provider Termination Committee Structure Quality Improvement Committee Quality Management Committee Self-Referral Guidelines Referral Guidelines Radiology Services Physical and Occupational Therapy Medically Necessary Services and Medical Criteria Requirements Overview Case Management Model of Care Member Medical Records Standards Documentation Standards for an Episode of Care Patient Visit Data Records Standards Medical Record Review Risk Adjustment Data Validation Clinical Practice Guidelines Advance Directives Emergent Admission Notification Requirements Inpatient Admission Reviews Affirmative Statement About Incentives Confidentiality Statement Emergency Services Post-Stabilization Care Services Nonemergency Services Urgent Care Welcome Call Appointment Scheduling Nurse HelpLine Care Management Support Interpreter Services Health Promotion Member Satisfaction Claims- Billing and Reimbursement Claims Status Provider Claims Coordination of Benefits Electronic Claims Paper Claim Submission Encounter Data Claims Adjudication Clean Claims Payment Provider Obligations and Notifications Member Liability Appeals Further Appeal Rights Member Grievance Noncovered Services Client Acknowledgement Statement The goal of this program is to integrate care for those dual-eligible individuals who are eligible for both.

Medicare and Medicaid. At Amerigroup , our goals are to assist you in providing unequaled care to your patients while making the practice of medicine more rewarding in terms of better patient outcomes, better practice economics and diminished practice difficulties. By furnishing the means to accomplish these ends and by helping you and your patients access them, we are confident you will be proud to have joined us. Members who temporarily as defined by CMS as six months or less move outside of the service area are eligible to receive emergency and urgently-needed services outside the service area.

It requires familiarity with the rules and requirements of a system that encompasses a wide array of health care services and responsibilities.

We want to help you navigate our managed health care plan to find the most reliable, responsible, timely and cost-effective ways to deliver quality health care to our Members. Providers may view it online, download it to their desktop or print it out from the site. If you have questions about the manual, please contact our Provider Services team at We understand that some of the information in this manual may need to be revised or changed.

To that end,. The website features an online Provider inquiry tool to reduce unnecessary telephone calls by enabling easy access at your convenience to the following resources:.

Forms to update Provider demographics and information such as tax ID or group affiliation changes. Unless otherwise specified in the Provider Agreement, the information contained in this manual is not binding upon Amerigroup and is subject to change. Amerigroup will make reasonable efforts to notify Providers of changes to the content of this manual. This manual, as part of your Provider Agreement and related Addendums, may be updated at any time and is subject to change.

In the event of an inconsistency between information contained in this manual and the Provider Agreement between you or your facility and. In the event of a material change to the Provider Manual, Amerigroup will make all reasonable efforts to notify you in advance of such changes through newsletter communications and other mailings.

In such cases, the most recently published information shall supersede all previous information and be considered the current directive. The manual is not intended to be a complete statement of all Amerigroup program policies or procedures.

Other policies and procedures not included in this manual may be posted on our website or published in specially targeted communications. These communications include, but are not limited to letters, bulletins and newsletters.

Throughout this manual, there are instances where information is provided as a sample or example. This information is meant for illustration purposes only and is not intended to be used or relied upon in any circumstance or instance. This manual does not contain legal, tax or medical advice.

Please consult other advisors for such advice. The Amerigroup website and this manual may contain links and references to Internet sites owned and maintained by third party entities. Neither Amerigroup nor its related affiliated companies operate or control in any respect any information, products or services on these third-party sites. Amerigroup disclaims all warranties, express or implied, including but not limited to implied warranties of merchantability and fitness.

Amerigroup does not warrant or make any representations regarding the use or results of the use of third-party materials in terms of their correctness, accuracy, timeliness, reliability or otherwise. To find these statements, go to providers. Please be aware that when you travel from the Amerigroup website to another website, whether through links provided by Amerigroup or otherwise, you will be subject to the privacy policies or lack thereof of the other sites.

We caution you to determine the privacy policy of such websites before providing any personal information. PHI includes information about Members that a Provider or facility is not treating or are not enrolled to your practice. PHI can be misrouted to Providers and facilities by mail, fax, email or electronic remittance advice.

Providers and facilities are required to destroy immediately any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are Providers or facilities permitted to misuse or re-disclose misrouted PHI. If Providers or facilities cannot destroy or safeguard misrouted PHI, please contact Provider Services at Amerigroup will collect and release all personal and clinical information related to Members in keeping with Texas and Federal laws, including HIPAA, court orders or subpoenas.

Release of records according to valid court orders or subpoenas is subject to the provisions of that court order or subpoena. The person or entity that is seeking to obtain medical information must obtain the authorization from the Member and is to use that information only for the purpose it was requested and retain it only for the duration needed.

The individual physician, Provider, person or entity may not intentionally share, sell or otherwise use any medical information for any purpose deemed not necessary to provide health care services to the Member. Only necessary information shall be collected and maintained.

Reasons for collecting medical information may include but are not limited to:. This database includes a secured system restricting access to only those with authorized entry. Computers, workstations and laptops are protected by a password known only to the user assigned to that computer. Devices displaying Member or Provider information shall not be left on and unattended. No confidential information or documents shall be unattended i.

Review matters are privileged communications. As such, these records are considered as confidential. Such records are labeled Confidential with a warning that its release is subject to. Members may access their medical records upon proper request. Upon reviewed and approved requests to the Amerigroup compliance office, the Member may provide a written amendment to their records if they believe that the records are incomplete or inaccurate.

Amerigroup verifies the identity of the individual. An initial consent to treat may be signed at the point of entry into services prior to the provision of those services, but does not allow records to be released for any reasons other than those delineated in that original consent i.

Letters of Conservatorship may need to be reviewed by legal counsel to determine who may consent to the release of Member information. Electronic, facsimile or written clinical information sent is secured with limited access to those employees who are facilitating appropriate patient care and reimbursement for such care. Anyone requesting Member outpatient psychotherapy records must submit a written request, except when the patient has signed a written letter or form waiving notification to the Member and treating Provider.

The request must be sent to the Member within 30 days of the receipt of the records except when the Member has signed a written letter or form waiving notification. A person or entity may extend the timeframe, provided the person or entity notifies the practitioner of the extension.

Any notification of the extension will include:. Member information will only be released in compliance with a subpoena duces tecum received by Amerigroup as follows:. Should a notice contesting the subpoena be received prior to the required date, records will not be released without a court order requiring so.

If no notice is received, records will be released at the end of the day period. All Amerigroup. Therefore, these types of providers do not require an NPI number. The NPI is a digit intelligence-free numeric identifier. Intelligence-free means the numbers do not carry information about health care Providers, such as the state in which they practice or their specialty.

Appeals are determined by the liable party, not by the initiator. The time frame to review your request will commence once your appeal is routed to the appropriate department. Please refer to the denial letter or Explanation of Payment EOP issued to determine the correct appeals process.

For more information, contact Provider Services at or your local Provider Relations representative. Amerigroup and our Members, we provide frequent communications to Providers in the form of broadcast faxes, Provider Manual updates, newsletters and information posted to the website. As per Amerigroup policy, we also provide orientation and training to Providers, which will include the state mandated minimum number of hours and topics of training to ensure awareness of the procedures as part of the Dual Demonstration program.

The training will be consistent with the requirements contained in the contract between the health plan, state and. Centers for Medicare and Medicaid Services CMS , as well as providing resources and access information for the disability-competent care population. Amerigroup contracts with certain physicians that.

Members may choose as their PCPs and may be individual practitioners associated with a contracted medical group or an independent practice association. The PCP is responsible for referring or obtaining precertification for covered services for Members. Federally Qualified Health Centers. Members, whether providing it himself or herself or by referral to the appropriate Provider of care within the network.

To assist the specialty care Provider, the PCP should provide the specialist with the following clinical information:.

Any referral to a nonparticipating Provider will require precertification from Amerigroup , or the services may not be covered. Amerigroup believes that quality primary care and active care coordination are essential components to providing high-quality and cost-effective health care to our Members. This philosophy supports the relationship between our contracted PCPs and other health care professionals who coordinate the medical needs of our Members.

The goal is to ensure each. Member receives appropriate care and all of his or her Providers are in communication with one another so that the Member achieves healthier outcomes. To successfully complete the PHRA, the following fields must be legibly documented for processing and claims reimbursement:. A specialist is any licensed Provider as defined by Medicare providing specialty medical services to Members.

A PCP may refer a Member to a specialist when medically necessary. Specialists must obtain authorization from Amerigroup before performing certain procedures or when referring Members to non-contracted Providers. You can review precertification requirements online at providers.

Any referral to a nonparticipating Provider will require precertification from Amerigroup. In some cases, a specialist, physician assistant, nurse practitioner or certified nurse midwife under physician supervision may be a PCP. Management department. Referrals to Amerigroup contracted specialists do not require precertification. Some procedures performed by specialist physicians may require precertification.

You must obtain authorization from Amerigroup before referring Members to noncontracted Providers. Note: Amerigroup does not cover the use of any experimental procedures or experimental medications, except under certain circumstances. Examples of transitions in care include a referral from a PCP to a specialist, an admission to a hospital or a discharge from a hospital to home care or a skilled nursing facility.

The Provider is an integral part of effectively managing transitions. Communication is the key with both the Member and other treating Providers. To prevent duplicate testing and provide critical information about the Member, the following processes should be followed:. All health care Providers are responsible for verifying enrollment and eligibility before services are rendered, except in the case of an emergency.

In general, eligibility should be verified at the time of service and at least once monthly for ongoing services. When a patient presents as a Member, Providers must verify eligibility, enrollment and coverage by performing the following steps:. Members may sometimes cancel or not appear for necessary appointments and fail to reschedule the appointment.

This can be detrimental to their health. Amerigroup requires. Providers to attempt to contact Members who have not shown up for or canceled an appointment without rescheduling. The contact must be by telephone and should be designed to educate the Member about the importance of keeping appointments and to encourage the.

Members who frequently cancel or fail to show up for appointments without rescheduling may need additional education in appropriate methods of accessing care. In these cases, please call. Our goal is for Members to recognize the importance of maintaining preventive health visits and to adhere to a plan of care recommended by their PCP. Amerigroup recognizes Providers may need help in managing non-adherent Members. Customer Care at A Member or Provider Services representative will contact the Member by telephone, or a Member advocate will visit the Member to provide education and counseling to address the situation and will report the outcome of any counseling efforts to you.

Amerigroup will ensure newly enrolled Members will continue to have access to medically necessary items, services, prescription drugs, and medical, behavioral health and LTSS Providers for the transition period. Members will be allowed to maintain their current Providers for 90 days from the date of enrollment. Members will be allowed to maintain their current LTSS.

Providers for days. Members will also be allowed to maintain their preauthorized services for the duration of the prior authorization or days from enrollment, whichever is sooner. Amerigroup will also advise, in writing, both Members and Providers when Members have received care that would not otherwise be covered at an in-network level.

Amerigroup will contact noncontracted Providers to inform them on the procedure for becoming an in-network. Individuals residing in nursing facilities at the time of program implementation may remain in the facility as long as they continue to meet Texas State Health and Human Services. Commission HHSC criteria for nursing home care, unless they or their families prefer to move to a different nursing facility or return to the community.

During the transition period referenced above, a change from the existing Provider can only occur in the following circumstances:. The Provider will either: i make arrangements with one or more Amerigroup. In addition, the covering Provider will agree to the terms and conditions of the network Provider Agreement, including any applicable limitations on compensation, billing and participation. Providers will be solely responsible for a non-network.

Amerigroup process is designed to comply with all state and federal regulations regarding the termination appeal process. Amerigroup may also use financial incentives to reward. Providers to limit or reduce medically necessary services furnished to individual enrollees. In cases where Amerigroup approves Provider subcontracting arrangements, those subcontractors cannot employ any financial incentives inconsistent with this policy or CMS regulations.

Payments Providers receive for furnishing services to Members are derived in whole or part from federal funds. Therefore, Providers and any approved subcontractors must comply with. Neither Amerigroup nor its contracted Providers may deny, limit or condition the coverage or furnishing of services to Members on the basis of any factor related to health status, including but not limited to the following:. Amerigroup will determine reasonable cause for transferring a Member based on written request and documentation submitted by the Provider.

Amerigroup is required to submit information to CMS necessary to characterize the context and purposes of each encounter between a Member and Provider, supplier, physician or other practitioner encounter data.

Providers that furnish diagnostic data must certify to the best of their knowledge, information and belief the accuracy, completeness and truthfulness of the data. Cultural competency is the integration of congruent behaviors, attitudes, structures, policies and procedures that come together in a system or agency or among professionals.

Cultural competency assists Providers and Members to:. Cultural Competence. A competency based on the premise of respect for Member and cultural differences and an implementation of a trustpromoting method of inquiry and assistance. The quality of the Patient-Provider interaction has a profound impact on the ability of a patient to communicate symptoms to his or her Provider and to adhere to recommended treatment.

Cultural barriers between the Provider and Member can impact the Patient-Provider relationship in many ways, including but not limited to:.

To be culturally competent, Amerigroup expects Providers serving Members within their geographic locations to demonstrate the following:. Additionally, Providers can have plan marketing materials in their office as long as marketing materials for all plans the.

Providers participate in are represented. This action plan includes the following:. This includes individuals enrolled in the Elderly or. Individuals who meet at least one of the exclusion criteria listed below shall be excluded from the Demonstration as appropriate. These individuals may receive Medicaid coverage for the following: Medicare monthly premiums for Part A, Part B or both carved-out payment ; coinsurance, copayment and deductible for Medicare-allowed services; Medicaid-covered services, including those that are not covered by Medicare.

HHSC will focus on developing clear and accessible information ensuring availability in alternative formats and languages on available MCOs and consumer protections. To help facilitate enrollment choices,. Notations regarding some benefit categories are listed below. Please note availability and limitations. Please refer to the appropriate Summary of Benefits listed below for detailed information. Precertification requirements are described in later sections and in detail on the Provider website.

All services from non-contracted Providers with the exceptions of urgent and emergent care and out-of-area dialysis require precertification. Acupuncture Therapy as a supplemental benefit. Members may get up to six 6 acupuncture treatments per calendar year with no co-payments or out-of-pocket expense. Members need to obtain a prior authorization to receive this service. Coverage includes one alcohol-misuse screening SBIRT for adults who misuse alcohol but are not alcohol dependent.

This includes pregnant women. Members who screen positive for alcohol misuse can get up to four brief, face-to-face counseling sessions each year with a qualified primary care provider or practitioner in a primary care setting.

Covered ambulance services include fixed-wing, rotary-wing, and ground ambulance services. The ambulance will take member to the nearest place to provide care.

ACT is a mobile team-based approach to delivering comprehensive and flexible treatment, rehabilitation, case management and support services to individuals in their natural living setting. The adaptations must be necessary to ensure the health, welfare, and safety of the Participant or enable the Participant to function with greater independence in the home. These procedures identify bone mass, find bone loss, or find out bone quality. Amerigroup will pay for the services once every 24 months or more often if they are medically necessary.

Amerigroup will also pay for a provider to look at and comment on the results. Coverage includes cardiac rehabilitation services such as exercise, education, and counseling. Coverage also includes intensive cardiac rehabilitation programs.

Coverage includes one visit a year with primary care provider to help lower your risk for heart disease. During this visit, providers may:. Coverage includes blood tests to check for cardiovascular disease once every five years 60 months.

These blood tests also check for defects due to high risk of heart disease. Care management is an individually designed intervention that helps the Participant get access to needed services. These care management interventions are designed to ensure the. Participant is at high risk for colorectal cancer, when this test is used instead of a flexible sigmoidoscopy or colonoscopy.

This is a counseling service provided to. Members who are coping with altered abilities and skills, a revision of long term expectations, or changes in roles in relation to significant others. Community integration counseling services are usually provided in one-to-one counseling sessions. However, there are times when it is appropriate to provide this service to the Participant in a family counseling or group counseling setting.

Transitional Services CTS. These services help a Participant transition from living in a nursing facility to living in the community. Services can include any of the services provided by a personal care aide. The Participant or the person acting on the Participant's behalf such as the parent of a disabled or chronically ill child is responsible for recruiting, hiring, training, supervising, and, if necessary, terminating caregivers providing CDPAS services. This service helps Members maintain or enhance current levels of functioning and skills, maintain community living, and develop self-awareness and self-esteem.

Day treatment is a combination of diagnostic, treatment, and rehabilitative procedures that provide the services of the clinic treatment program, as well as social training, task and skill training, and socialization activities. The screening must be done in a primary care setting that can give follow-up treatment and recommendations for additional treatments.

Coverage includes screening including fasting glucose tests if the member has any of the following risk factors:.

Tests may be covered in some other cases, such as if the member is overweight and has a family history of diabetes. Depending on the test results, members may qualify for up to two diabetes screenings every 12 months.

Coverage includes the following services for all members who have diabetes whether they use insulin or not :. One pair of depth shoes and three pairs of inserts each year not including the non-customized removable inserts provided with such shoes. During this time, the Member should talk with their Service Coordinator or SCT to decide what brand is medically right for the Member after this day period.

A medical or behavioral emergency is a condition with severe pain or serious injury. Members may get covered emergency care whenever they need it, anywhere in the United States or its territories. Participants may choose any Provider for certain family planning services. This includes any doctor, clinic, hospital, pharmacy, or family planning office. Coverage includes the following services:.

At least 30 days, but not more than days, must pass between the date that the Member signs the form and the date of surgery. These services are provided on topics including, but not limited to: heart attack and stroke prevention, asthma, living with chronic conditions, back care, stress management, healthy eating and weight management, oral hygiene, and osteoporosis. This benefit also includes annual preventive care reminders and caregiver resources. They are covered as outpatient care when a Participant gets them from a physician, audiologist, or other qualified provider.

Hearing services and products are covered when medically necessary to alleviate disability caused by the loss or impairment of hearing.

This is an individually designed service that provides meals to Members who cannot prepare or obtain nutritionally adequate meals for themselves, or when providing such meals will decrease the need for more costly supported inhome meal preparation.

This benefit includes three meals a day for 52 weeks a year. Chore services are provided on two levels:. Light chores are provided when needed. The purpose of these home visits is to preserve the. Wellness monitoring includes disease prevention, health education, and identifying health risks that can be reduced. Independent Living Skills Training and Development ILST services are individually designed to improve or maintain the ability of the Participant to live as independently as possible in the community.

If a Member needs a transplant, a Medicare-approved transplant center will review their case and decide whether they are a candidate for a transplant. Transplant providers may be local or outside of the service area. If local transplant providers are willing to accept the Medicare rate, then the. Member can get their transplant services locally or at a distant location outside the service area. MMP provides transplant services at a distant location outside the service area and the Member chooses to get their transplant there, Amerigroup will arrange or pay for lodging and travel costs for the Member and one other person.

Coverage includes mental health care services that require a hospital stay, including days in excess of the Medicare day lifetime maximum.

Members must have stage IV chronic kidney disease, must refer be referred by their physician. Coverage includes up to six sessions of kidney disease education services. Coverage for Members with diabetes or kidney disease without dialysis. It is also for after a kidney transplant when referred by your provider. Coverage includes three hours of one-on-one counseling services during the first year that the Member receives medical nutrition therapy services under Medicare.

This includes our plan, any other Medicare Advantage plan, or. Coverage includes up to two hours of one-on-one counseling services each year after that. These drugs are paid for if member is homebound, has a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot inject the drug themselves.

This service is available to Members who have a medical condition or disability that limits their ability to come into an office for regular outpatient therapy sessions. Participant must be moved from inadequate or unsafe housing to an environment which more adequately meets the.

Coverage available for Members with a body mass index of 30 or more, includes counseling to help the Member lose weight. This is meant to cover items or services that are not traditionally included in the Medicare or. Medicaid programs but that are necessary and appropriate for the Participant.

Coverage available for medically needed services available in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Members can get outpatient rehabilitation services from hospital outpatient departments, independent therapist offices, comprehensive outpatient rehabilitation facilities. OT, PT, and ST services are limited to twenty 20 visits per therapy per calendar year except for individuals with intellectual disabilities, individuals with traumatic brain injury, and individuals under age Coverage available for outpatient surgery and services at hospital outpatient facilities and ambulatory surgical centers.

These services help to prevent or relieve pain and suffering and to enhance the Participant's quality of life. Partial hospitalization is a structured program of active psychiatric treatment. It is offered in a hospital outpatient setting or by a community mental health center. It can help keep members from having to stay in the hospital. This is a person who assists individuals with their recovery from mental illness and substance abuse disorders.

Members who have recently transitioned into the community from a nursing facility or during times of crisis. This is an individually designed service intended to improve the. This will be accomplished through education, teaching, instruction, information sharing, and self-advocacy training. This includes the coordinated delivery of a customized array of rehabilitation, treatment, and support services in traditional settings and in off-site locations.

Prescription Drugs Prescription drugs are only available by prescription, are used or sold in the United States and must be used for medically accepted indications. The formulary includes all generic drugs covered under the program, as well as many brand-name drugs, non-preferred brands and specialty drugs.

One can view a copy of the formulary on the Amerigroup website at providers. Some of these drugs have precertification or step-therapy requirements or quantity limits. Providers may request authorization for a drug or coverage of a drug not on the formulary by contacting the. ESI services also include home infusion, specialty pharmacy and mail-order pharmacy. More information on these services can be obtained by contacting the Pharmacy department at the number listed above.

Participants can use the mail-order service to fill prescriptions for maintenance drugs i. For mail-order prescriptions, the physician must write on the maintenance drug prescription whether it is for a , or day supply. When mailing in a prescription to the mail-order service for the first time, the. Participant should allow up to two weeks for the prescription to be filled. For refills of the same prescription, Members should allow up to two weeks for mailing and processing. If a Participant runs out of a medication before receiving a new supply from the mail-order pharmacy, please call the Pharmacy at.

Participants are not required to use mail-order prescription drug services to obtain an extended supply of maintenance medications. Some retail pharmacies may agree to accept the mail-order reimbursement rate for an extended supply of medication, which may result in no out-of-pocket payment difference to the Participant.

This includes, but is not limited to, all the preventive services listed in this chart. Coverage also includes some supplies related to prosthetic devices, including repair or replacement of prosthetic devices. This service is initially limited to 36 visits over a week period, but can be renewed.

No prior authorization is required for the first course of treatment. Physician authorization is required for additional courses of treatment. Respiratory therapy includes preventive, maintenance, and rehabilitative airway-related techniques and procedures.

The service may be provided in a. These screenings are covered for pregnant women and for some people who are at increased risk for an STI. A PCP or other primary care practitioner must order the tests. We cover these tests once every 12 months or at certain times during pregnancy. Each session can be. Participants will usually get care from network facilities. However, members may be able to get care from a facility not in our network.

If you use tobacco but do not have signs or symptoms of tobaccorelated disease, you use tobacco and have been diagnosed with a tobacco-related disease, or you are taking medicine that may be affected by tobacco:. This service is free for you. Each counseling attempt includes up to four face-to-face visits. This smoking cessation counseling is in addition to benefits for prescriptions and over-the-counter smoking cessation products.

Services may include:. The services included in this benefit provide Members with socialization, supervision and monitoring, personal care, and nutrition in a protective setting. Services are designed to improve or maintain the.

Opioid treatment programs administer medication, generally methadone by prescription, along with a variety of other clinical services. These programs help Members control the physical problems associated with opiate dependence and provide the opportunity for. Members to make major lifestyle changes over time. Participants may directly access one assessment from a network provider in a twelve 12 month period without getting prior authorization.

Participants eligible for this service include those with the following conditions: congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, mental or behavioral problems limiting self-management, and technologydependent care such as continuous oxygen, ventilator care, total parenteral nutrition or enteral feeding.

Transportation is provided for medical appointments and services. Transportation is also available for nonmedical events or services, such as religious services, community activities, or supermarkets, through transportation modes including but not limited to:. Participants requiring urgent care, should first try to get it from a network provider.

However, you can use out-of-network providers when you cannot get to a network provider. Urgent care does not include primary care services or services provided to treat an emergency medical condition.

Participants may get covered emergency care whenever you need it, anywhere in the United States or its territories. This includes treatment for age-related macular degeneration. Examinations for refraction are limited to one 1 exam every two 2 years unless medically necessary. Coverage also includes the repair or replacement of parts. Eyeglasses lenses and frames and contact lenses are provided once every two 2 years unless it is medically necessary to have them more frequently or unless the glasses or contact lenses are lost, damaged or destroyed.

If you have two separate cataract surgeries, you must get one 1 pair of glasses after each surgery. You cannot get two 2 pairs of glasses after the second surgery, even if you did not get a pair of glasses after the first surgery.

The visit includes:. A Registered Professional Nurse RN works with the Participant to reinforce or teach healthy habits such as the need for daily exercise, weight control, or avoidance of smoking. The RN is also able to offer support for control of diseases or disorders such as high blood pressure, diabetes, morbid obesity, asthma or high cholesterol. The RN can help the Participant to identify signs and symptoms that may require intervention to prevent further complications from the disease or disorder.

The website formulary is updated frequently with any changes. MMP Pharmacy Department to be sure a drug is covered. If the Pharmacy Department confirms the drug is not on the formulary, there are two options:. If the Participant pays out-ofpocket for a nonformulary drug and requests an exception Amerigroup approves,. See the Participant Liability Appeals section for more information on requesting exceptions and appeals.

In some cases, Amerigroup will contact a Participant who is taking a drug that is not on the formulary. Amerigroup will give the Participant the names of covered drugs used to treat his or her condition and encourage the Participant to ask his or her physician if any of those drugs would be appropriate options for treatment. Also, Members who recently joined the. Members are encouraged to talk to their Providers to decide if they should switch to a different drug Amerigroup covers or request a formulary exception in order to get coverage for the drug.

During the period of time Members are talking to their Providers to determine the right course of action, Amerigroup may provide a temporary supply of the nonformulary drug if those. For current Members affected by a formulary change from one year to the next, Amerigroup will provide a temporary supply of the nonformulary drug for. Amerigroup provides a temporary supply of a drug that is not on the formulary or that has coverage restrictions or limits, Amerigroup will cover at least a one-time, day supply unless the prescription is written for fewer days.

If necessary, Amerigroup will cover more than one refill of these drugs during the first 90 days a Participant is enrolled in our plan.

Amerigroup will provide the Participant with a written notice after it covers a temporary supply. The notice will explain the steps the Participant can take to request an exception and the way to work with the prescribing physician to decide if switching to an appropriate formulary drug is feasible.

If a new Participant is a resident of a long-term care facility like a nursing home , Amerigroup will cover a temporary day transition supply unless the prescription is written for fewer days.

If the Participant has been enrolled in the plan for. For example, if a Participant leaves the hospital and enters a long-term care facility or leaves hospice status and reverts back to standard care, the Participant may receive a temporary transition supply of the non-formulary drug for up to 31 days, unless the prescription is written for fewer days.

Electronic Visit Verification EVV is the electronic verification and documentation of visit data, such as the date and time the services begin and end, the name of the attendant and the service recipient, and the services provided.

This requirement is optional for members who get attendant care services through the Consumer Directed Services. Amerigroup matches the applicable EVV record. The claim and EVV record will be evaluated during claim review. Medicaid-eligible adults with disabilities and elderly persons as a cost-effective alternative to living in a nursing facility.

These members must be age 21 or older, enrolled in Medicaid or otherwise financially eligible for waiver services. All LTSS services must be precertified. Coverage of these services is limited to Members who need assistance with the activities of daily living.

Some services are limited to Members who meet the nursing home level of care. If you have an Amerigroup patient who needs these. A member may not need long-term services and supports right now, but they can get these benefits if needed in the future. Services include, but are not limited to, the following:. DAHS includes nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services.

These services are provided at facilities licensed or certified by the Texas Department of Aging and Disability. Services may include meal preparation, housekeeping, personal care, nursing tasks, supervision, companion services, daily living assistance and provision of, or arrangement for, transportation.

Providers of AFC must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. The individual enrolled to provide AFC must be the primary caregiver. Up to four residents may be served in a foster home, though there are limitations as to the number of Members at each level who may reside in one home. Members are required to pay for their own room and board costs, and contribute to the cost of their care, if able, through a copayment to the AFC provider.

Member to have optimal function, independence and well-being are identified and approved by the managed care organization in the individual service plan. Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances specified in the plan of care, that enable individuals to increase their abilities to perform activities of daily living or perceive, control or communicate with the environment in which they live.

Adaptive aids and medical supplies are reimbursed with the goal of providing individuals a safe alternative to nursing facility NF placement. Items not of direct remedial benefit providing a remedy to cure or restore health or medical benefit to the individual are excluded from reimbursement. Allowable services include:. Amerigroup must review and approve any treatment in excess of the waiver plan year limit prior to services being rendered.

Cognitive rehabilitation therapy may be provided when an appropriate professional assesses the member and determines it is medically necessary. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. Employment Assistance means assistance provided to a Member to help the member locate paid employment in the community.

Employment assistance includes:. Employment Assistance is not available to members receiving services through a program funded by the Rehabilitation Act of or the Individuals with Disabilities Education Act. Supported Employment means assistance provided to a Member in order to sustain paid employment to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which members without disabilities are employed.

Supported Employment includes employment adaptations, supervision and training related to a member's diagnosis. Supported Employment is not available to members receiving services through a program funded by the Rehabilitation Act of or the Individuals with Disabilities Education Act. The assistance is provided by the CDS agency. This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.

It is an optional service. A member's service planning team may recommend the service when the employer the individual or legally authorized representative LAR or the designated representative DR would benefit from additional support with employer responsibilities.

Support Consultation services must not duplicate or replace services to be delivered through a case manager, a service coordinator, the Financial Management Services Agency FMSA or other sources. A support advisor provides skills-specific training, assistance and supports to the employer or the employer's designated representative DR to meet responsibilities of the CDS option. Examples of services a support advisor may provide include training related to recruiting and screening applicants for employment and verifying employment eligibility, assistance with developing job descriptions, coaching on problem solving and coordinating employee management activities, training on developing and implementing service backup and corrective action plans, and coaching on handling other employer responsibilities.

MMP members. The Member will be notified by letter of the name and direct telephone number of their assigned personal service coordinator. We will promptly assess the needs of a member discharged from a hospital, nursing facility, or other care or treatment facility. MMP who is already receiving long-term services and supports including nursing facility services. We will ensure that existing services continue and that there is no break in services. For the carve-in of Nursing Facility services effective.

The transition plan may include information about services outside the scope of covered services such as how to access affordable, integrated housing. All LTSS require authorization before services are rendered.

Requests may be submitted via fax, telephone or our website for review and approval. We will send a fax confirmation of the service approval. Authorizations can be submitted at:. In the case of other insurance, submit a clean claim within 95 days of receiving a response from the third-party payer. Refer to the Billing and Claims Administration chapter of this manual for the definition of a clean claim.

When billing a span of dates on a single outpatient claim, the filing timeline is calculated from the first or earliest service date on the claim.

Acute care and outpatient claims should be submitted in accordance with the requirements in the Billing and Claims Administration chapter of this manual. Use only the uniform billing defined code, modifier, type and place of service combinations. Long-term services and supports providers have three options for submitting claims: our website, Electronic Data Interchange EDI or paper.

The Provider liability appeals process is located under the section titled Provider Payment Appeals. Appeals must be filed within 60 days of the Amerigroup notification of the denial.

The request may be made telephonically or in writing. If a physician requests the expedited appeal and indicates the case meets the expedited criteria, Amerigroup will automatically expedite the appeal. The Appointment of Representative Form can be found online and downloaded at. Providers can also obtain a signed written statement from the Member. Expedited Turnaround Time Payment 60 calendar days.

Appeals should be lodged as per the denial letter issued to the appropriate QIO within the. The QIO will provide an immediate review. If Amerigroup is unable to reverse the original denial decision in whole or part, the following additional steps will be taken:.

If the Medicare Appeals Council refuses to hear the case or issues an adverse decision, the Member may be able to appeal to a federal court. The outcome more favorable to the Member will be what Amerigroup is bound to. A Member grievance is the type of complaint a Member makes regarding any other type of problem with Amerigroup or a Provider. Amerigroup must accept grievances from Members orally or in writing within 60 days of the event.

Amerigroup must make a decision and respond to the grievance within 30 days. A Member can request an expedited grievance, in which case Amerigroup has 24 hours to respond. Amerigroup can request up to 14 additional days to respond to a grievance with good reason.

Amerigroup will display on its main website page a link to the electronic grievance form located on the Medicare. Gov Internet Web site. Associates will also provide assistance in completing any forms, or other procedural steps, to support the Member filing the grievance. If a Member has a grievance about Amerigroup, a Provider or any other issue, Providers should instruct the Member to call Member Services at and TTY users should call during regular business hours or send a written grievance to:.

The Amerigroup self-service website at providers. You can also submit a claim or precertification request, print referral forms or directories or obtain a Member roster.

Detailed instructions for use of the Online Provider Inquiry Tool can be found on our website. I understand Amerigroup has established the medical necessity standards for the services or items I request and receive. I also understand I am responsible for payment of the services or items I request and receive if these services or items are determined to be inconsistent with the Amerigroup medically necessary standards for my care or not a covered benefit.

This system provides a continuous cycle for assessing the level of care and service among plan initiatives including preventive health, acute and chronic care, behavioral health, over-. Preventive nursing services. You must be found eligible to receive waiver. Other services covered by Medicare or.

Other services covered. Su proveedor de cuidado primario. Provider Complaint and Grievance Procedures Overview Amerigroup has a formal process for the handling of complaints pertaining to administrative issues and nonpayment-related matters. If a representative can be contacted, the representative should sign the notice.

Hospitals The Important Message from Medicare IMM is a statutorily required notice issued to Medicare Advantage Members to alert them of a discontinuation of acute inpatient hospital services. The hospital is required to deliver the notice in person and obtain the signature of the Member or representative and provide a copy at that time. Precertification Providers are responsible for obtaining precertification from Amerigroup before performing certain procedures or when referring Members to non-contracted Providers.

Amerigroup will render a determination on the request within the appropriate time frame and provide notification of the decision. Appeals Both Member and Provider Appeals Providers must cooperate with Amerigroup and with Members in providing necessary information to resolve appeals within the required time frames.

The Appointment of Representative Form can be found online and downloaded at www. Related documents.