1 Florida Health Care Plans And Community Health Partners Healthy Kids Provider Handbook Collier County
2 Dear Healthy Kids Provider, Attached is the Provider Manual for the Healthy Kids Program for Collier County. This program is administered by Community Health Partners, the Naples Physician Hospital Organization and Florida Health Care Plans. CHP holds the financial risk, provides the provider network, utilization management and case management for this program. CHP contracts with Florida Health Care Plans to maintain the Healthy Kids membership information and provide claims administration. (Florida Health Care Plans does have other products in other parts of Florida, but the Collier Healthy Kids Program is their only business in Collier County.) Healthy Kids programs operate under the rules of the Healthy Kids Corporation as established by the Florida legislature and Medicaid guidelines. This manual contains information provided by both Florida Health Care Plans and Community Health Partners. In most every chapter you will find a section with the CHP procedure followed by the Florida Health Care Plans information. You will find information on membership verification, eligibility, benefits, physician responsibilities, pre-certification, referrals, utilization review, case management, and claims submission. There are also key contact people to help you, phone and Fax numbers and addresses. We have tried to make clear whom to contact at which organization for various tasks that you will encounter. Please review this manual and distribute to your staff as appropriate. If you have questions, please contact Community Health Partners, Sincerely, Nicole Slivanik, Director of provider Relations and Contracts
3 OFFICE AND PHYSICIAN INFORMATION Attached is information for the office for: Co-payments to be collected for services provided to Collier County Healthy Kids. Collier County Healthy Kids Pre-certification and Referral forms are to be faxed to Community Health Partners (239) Primary Care Physicians are paid fee for service until their patient load (or if in a group practice the number of children assigned to that group) reaches 101 children, when they become capitated. Once a provider becomes capitated, they remain capitated. Primary Care physicians will receive a membership list monthly from Florida Health Care Plans. Children will be on your list unless the parent and/or the physician s office requests a transfer to another Primary Care Physician. Initial assignment of a child is done via selection by the parent or legal guardian of the Healthy Kids member to physicians with an open panel. There is a transfer form attached to use to request that a child be removed from your panel (only in extenuating circumstances) or to allow a child to be added to your panel if your panel is closed. Community Health Partners maintains the information on the number of Healthy Kids participants you are willing to accept in your practice. When you reach that number, CHP notifies Florida Health Care Plans that your panel is closed.
4 CREDENTIALING All credentialing for Community Health Partners providers in the Collier County Healthy Kids program is handled through CHP and the Naples Community Hospital Medical Staffing Office. Re-credentialing of all providers is every two years. Participation in the Healthy Kids product is by Messenger Model and therefore, providers may elect to participate or not. Written notice must be given to CHP 90 days in advance of any changes in location or practice or any decision to term participation to allow time to notify FHCP. Attached is a CHP Provider status change form for this purpose. CHP must follow the Healthy Kids Corporation regulations for participation. This includes who may serve as a Primary Care Physician and the requirement to be Board Certified. This information is further reviewed in the following Florida Health Care Plans Manual chapter. Any questions about status or effective dates of CHP providers must be directed to Provider Relations at Community Health Partners at (239)
5 QUALITY IMPROVEMENT Community Health Partners through the SWFPA Board maintains a quality committee that meets quarterly. Any problems/issues with Community Health Partners providers must be submitted in writing to CHP for review. These matters are reviewed and presented to the CHP Quality Committee. The Healthy Kids program also requires that any issues that relate to the Healthy Kids program must also be submitted to Florida Health Care Plans for review. CHP Provider Relations Representatives make site visits on a regular basis to provider s offices as well as to all new facilities. CHP also sends surveys to Healthy Kids providers regularly for feedback on both provider relations and utilization management. Suggestions for improvement are always welcomed at Community Health partners at (239)
6 UTILIZATION MANAGEMENT And OUTPATIENT UTILIZATION MANAGEMENT Community Health Partners performs all Utilization Management functions for the Collier County Healthy Kids program. Phone (239) for the Nurse Case Managers for authorization for all admissions and procedures as listed on the pre-certification form. That form is attached and is also available in the Forms section. You must Fax the precertification form and case notes to the Nurse Case Managers at CHP at (239) Decisions to approve or deny admissions or services are based on InterQual Guidelines. Denials of any services will be given from Florida Health Care Plans. Contact the CHP case managers for any questions about medical services, surgeries, hospitalization and referrals. Referrals must be made to providers in the CHP Healthy Kids network, unless there is not an appropriate facility or provider available in the network. The case managers are available to help with these referrals or questions.
7 PROCESS FOR A DER OVERIDE FOR CHP PHYSICIANS Florida Health Care Plans/Envision RX Options will utilize the Medicaid Formulary. This is available at: Any medication that is not on the formulary will require prior authorization. The process is as follows: Envision RX Options prefers that you call in the request for prior authorization to These calls will be handled promptly. You may also fax your requests to Faxed request could take 48 hours. If you fax, it is necessary to use drug specific forms. There is also a miscellaneous form for use for drugs other than those on the Medicaid Formulary. A copy of the Florida Health Care Plans/Envision RX Options forms is included with your packet. Contact Community Health Partners nurse case managers at (239) for assistance if response not received within 48 hours.
8 BEHAVIORAL HEALTH Referrals to individual providers for Behavioral Health care evaluations and treatment require prior authorization. Community Health Partners provides the network for these services. For all outpatient services authorization must be obtained by the Primary Care Physician s office for the referral to a Community Health Partners network provider. If treatment is recommended past 6 initial visits, a plan of care must be provided by the Behavioral Health provider to Community Health Partners for review and consideration of ongoing treatment. If the referral is to David Lawrence Center for either inpatient or out-patient care, the Primary Care Physician must contact David Lawrence Center directly to make the referral. The patient must take their ID card with them to their appointment. Any inpatient stays must provide a care plan at 7 days for review by Community Health Partners. Behavioral Health Providers must use the attached form to submit treatment plan to Community Health Partners to obtain authorization for additional sessions or services.
9 NOTE TO PROVIDER Welcome! Thank you for becoming a participating provider in Florida Health Plans (FHCP) Healthy Kids program. We recognize that, at times, the administrative requirements of managing your patients' health care can be complex. This Provider Manual is a source of answers to questions you may have about FHCP and Healthy Kids health plan coverage procedures, policies and other facts related to your provision of health care services to our Healthy Kids members. As described in your contract with CHP, this Provider Manual supplements and provides additional terms and conditions regarding your provision of Covered Services to FHCP Healthy Kids Members. In the event of a conflict between the Provider Agreement or any contract providing member coverage ("Coverage Document"), the Provider Agreement or Coverage Document will control over this Provider Manual. The purpose of any medical policy that may be included in this Provider Manual is to provide guidelines to facilitate coverage decisions and is not intended to influence treatment decisions. While FHCP and CHP medical policy assists in making appropriate coverage decisions that promote consistent, high quality, and costeffective health care, providers are independent contractors and have an independent professional responsibility for the provision of health care to their patients in accordance with community standards regardless of any FHCP or CHP coverage decision. Nothing in this Provider Manual shall be construed as creating any relationship between you and FHCP other than that of independent entities that have contracted solely for the purpose of providing the services described in the Provider Agreement. FHCP makes no representations or warranties with respect to the content herein and specifically disclaims any implied warranties of merchantability of fitness for any particular purpose. This Provider Manual is provided for the convenience of providers participating in FHCP s Healthy Kids network. Nothing in this manual shall be interpreted as guaranteeing coverage of any service, treatment, drugs or supplies because coverage or non-coverage is always governed exclusively by the terms of the member's Coverage Document. Accordingly, in case of any question or doubt about coverage, you should always review the member's Healthy Kids health benefit plan. Florida Health Care Plans
10 Updates to any part of this Provider Manual may be made by FHCP at any time, so you should not assume that the Provider Manual remains current just because you have not received a replacement manual. As described in your Provider Agreement; FHCP may give notice of such updates in a variety of ways, depending on the nature of the update, including issuance of a new manual, a letter, a provider newsletter or other publication of FHCP, or by posting to the FHCP website.
11 Table of Contents Section 1 Who To Contact Section 2 Sample Healthy Kids I.D. Card Section 3 FHCP Profile and Overview Section 4 Healthy Kids Enrollment Process Section 5 PCP Assignment and Panel Management Section 6 Healthy Kids Member Handbook Collier County Section 7 Claims, Capitation Payments and Coding Section 8 Referrals and Pre-Certification Section 9 Member Services, Grievances & Appeals Section 10- FHCP Holiday Schedule Section 11- Florida Shots & Immunizations Section 12- Anticipatory Guidance for Parents Section 13- Pharmacy Section 14- FHCP Provider Portal Section 15- Quality of Care
12 Section 1 Who To Contact
13 Org Responsibility First Name FHKP Healthy Kids Enrollment, Premium Payments CHP Rev. 7/2014 Authorizations and Referral Requests Who to Contact Last Name Department/Title Website/ Phone Florida Healthy Kids Corporation Utilization Review Dept CHP Provider Network Questions Provider Relations CHP ESI Pharmacy Issues Envision RX Options FHCP Capitation Payments Sandy Dawson Capitation Coordinator Ext 7154 FHCP Claims Payment Denials Pat Wellday Claims Department Manager Ext 5020 FHCP FHCP Claims Payment Issues for Fee Service Claims from Members Claims Payment Issues for Fee For Service Claims from Providers FHCP Claims Customer Service Ext 5010 or Ext 2474 Jean Tyminski Claims Unit Supervisor Ext 4084 FHCP FHCP After-Hours Call Center Sue Karparis, LPN Referral Department Manager Ext 3301 FHCP Healthy Kid Benefit Questions Judith Torres Benefits Coordinator Ext 7204 FHCP FHCP Policy & Procedure Carol Cooper, LPN Provider Relations Coordinator Ext 4001 Questions, FHCP FHCP Website, Provider Search, Provider Portal Access (PPA) Kerry Wert Network Provider Services Ext FHCP FHCP Team Leader/Facilitator Sherrie Hutchinson Contract Services Administrator Ext 4020 FHCP HKid Enrollment or Eligibility Cynthia Martinez Enrollment Dept. Manager Ext 7277 Issues for FHCP FHCP Member Complaints, Information, Appeals, Benefits, PCP Selection FHCP Member Services Dept. com FHCP PCP Panel Management & Assignment (Provider Liaison) Mavis Anderson PCP Assignment Coordinator Ext 7621 FHCP Quality of Care Issues Theresa Watson, RN Quality Mgmt Administrator Ext 7246 FHCP 24/7 Nurse Advice Line LCI LabCorp Issues LabCorp
14 Section 2 Sample Healthy Kids ID Card
17 Section 3 FHCP Profile and Overview
18 Florida Health Care Plans Profile Florida Health Care Plan, Inc. (FHCP) is proud to be the Health Care Provider for the Healthy Kids program. FHCP joined along with Community Health Partners and Envision RX Options will be providing care to Healthy Kids in Collier County. From the time FHCP was chosen as the first Healthy Kids provider until today, we have viewed this program as a partnership between the children and their parents, the community, the schools, Healthy Kids Corporation, all the local hospitals, and ourselves. This partnership has created a program in Collier County that, in many cases, has transcended the imagination of its early supporters to become a program that the entire community embraces as its own. Our goal is to bring the same expertise and experience to Collier County. FHCP will serve the health care needs of Collier County through the following Mission, Vision and Values statements. Our Mission is: To provide Florida Health Care Plans' members with health care related services through dedicated employees and service partners who manage both the quality and the cost of health care. Our Vision is: To set the standard for managed health care in our community. We intend to be acknowledged as the leader by our members, employees, service partners and Governing Body. Our Quality Policy is: In our community, we manage both the quality and the cost of health care provided to the members of our health plan. We are committed to understanding the health care needs and meeting the requirements of our members, fellow employees and service partners. We will strive to do our jobs right the first time, every time. Florida Health Care Plans
19 SERVICE LOCATION Florida Health Care Plans is a Health Care organization owned and operated in the State of Florida. 100% of customer service functions are located within Florida, including Administration, Member Services, Claims, Provider Relations and Marketing Departments. FHCP will be contracting with Southwest Florida Physician s Association, Inc., doing business as Community Health Partners in Collier County to provide a comprehensive provider network to provide covered services to Healthy Kids enrollees in Collier County. 98% percent of the total contract will be performed in Florida. FHCP will be contracting with Envision RX Options for pharmacy benefits administration which is estimated to be the remaining 2% of the total contract. However, all pharmacy dispensing will be done in Florida. ACCREDITATION In 2012, FHCP received the highest accreditation status of Excellence in service and clinical quality from the National Committee for Quality Assurance (NCQA). Certification of such is attached. For contracting and utilization management, our partner, Community Health Partners, is accredited by URAC for Case Management and Call Center Services. Florida Health Care Plans, Inc. has been accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) since FHCP was the second HMO in the US, and the first in the state of Florida to be accredited. Recently, due to changes in the JCAHO policy, JCAHO no longer accredits staff models or other health plans. Therefore, it was necessary for FHCP to become accredited by an agency recognized by the Agency for Health Care Administration. Florida Health Care Plans
21 BENEFITS & COST SHARING Benefits Package: FHCP covers all benefits in accordance with the requirements of the Healthy Kids Program. There have been no changes to the existing Healthy Kids benefits package currently provided by FHCP. FHCP has developed a separate benefit plan to reflect $0 copayments to meet the requirements that certain Enrollees may be prohibited from participation in cost sharing (if costs exceed 5% of family income or if an American Indian or Alaska Native Enrollee). Coordination of Benefits: Under certain circumstances, payment for services which are covered benefits of the Healthy Kids Program is the responsibility of another party. These circumstances are stated in the Healthy Kids Handbook.
22 MEMBER SERVICES Member Education: Initial Enrollment and Re-enrollment: Member materials are mailed upon initial enrollment and re-enrollment to every Healthy Kid. The following materials are included in every initial enrollment packet: A bright colored notice in Spanish indicating that all materials are available in Spanish upon request, along with a telephone number to use to obtain same. Welcome letter indicating effective date, Group Number, Group Name. The letter also provides information about the use of identification cards and provides contact information for any questions the new Healthy Kids member may have. Information is also provided about FHCP and how to use their Healthy Kids benefits. Identification Card for each child. Member Handbook Provider Directory FHCP Website: Healthy Kids members are provided with the website address for FHCP, The website contains copies of the Healthy Kids Handbook, Provider Directory, up-to-date news regarding FHCP and services available to members. Healthy Kids can ask questions regarding benefits, services or other issues via links from this site. Health Education: Based on various risk factors, Healthy Kids are included in many FHCP Health Education Initiatives such as our pediatric weight management initiative (Move Right-Eat Right Program); diabetic education program, asthma management, behavioral health and other disease specific education programs. Ongoing Education: Healthy Kids are included in FHCP Member Newsletters which are published quarterly. Newsletters provide information regarding changes in FHCP participating providers, information about special programs, education of various medical topics, etc. Rev. 10/2012
23 Member Access to Services: Members will access non-emergency services through a Medical Home model by being automatically assigned a primary care provider (PCP) to provide and coordinate their care. The PCP will make arrangements for specialty services as needed. Members are encouraged to contact their PCP first for urgent care Monday Friday, but coverage is also provided by FHCP for services at various urgent care centers and emergency departments within the service area. Members are provided a Provider Directory upon enrollment which lists urgent care and emergency providers within the service area. Information is also provided regarding participating pharmacies, outpatient laboratories, hospitals, specialists, etc. Members with benefit or access inquiries may contact CHP or FHCP s Member Services Department. Contact with Member Services can be either via telephone, walk-in, , or regular mail. There are six representatives and six counselors in the Department. All are equipped with a current Healthy Kids Member Handbook and have the capability to access the computer system for an immediate reference to the Health Kids Plan and the corresponding benefits package. All twelve Member Services personnel are trained and able to assist with any benefit or access question presented by a Healthy Kid Member. A FHCP Call Center is also available to members twenty-four hours a day, seven days per week to answer questions regarding benefits, provider access and PCP assignment. Hours of Operation: The FHCP Member Services Department has the following hours of operation: Direct telephone access: Monday Friday, 8 a.m. to 5 p.m. Dedicated telephone number: (386) or toll free: After hours call center evening, nights, weekends: (386) A dedicated hearing impaired line: (386) For Deaf or Hard of Hearing Services: Calls may be made through the Florida Relay Center by dialing or using the toll free access number: /7 Nurse Advice Line: Bilingual Services: FHCP employs several Spanish speaking Member Service Representatives as well as contracts with World Wide Interpreters to provide bilingual services to our members. Rev. 10/2012
24 Non-English Materials: FHCP provides some member Education materials in Spanish as well as English. New enrollees are informed in Spanish of the availability of these materials and how to go about requesting them. Members may also contact a bi-lingual Member Service Representative to obtain copies of materials. Rev. 10/2012
25 Referral Process PCP s will refer Healthy Kids Enrollees to participating specialists within Collier County. CHP will perform prior review and approval for specialty care by these participating providers. Non-emergent services provided outside the designated network, or by non-network providers will be prospectively reviewed by Community Health Partners (CHP) Case Management staff. The CHP Utilization Management Program includes prospective, concurrent and retrospective review of health care services. Emergent and urgent care provided outside the service area or primary provider network will receive concurrent or retrospective review. The Utilization Management Program includes the following aspects: Precertification of all non emergent inpatient admissions Precertification of selected outpatient services Concurrent review of inpatient services Precertification of out of network services Retrospective review of emergent and urgent admissions Identification of potential high dollar/complex cases which would benefit from Medical Case Management Where Precertification is required but not feasible, retrospective review will be conducted. The CHP clinical staff is directly responsible for accomplishing the activities of utilization management through providers who are affiliated with an approved physician network. Review Criteria Procedure: It is the policy of Community Health Partners to use nationally recognized review criteria that promotes cost-effective quality health care to members. Community Health Partners Utilization Management Program uses InterQual Criteria. The continued use of the nationally recognized review criteria is reviewed and approved by the Utilization Management Committee at least every two years. The criteria used are communicated to the providers through the Provider Portal and periodic written communications. Medical Consultants may be used by Community Health Partner s Medical Director for advice on specialty or complex issues. Consultants
26 are Board eligible; with their active practices within the community, and who are recognized in their field. They may represent the areas of academia, research and/or clinical medicine. Precertification Process: Review determinations will be conducted within two (2) business days of receipt of the necessary information on a proposed admission or service requiring a review determination. Precertification of Non-Emergent Inpatient Admissions All planned Hospital and Skilled Nursing Facility admissions must be precertified, Case review, to determine medical necessity, will be performed by the Medical Services Department. The decision to approve or deny the admission is based on information submitted by the enrollee s primary physician using a designated Precertification form attached to any additional information to be reviewed and considered. Precertification of Select Outpatient/Facility Based Services There are two aspects of the precertification review. A procedure may require review for medical appropriateness and/or to verify the services will be performed at a network facility. Selected services require precertification. The list of services requiring precertification may be modified based on the specific needs of the individual clients. If a decision to deny services (medical necessity or benefit) has been rendered by CHP or FHCP, the Referring Provider and the patient will be notified in writing, including their appeal rights. Appeal processes are in place to allow for review of appealed determinations by licensed physicians of similar specialty related to the request. Timeframes for review are established and monitored on a continuous basis. CHP Personnel are available twenty-four hours per day, 7 days per week to answer any questions regarding the referral process and to assist in making arrangements for covered services. Second Opinions: FHCP recognizes each member s right to a second opinion in any instance in which the patient disputes the organization of the physician s opinion of the reasonableness or necessity of medical/surgical procedures or is subject to a serious injury or illness. Requests for second opinions are reviewed and approved by CHP. FHCP covers approved second opinions within CHP s network in full.
27 Medical Home Florida Health Care Plan, Inc. (FHCP) will work with Community Health Partners (CHP) to match eligible Healthy Kids with their current Primary Care Physician (PCP). For new enrollees, each Healthy Kid will be provided with a list of available Primary Care Physicians. Each Healthy Kid member will be assigned by FHCP a PCP. Members are notified by mail of every assignment, and provided with information regarding their PCP s office location, telephone, and hours of operation. The use of a PCP allows each member to receive care that is managed and coordinated by a personal physician. Through the use of information technology for care coordination, a vast specialty network, disease management and education with an emphasis on Quality Improvement, FHCP provides a medical home to all Healthy Kids members. Members will also be given the opportunity to call and select another provider if they are not happy with the assignment by contacting FHCP s Member Services Department via phone to make their selection. Call Center personnel are also available after hours to assist with this process. Changes are effective the first of the month following the change request. Members should contact FHCP s Member Services Department to request the change. Changes to Provider Network: PCP Changes When a PCP leaves FHCP s network, FHCP will re-assign the PCP s members to another participating PCP. At least thirty days prior to a provider s termination of participation in FHCP s HMO Network, the Provider Access Coordinator (PAC) notifies each member in writing of their newly assigned PCP. Members are also provided with the Member Services telephone number to answer any questions they may have regarding assignment of a new PCP.
28 A written confirmation of the new PCP assignment is mailed to each member giving the new provider s address, telephone number, and hours. Members are encouraged to call and establish a relationship with their new PCP. Members can change PCP s effective the first day of each month. There is no limit as to the number of PCP changes per enrollee. Specialty Provider Changes Healthy Kids under active treatment with a provider who is leaving the network are advised of same in writing at least 30 days prior to such a change. Patients are provided with information regarding other participating providers of like specialty who are available within FHCP s network. Members are asked to select an alternative provider. CHP and FHCP Provider Relations staffs coordinate the transfer of medical records from the old to the new specialist to assure continuity of care and appropriate access to services.
29 Grievance & Resolution Process FHCP has a grievance and appeal procedure, which complies with applicable State and Federal law ( The Grievance Procedure ). FHCP will try to resolve any problems that may be encountered over the telephone, but sometimes, additional steps are necessary. In these cases, FHCP has a Grievance Procedure available that provides channels for Members, or a provider acting on a Member s behalf, to voice concerns and have them reviewed and addressed at several levels within the organization. There are situations when Members have questions or concerns about their care or are dissatisfied with their Health Plan services. The vast majority of Member concerns are received and handled verbally. They may be expressed verbally at the time of the incident or a subsequent telephone call. Such inquiries can be handled in a timely manner by the FHCP Member Service Department. The FHCP Member Services Department manages the complaint/grievance resolution process including the maintenance of related records. Rev