Manual Purpose and Introduction


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July 1, 2016






CONNECTICUT PROVIDER MANUAL

July 1, 2016


Contents



Introduction and Guide to Manual

Purpose and Introduction

Information Sources
Legal and Administrative Requirements Overview

Insurance Requirements

Dispute Resolution and Arbitration

Misrouted Protected Health Information (PHI)

Risk Adjustments
Directory of Services

Secure E-Mail

Network Update and Network eUpdate Services

Quick Reference Guides

Who is Here for You?

The BlueCard® Program

Federal Employee Program
Provider Websites

Anthem.com

Anthem Online Provider Services (AOPS)

Availity Multi-Payer Portal
Eligibility
Member Identification Cards
Claims Submission

Electronic Data Interchange (EDI) Overview

National Provider Identifier (NPI)

National Uniform Billing Committee –UB04 Data Specifications Manual

NUCC CMS-1500 Reference Instruction Manual

MD-Online Web-Based Electronic Claim Submission Services

Paper Claim Submission

Mailing Addresses for Paper Claims and other Submissions


Ancillary Claim Filing

Commercial Plans Overpayment Recovery Process

HCPCS and CPT Code Requirements

Claim Filing Tips

Timely Filing Limits

Balance Billing

Frequency codes and Type of Bill on UB04’s

Urgent Care Step Down Process

Facility Charge Update during an Inpatient Stay

Emergency Room Services with Next Day Admission

Emergency Room Billing Guidelines

CMS Hospital Acquired Conditions (“HAC”)

Preventable Adverse Events (“PAE”) Policy
Reimbursement and Billing Policies

Medical Policies and Clinical Utilization Management (UM) Guidelines




Utilization Management

Utilization Management Program

Pre-Service Review and Continued Stay Review

Medical Policies and Clinical UM Guidelines

On-Site Review

Retrospective Utilization Management

Failure to Comply with Utilization Management Program

Case Management

Utilization Statistics Information

Electronic Data Exchange
Reversals

Peer-To-Peer Review Process

Quality of Care Incident

Audits/Records Requests

UM Definitions

MCG (formerly known as Milliman Care Guidelines®)

Prior Authorizatiion Guidelines

Responsibility for Prior Authorization

Balance Billing for Services Considered Not Medically Necessary

Emergency Admission Authorization

Urgent Care

Behavioral Health/Substance Abuse

Mental Health Parity Legislation

UM Decisions – Appropriateness of Care and Services
Physician/Provider Participation Requirements
Participating Physician, Provider and Group Agreements

Participation Confirmation and Effective Dates

Defining Solo vs. Group Practices

Moving To a New Group Practice

Notifying Covered Individuals of Participation Status

Open Practice

Adding New Providers to Group Practices

Participation through a Provider Sponsored Organization

Joining Our Network

Notification of Changes

Physician/Provider HMO Access Goals and Calendar Requirements

Calendar Access Requirements

After Hours Coverage

24/7 Coverage Requirements for Par Providers

Provider Self/Family Treatment

Hospitalist Programs

Locum Tenens

Provider Termination Without Cause

Continuation of Care
Credentialing

Credentialing Scope

Credentials Committee

Nondiscrimination Policy

Initial Credentialing

Recredentialing

Health Delivery Organizations

Ongoing Sanction Monitoring

Appeals Process

Reporting Requirements
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