Table of Contents 2010 Gateway Provider Manual

Quick Reference

• Important Phone Numbers
• Important Addresses
• Mental Health/Substance Abuse Contact Information

Introduction

• About This Manual
• Overview of Gateway Health Plan
  • History
  • Mission
  • Prospective Care Management
  • Gateway Lines of Business
  • Membership/Network
  • Quality Accomplishments
  • Continuing Quality Care
  • Wellness and Disease Management
  • Healthcare Disparities
  • Community Involvement
  • Awards and Honors
• How Does Gateway Work?
  • Gateway’s Practitioner Network
  • Gateway Provider Relations Role
  • Primary Care Practitioner’s Role
• Department of Public Welfare Master Provider Index Number
• Contracts/No Gag Clause
• Quality Improvement
  • Purpose of the Quality Improvement/Utilization Management Program
  • Goal of the Quality Improvement/Utilization Management Program
  • Objective of the Quality Improvement/Utilization Management Program
  • Scope of the Quality Improvement/Utilization Management Program
  • Quality Improvement Manual
• Patient Safety
• Living Will Declaration
  • Advance Directives
• Member Outreach

Member

• The Enrollment Process
• Medical Assistance ACCESS Cards
• Determining Eligibility Through Gateway
• Member Identification Number?
• Verification of Date?
• Primary Care Practitioner’s Role in Determining Eligibility
• Addition of Newborns
• Member Benefit Packages and Copayments
• Exception for Service Limits
• Benefits
  • Medical Benefits
  • Medical Assistance Benefits Package
  • Medial Assistance Categories
  • Covered Benefits
  • Drugs Covered Under the Full Benefit
  • Gateway Over-The-Counter Formulary
  • Audiology and Speech Therapy
  • Chiropractic/Podiatric Services
  • Dental
  • Durable Medical Equipment, Orthotics and Prosthetics
  • Dialysis
  • Family Planning
  • Home-Based Services
  • Hospice Services
  • Mental Health/Substance Abuse Services
  • Skilled Nursing Facility
  • Prescription Drug and Over-the-Counter Benefits
  • Drugs Covered Under Full Benefits
  • Gateway Over-The-Counter Formulary
  • Medical Supplies
  • Rehabilitation
  • Vision
• Members’ Rights and Responsibilities

Coverage Arrangements

Laboratory Services

• Primary Care and OB/GYN Practitioner
• Specialty Care Practitioner
• Preadmission Laboratory Testing
• STAT Laboratory
• Blood Lead Screening
• Unusual Circumstances

Primary Care Practitioner

• Gateway to Physician Excellence^SM
• Reporting
• Primary Care Practice Dashboard Reports
• Encounters
  • Accurate Submission of Encounter Data
• Capitation
• Capitation Reports
• Vaccines For Children
• Addition of Newborns
• Processing PCP Change Requests
• Transfer of Non-Compliant Members
• Transfer of Medical Records
• Coordination of Behavioral Health and Physical Health Services
• Appointment Standards

Growing Up With Gateway^SM

• General Information
• Service Delivery Requirements Under HealthChoices
• Growing Up With Gateway^SM Unit
• Claim Filing
• Authorization
• Required Screens and Tests
• Detail of Screens and Tests
  • Family and Medical History
  • Height
  • Weight
  • Head Circumference
  • Physical Growth/Nutritional Status
  • Blood Pressure
  • Dental Screening
  • Vision Testing
  • Hearing Screening
  • Developmental/Behavior Appraisal
  • Structured Screening for Developmental Delays
  • Tanner Score
  • Standards for Genitalia Maturity Ratings for Males
  • Breast Development Standards for Females
  • Pubic Hair Development Standards for Males and Females
  • Anemia Screening
  • Sickle Cell
  • Tuberculin Test
  • Albumin and Sugar
  • Blood Lead Level Screening
  • Environmental Investigation
  • Sexually Transmitted Disease Screening and Pap Tests
  • Bacteriuria
  • Immunizations

Specialty Care Practitioner

• Verifying Eligibility
• Specialty Care Office Visit
• Referrals
• Reimbursement
• Emergency Services
• Specialists Functioning as Primary Care Practitioners
• Appointment Standards

OB/GYN Services

• General Information
• Obstetrical Needs Assessment Form
• OB/GYN Referrals
• Diagnostic Testing
• Medical Assistance Sterilization/Hysterectomy Consent Forms
• Newborns
• Universal OB Access Program Follow-up Requirements
• Coding
• Family Planning Guidelines
• Appointment Standards

Policies and Procedures

• Department of Public Welfare Policy Changes
• Practitioner Education and Sanctioning
• Practitioner Due Process
• TITLE VI of the Civil Rights Act of 1964
• Access and Interpretters for Disabled Members
• Confidentiality
• Fraud and Abuse
• Environmental Assessment Standards
  • Environmental Assessment Standards

Hospital Services

• Inpatient Admissions
• Reimbursement
• Hospital Transfer Policy
• Outpatient Surgery Procedures
• Emergency Room
• Ambulance Services

Referrals and Authorizations

• General Information
• Referral
  • Voice Activated Referral-DIVA
  • Paper Referrals
  • Out-of-Plan Referrals
  • Referrals for 2nd Surgical Opinions
  • Specialty Care Practitioners
  • Renal Dialysis Services
  • Audiology and Speech Therapy
  • Self-Referral
• Authorizations
  • Guidelines/Criteria
  • Review of Authorized Services
  • Chiropractic Services
  • Durable Medical Equipment
  • Skilled Nursing Facility
  • Physical/Occupational/Speech Therapy
  • Rehabilitation
  • Home Health Care
  • Home Infusion
  • Hospice Services
  • Pharmacy Services
• New Technology

Claims and Billing

• CLAIMS
  • Member Billing Policy
  • Claims
  • General Information
  • Timely Filing
  • Electronic Claims Submission
  • Electronic Remittance Advice
  • Claims Review Process
  • Administrative Claims Review
  • Medical Claims Review
  • Coordination of Benefits
  • Primary Care Services
  • Specialty/Fee-For-Service Procedures
  • Medicare
  • Nursing Care
  • Extended Nursing Sibling Case Billing
  • Subrogation
  • Claim Coding Software
• BILLING
  • Billing Procedures
  • Primary Care Services
  • EPSDT Services
  • CMS-1500 Format
  • UB-92 Format
  • Electronic 837P Format
  • Obstetrical Care Services
  • Surgical Procedure Services
  • Anesthesia Services
  • Hospital Services
  • Home Infusion
  • Skilled Nursing Facility
  • UB-92 Data Elements for Submission of Claims
  • CMS Data Elements for Submission of Claims

Appeals, Complaints and Grievances

• Provider Appeals
  • First Level Appeal
  • Second Level Appeal
• Member Complaint Process
  • External Complaint Review
  • Expedited Complaint
• Member Grievance
  • Member Grievance - The First Level
  • Member Grievance - The Second Level
  • Expedited Grievances (Internal)
  • Expedited Grievances (External)
  • External Grievances (Standard)
  • DPW Fair Hearing
  • Provider Initiated Member Grievances
  • Provider Responsibilities When Initiating Member Appeals
  • Provider Initiated Member Grievances: The First Level
  • Provider Initiated Member Grievances: The Second Level
  • Expedited Grievances (Internal)
  • Expedited Grievances (External)
  • External Grievances (Standard)
  • DPW Fair Hearing

Case Management

• Disease Management Programs
  • MOM Matters^® Program
  • Asthma Program
  • Diabetes Program
  • Help Your Heart Cardiac Program
• Special Needs Care Management
  • General Information
  • Criteria for Referrals to the Special Needs Case Management Unit
• Complex Case Management
• Chronic Case Management

Credentialing

• Purpose of Credentialing
• Who is Credentialed?
• Credentialing Standards
• Ongoing and Performance Monitoring
• Military Leave Process
• Denial and Termination
• Delegated Credentialing

Forms & Reference Materials