Provider Manual - Table of Contents

Quick Reference

• Important Phone Numbers
• Important Addresses

Introduction

• About This Manual
• Overview of Gateway Health Plan Medicare Assured^SM
  • Background of Gateway Health Plan^®
  • Gateway Health Plan^® Mission Statement
  • Benefits of Gateway Health Plan^®
• How Does Gateway Work?
  • Gateway's Medicare Assured^® Practitioner Network
  • Primary Care Practitioner's Role
• Outpatient Mental Health Providers
• Fraud and Abuse
• Contracts/No Gag Clause
• Quality Improvement
  • Purpose of the Quality Improvement/Utilization Management Program
  • Goal of the Quality Improvement/Utilization Management Program
  • Objectives 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/Disenrollment Process
• Member ID Cards
• Determining Eligibility Through Gateway Health Plan Medicare Assured^SM
• Primary Care Practitioner's Role in Determining Eligibility
• Benefits
  • Medical Benefits
  • Pennsylvania Benefits
  • Ohio Benefits
  • Excluded Services
  • Prescription Drug Benefits
  • Drugs Covered
  • Over-The-Counter Drug Benefit
  • Self-Referred Services
• Members' Rights and Responsibilities

Coverage Arrangements

Primary Care Practitioner

• Encounters
  • Accurate Submission of Encounter Data
• Transfer of Non-Compliant Members
• Transfer of Medical Records
• Appointment Standards

Specialty Care Practitioner

• Verifying Eligibility
• Referrals
• Emergency Services
• Appointment Standards

OB/GYN Services

• General Information
• Obstetrical Needs Assessment Form
• Diagnostic Testing
• Appointment Standards

Policies and Procedures

• Policy Changes
• Practitioner Education and Sanctioning
• Practitioner Due Process
• TITLE VI of the Civil Rights Act of 1964
• Translators During Clinical Visits
• Confidentiality
• Provider Changes

Hospital Services

• Inpatient Admissions
• Emergency Room
• Ambulance Services

Referrals and Authorizations

• Referals
  • General Information
  • Primary Care Practitioner
  • Specialty Care Practitioners
  • Out-of-Plan Referrals
  • Referrals for Second Opinions
  • Self-Referral
• Authorizations
  • Process for Requesting Prior Authorizations
  • Speech Therapy and Hearing Services
  • Physical and Occupational Therapy
  • Durable Medical Equipment
  • Services Requiring Authorization
  • Prior Authorization Decision Timeframes and Notification
  • Home Infusion
  • Pharmacy Services
• New Technology

Claims and Billing

• Claims
  • General Information
  • Timely Filing
  • Electronic Claims Submission
  • Requirements for Submitting Claims to Gateway Through Emdeon
  • Claims Review Process
  • Administrative Claims Review
  • Coordination of Benefits
  • Claim Coding Software
• Billing
  • Billing Procedures
  • Family Planning Services
  • Surgical Procedure Services
  • Hospital Services
  • UB-04 Data Elements for Submission of Claims
  • CMS-1500 (08-05) Data Elements for Submission of Claims

Adjustment Codes

• Rejection/Denial Codes
• Remark Codes
• Adjusted/Appealed/Corrected Codes
• Claim Line Changes

Appeals and Grievances

• Introduction
• What are appeals and grievances?
• Acting as an Appointed Representative
• Categories of Complaints
• Appeals Regarding Hospital Discharge
• Skilled Nursing Facility (SNF), Home Health (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) services
• Quality Improvement Organization (QIO) Review
• Appeals for Coverage of Other Medical Services
• IRE Review
• Administrative Law Judge Review
• Medicare Appeals Council
• Federal Court
• Appeals for coverage of Part D Drugs
• Member Appeals
• Independent Review Entity (IRE)
• Administrative Law Judge (ALJ) Review
• Departmental Appeal Review
• Federal Court
• Member Grievances
  • First Level Grievance
  • Second Level Grievance
  • Expedited Grievances
• Quality Improvement Organization Review
  • How to file a quality of care complaint with the QIO
• Formal Provider Appeals
  • First Level Appeal (The Informal Dispute Resolution Process)
  • Second Level Appeal (The Informal Dispute Resolution Process)

Preventive Health, Disease and Case Management

• Preventive Health Program
• Disease Management Programs
  • MOM Matters^® Program
  • Asthma Program
  • Diabetes Program
  • Help Your Heart Cardiac Program
• Case Management
  • General Information
  • Criteria for Referrals to the Case Management Department

Credentialing

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