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Bravo! Marine Heating System Bravo User's Manual

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1. 67 ADULT PREVENTION AND SCREENING GUIDELINES 71 Dear Valued Provider and Staff I would like to extend a warm welcome and thank you for participating with Bravo Health s network of Participating Providers We value our relationship with all of our Providers and are committed to working with you to meet the needs of your Bravo Health patients For more than ten years we have been focusing on serving the healthcare needs of people with Medicare We will continue to serve the Medicare market and in doing so will continue to seek ways to bring the benefits and services our Members need to live life well Thank you for continued participation with Bravo Health Sincerely Pat Feyen Senior Vice President and Executive Director Bravo Health Texas Inc 99LL TZE OTZ ISv8 vSv 1L uojsnoH 81v LLS S16 osed JA SNOLLV TAYA THGIAO Id ILOVINOO oruojuy ues AYVI1IAdOYAd Y TVILNACIANOD AAAINOAA STVAAHAHA ON OWH SSHOOV NAdO NV SI HLIVAaH OAV IH S6SS T8 LL8 suonezuougny q Weg pue suond oxq Ae nulo y LLO UJEDUYOAB IQ MMM j QUIJUO JE NULIO s uj e9H OARIG MALA EUI NOX a LAVd AYVINANY1OA TS10 1 6 008 euouq Suruue q oS1eqosiq fueuroSeue A 918 LO uo siog 19 Y VPEI L9V 998 XeJ S 9
2. 15 PROVIDER amp ALLIED HEALTH PRACTITIONERS CREDENTIALING CRITERIA 15 Required Information eee eet ree eie e Re eR e e e ORT EE ie E IN I eve eere aed 15 Credentials Criteria secet e i e e e te eee eite it E dee AE Ede da 16 Additional Requirements nete ee eie Ue ae ce deir feeit eee iste e niet vie eee s 19 Initial Credentialing Office Site RevIewsS n eene eene nennen trennen nein VOR FES RR Ka nennen nennen nennen 19 Provider Re Credenti ling a et teer diia 20 Prac tionet s Riglits 4 A ce ite eae idus ee nes 20 PROVIDERS DESIGNATED AS PRIMARY CARE PHYSICIAN S 21 CHANGES IN ADMINISTRATIVE MEDICAL AND OR REIMBURSEMENT POLICIES 21 NOTIFICATION REQUIREMENTS FOR PROVIDERS 21 CLOSING PA TIENT PANELS eres cave tesi seta u eeu PS aea eve epa sh Fee ehe eren e Reeve ev oe PUER Tous dese ses Inca e ha as ene oe UR UN vne aeo Vera a eV onn 22 PROVIDER ACCESS AND AVAILABILITY STANDARDS 22 CLAIMS SUBMISSION o 23 Professional Claims e CRA Ae hen Deane CE IRIS 23 A gu RR ER Rote e
3. Accuneb Cellcept Fosamax 40mg Myobloc Rebetol Testoderm Actimmune Cerezyme Inj Foscarnet Inj Nebupent Rebetron Testred Actiq Ciprofloxacin Inj Gabitril Neoral Rebif Thalomid Actonel 30mg Cis Platin Inj Gammar Nicotine Patch Regranex Tobi Acyclovir inj Cladribine Inj Gammimune N Nicotrol Relenza Tracleer Adderall Adderrall Nitroglycerin XR Cognex Gangiclovir Inj Inj Remicaid Triseonx Inj Alupent Nebulizer Concerta Genotropin Norditropin Reminyl Ultracet Amevive Copaxone Gleevec Ofloxacin Inj Restatis Ultram Amphotericin B Inj Copegus Halotestin Orthoclone Retin A Venoglobulin Anabolic Steroids Delatestryl Hepsera Oxandrin Ribavirin Vfend Anadrol Depo Testosterone Humatrope Oxycodone SR Ritalin SR LA Vfend Inj Androgel Desoxyn Humira Panretin Roferon Vidaza Anzemet Dexedrine Infergen Pegasys Saizen Vitraset Apokyn Diflucan 150mg Tab Intron A Peg Intron Sandimmune Winstrol Arava Dobutamine Inj Iressa Penlac Sandoglobulin Xifaxin Atrovent Amp Dopamine Inj Kepivance Pentamidine Inj Sensipar Xolair Avastin Doxycycline Inj Kineret Prograf Skelid 200mg Xoponex Avelox Inj DuoNeb Kytril Prolastine Inj Somavert Zavesca Avonex Elidel Lotrenox Protonix Inj Stadol NS Zelnorm Balcofen Inj Emend Lunesta Protopic Straterra Zenapax BCG Vaccine Enbrel Metadate CD Protropin Symlin Zithromax Inj Methotrexate Betaseron Erbitux MTX Provigil Tamiflu Zofran Botox Farbazyme Inj Methylin ER Pulmicort Resp Tarceva Zyvox Brethine Amp Fludarabine Inj Metroni
4. Appointment Type Access Standard Emergency Within 6 hours of the referral Urgent Symptomatic Within 48 hours of the referral 22 Routine Within 4 weeks of the referral Availability Standards PCPs OB GYNs Behavioral Health Providers 1 Provider for every 500 Members 1 Provider for every 2500 1 Provider within 20 miles minutes to Members Member 1 Provider within 20 miles to 1 Provider within 20 miles to 1 Provider within 30 miles minutes to Member Member Member 1 Provider within 30 minutes to 1 Provider within 30 minutes to Member Member CLAIMS SUBMISSION While Bravo Health prefers electronic submission of claims both electronic and paper claims are accepted Please see quick reference guide for details page 3 Bravo Health pays Clean Claims according to contractual requirements and CMS guidelines A Clean Claim is defined as A claim for a Covered Service that has no defect or impropriety A defect or impropriety includes without limitation lack of data fields required by Bravo Health or substantiating documentation or a particular circumstance requiring special handling or treatment which prevents timely payment from being made on the claim The term Clean Claim shall not include a claim from a Provider that is under investigation for fraud or abuse regarding that claim The term shall be consistent with the Clean Claim definition set forth in applicable federal or state l
5. bravo Live life well HEALTH o 2008 Provider Manual Texas BH 0133 Revised January 2008 TABLE OF CONTENTS QUICK REFERENCE GUIDE ZL E Sup m 4 MEMBER INFORMATION Z L u eve ara eke eee aen ve Ease USE u aa Lure Pn eos Ee Loan e vea eo senken eese ere Uo eee eet aspa SSS RS ass 6 Member Eligibility zoe Ls eate O dr RR EUR 6 Eligibility VEAMOS E AE A E Cede epe ie bade EP ade HER E PORE e 6 Member Hold Hartmless 55 eot reete oet tti at dee ue rb e Utt dude et ttes 8 Member Confidentiality li cde ach sientes E e i in aduer d ep tete reri do 8 Member Rights and Responsibilities cccccceceesseessesscesseesecesecesecaeceaecssecseecaeeeneeaeeeeeseeeseeneeceaeceaecaaecaeecaeeeaeeeneeeeesereeereeeeees 9 Advance Medical Directives 4 ese esaet dede ve ier e en uie se t tee UR ndo ase Erud 13 Benetits and Services ia ated e te Quinetiam aret ec itin eda 13 PROVIDER INFORMATION 2 2 M emm 13 Role of the Primary Care Physician PCP cccccesssessesscesseeeecesecesecsnecseecseeeaeeeaeeaesseeeeeseeeeseceseseeeceaecaaecaaeeaeseaeeeseeeeeeerenaeees 13 Role of the Specialist Physician ect e dida 14 Communication between Providers n anaqman na n edet dpi e ie edet ded etienne ded 14 Provider Marketing Guidelines eee teet eiie e ee ie Te bee ede iet eee da 14 PROVIDER CREDENTIALING AND PARTICIPATION
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7. l A request may be pended in order for additional information to be obtained as requested In these cases the requesting Provider will be contacted by phone or facsimile within twenty four 24 hours by Bravo Health to obtain the required information If the addition al information is not received within 14 days Bravo Health will issue a determination based on the clinical information submitted Discharge Planning 54 Discharge Planning is a critical component of the process that begins with an assessment of the patient s potential discharge care needs to facilitate the transition from the acute setting to the next level of care It includes preparation of the patient and his her family for any discharge needs along with initiation and coordination of arrangements for placement and or services needed after acute care discharge Bravo Health s Utilization Staff will coordinate with the acute care discharge planning team to assist in establishing a safe and effective discharge plan The Bravo Health Utilization Review nurse will provide all needed discharge authorizations for services equipment and skilled needs Case Management Case Management is the focused arrangement of the sequence of services and resources necessary to respond to the patient s overall care requirements in catastrophic or complicated cases Case Management uses a team approach which includes the Primary Care Physician Specialist Home Health Agencies Social Workers
8. amp FAMILY COUNSELING PATIENT AND FAMILY x Nature of heart disease Drug Adherence Regimens EDUCATION AND Symptoms of worsening CHF What to do if symptoms occur COUNSELING a Mechanisms for complicated medical regimens Coping Presentation measures for further progression of the disease Accurate information concerning prognosis should be discussed in order for patients to make decisions and plans for the future Discuss the planning of advance directives with patients and family in the context of heart failure management LIFESTYLE Physical Activity Recreation leisure and work activity as tolerated CHANGES HABITS Exercise Establish a regular exercise program consistent with individual patient s capabilities and clinical status Program should be dynamic walking cycling not isometric to pervert or reserve physical including drug doses Sexual Activity Discuss sexual difficulties and coping mechanisms if they occur Smoking Cessation Emphasis on the importance of not smoking medications of financial assistance determine the willingness to stop smoking and strategies for smoking cessation should be tailored to each individual t Alcohol Usage Discourage alcohol use Sodium restriction Define and quantify the amount of salt that is allowed in the daily diet 3 grams or less Personal DIETARY MEASURES food preferences culture income and family support should be considered Management of Cachexia Management of Obesity Est
9. family and others as appropriate A collaborative approach is used to assist in meeting the health care needs and community service needs of the Member on a short or long term basis The Primary Care Physician s involvement in care of Members in case management is essential to support improved Member outcomes The Case Management program strives to deliver access to quality care in the most cost effective manner through appropriate utilization of all available health care resources Members that can be referred to Case Management include but are not limited to the following e Members discharged home from acute sub acute skilled settings with specific ambulatory sensitive diagnosis such as DM CHF angina without procedure and COPD e Members with frequent readmissions e Members in disease management programs to include but not limited to diagnosis of CHF or Diabetes Mellitus e Members enrolled in Special Needs Plans for Hypertension and Hyperlipidemia e Members receiving intensive level of home health care If you would like to refer a Bravo Health Member for Case Management services please call 1 888 454 0013 extension 336940 Skilled Nursing Care Bravo Health follows Medicare guidelines for skilled nursing care needs All Members will be reviewed and notified within two 2 days prior to the last covered approved day Only the Medical Director can deny skilled care based on medical necessity If additional skilled services are denie
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11. 27 2007 61 OUTPATIENT MANAGEMENT OF CORONARY AND OTHER VASCULAR DISEASE Start aspirin 75 to 162 mg d and continue indefinitely in all patients unless contraindicated Antiplatelet Agents Gastrointestinal side effects are dose dependent Since the benefits of aspirin have been measured at Anticoagulants doses as low as 81 mg enteric coated 81 mg tablets are reasonable and almost always tolerated For patients undergoing CABG aspirin should be started with in 48 hours after surgery to reduce saphenous vein graft closure Dosing regimens ranging from 100 to 325 mg d appear to be efficacious Doses higher than 162 mg d can be continued for up to 1 year Start and continue clopidogrel 75mg d in combination with aspirin for up to 12 months in patients after acute coronary syndrome or percutaneous coronary intervention with stent placement gt 1 month for bare metal stent gt 3 months for sirolimus eluting stent and gt 6 months for paclitaxel eluting stent Patients who have undergone percutaneous coronary intervention with stent placement should initially receive higher dose aspirin at 325mg d for 1 month for bare metal stent 3 months for sirolimus eluting stent and 6 months for paclitaxel eluting stent Manage Warfarin to international normalized ratio 2 0to 3 0 for paroxysmal or chronic atrial fibrillation or flutter and in post myocardial infarction patients when clinically indicated e g atrial fibrillation left v
12. AVA NON ZIS JO ILOK y SUIMOTIOJ 1e2K u1 Jo TE ZI Aq payrruuqns aq JSNU sispriao1g Suryediorjred uou JOJ SUTETI IV 1opu A YEOH Ie1u dq SU 93 WPO STU NUJGNS oseo d SOGNSA HITVSH TVLNSG OL LINENS 0T8 DINO 9u1 ut p pn out Ul SDAIIS STY 10 JUIVISSINQUIIA DWO NI GACNTONI 807 dno13 XIU 9889 SINO 9u1 0 SUTPIODIB poesunquiioJ SEM We SIU DINO LV dIVd 402 epoo dno13 xiu osto ojeudoudde su UJIM WEP JUQNsal 9sea3 d Jupe qeyal IM ue SI STUL DNO HLIM LINENS 902 S9poo SOGOH 91eudoudde y YIM JUJGNSAI ISPIA S3dOO O FAVOIGAW ONISN TIAA ZOL eureu pue poo 3994109 IY YIM 1JruIqns SIAVN XA HOLV LON SHOQ OAN 179 oseo d WUJ Jy uo pojsi JULU SNIP oY 10 PIJLA OU ST WP STU YIM pearuiqns Jagunu ON SUL S9poo VSV UJIM sueo HOO VSV OL GALNGANOO 1729 210313 Te WuIqns se q Surond JOJ 9poo VSV UB 0 D9349AUu02 SEA JOIAIVS SIU JOJ 2poo o1npoooJd Sul UOISTA SIAE T 0 wre sty HUJGNS oseo d NOISIA SIAVG OL LINENS 029 UOISTA SIAE T 0 wre sry HNUJGNS oseo d NOISIA SIAVA OL LINENS 029 9jou OAT eJOdO YIM we sry JUQNSII 9sea d SALON GALLVaadO LININS 619 yuoo sex L s poS UO0SeIY 1yu urysnf fpv Wep NATIONAL PROVIDER IDENTIFIER NPI Why the National Provider Identifier Providers utilize in many situations a different provider identification number for every health plan they are submitting claims to The Health Insurance Portability and Accountability Act of 1996 HIPAA mandated that the Secre
13. Apomorphine hcl inj J7639 Dornase alpha inhal J9211 Idarubicin hcl J2794 Risperidone long solud injection acting J0365 Aprotonin 10 000 kiu J9001 Doxorubicin hcl Q4080 Iloprost inhalation J9310 Rituximab cancer liposome inj solution treatment J9017 Arsenic trioxide J0600 Edetate calcium J1566 Immune globulin J2820 Sargramostim disodium inj powder injection J9020 Asparaginase injection J0886 Epoetin alfa esrd on J1745 Infliximab injection J2941 Somatropin injection dialysis J0475 Baclofen 10 MG injection Q4081 Epoetin alfa for J9065 Inj cladribine per 1 J9320 Streptozocin ESRD on dialysis MG injection J0476 Baclofen intrathecal trial J0885 Epoetin alfa non J0835 Inj cosyntropin per J3030 Sumatriptan esrd 0 25 MG succinate 6 MG J0480 Basiliximab J1325 Epoprostenol J1650 Inj enoxaparin Q4084 Synvisc inj injection sodium J9031 Beg live intravesical vac J1327 Eptifibatide injection J9245 Inj melphalan J7525 Tacrolimus injection hydrochl 50 MG J9035 Bevacizumab injection J1438 Etanercept injection J2260 Inj milrinone lactate J7507 Tacrolimus oral per 1 5 MG MG J0583 Bivalirudin J1430 Ethanolamine oleate J2850 Inj secretin synthetic J3100 Tenecteplase 100 mg human injection J9040 Bleomycin sulfate J9181 Etoposide 10 MG inj J3305 Inj trimetrexate Q2017 Teniposide 50 mg injection glucoronate J9041 Bortezomib injection J9182 Etoposide 100 MG J7187 Inj Vonwillebrand J9340 Thiotepa injection inj factor IU J0585 Botulinum
14. Develop Management and Treatment Plan Provide baseline information to monitor effects of treatment Establish baseline NYHA classification INITIAL EVALUATION OF Complete History and Physical Examination z Clinical Testing HEART FAILURE Chest X Ray 12 lead Electrocardiogram DIAGNOSTIC TESTING Assessment of Ventricular Function Transthoracic Doppler 2 D Echocardiography Radionuclide ventriculography Evaluation testing for ischemia Stress Nuclear Test OR Stress Echocardiography OR Cardiac Catheterization Complete Blood Count Urinalysis Fasting Lipid Panel Cholesterol Triglyceride HDL Cholesterol LDL and LDL HDL Ratio a Blood Chemistry Electrolytes BUN creatinine B Glucose Liver function test and TSH level ADDITIONAL DIAGNOSTIC Consider additional diagnostic testing for evaluation of other cardiac or non cardiac related causes in the absence of ischemia TESTING or Valvular Heart Disease Serum Iron and Ferritin Endomyocardial Biopsy Phosphorus Magnesium Calcium and Albumin levels SPECIALTY REFERRALS Cardiac Educator As indicated Nutritional Counseling As indicated Cardiology Consult Consider consultation during the initial evaluation and anytime during the ongoing management of CHF as appropriate Home Health Care Consider home health care for outpatient monitoring Cardiac Rehabilitation Programs Consider rehabilitation programs to maximize functional capacity MANAGEMENT PLAN EDUCATION
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16. activities through the QIC e Monitor and evaluate the quality of clinical healthcare service quality process improvement Member and Provider satisfaction complaint grievance resolution and Provider network credentialing re credentialing e Monitor and evaluate Provider practice patterns develop improvement plans as needed and review performance to assess whether improvements have occurred e Promote and monitor preventive health services e Identify educational needs of Members Providers customers and staff and develop resources to meet those needs e Maintain accurate data to ensure QI Program integrity e Ensure compliance with applicable accreditation and regulatory requirements e Conduct an annual review of all QI actions assessing the improvement achieved through the initiatives of the QI Work Plan and revising the Work Plan when necessary e Document and share improvements in healthcare delivery as a result of QI initiatives B Quality Improvement Committee QIC The QIC is responsible for the overall design and implementation of quality improvement activities for the organization as well as for the oversight of QI activities carried out by other committees and reports these activities to the Board of Directors The QIC ensures that all quality improvement tasks and functions are a reflection of Membership involvement the participation of Participating Providers and the compliance with all applicable regulatory an
17. breach of the terms of this confidentiality requirement will cause immediate and irreparable harm to the disclosing party As such in addition to any other rights or remedies available at law or in equity the disclosing party is entitled to injunctive relief to restrain or enjoin such breach without the need to prove actual damages Within sixty 60 days of the date of the decision and award of the arbitrators the Parties agree to return and or destroy and provide certification of destruction of any confidential materials provided by the other party during arbitration process The arbitrators will also return and or destroy and provide certification of destruction of any confidential materials provided to them by the Parties during the arbitration process The Parties and their respective counsel are permitted to keep their own confidential materials along with any attorney client privileged communications or attorney work products Fees and Transcript of Arbitration The fees and expenses of each arbitrator and all other costs and expenses incurred in the arbitration including reasonable attorneys fees shall become due as specified in the arbitration award The arbitration award shall not include any punitive exemplary or other non economic damage component A full and complete record and transcript of the arbitration proceeding shall be maintained If either Party desires a copy of the record and transcript that Party shall bear the fees and
18. call Member Services The right to get information about their health care coverage and cost The Evidence of Coverage tells Members what medical services are covered and what they have to pay If they need more information they should be directed to call Member Services Members have the right to an explanation from Bravo Health about any bills they may get for services not covered by Bravo Health Bravo Health must tell Members in writing why Bravo Health will not pay for or allow them to get a service and how they can file an appeal to ask Bravo Health to change this decision Staff should inform Members on how to file an appeal if asked and should direct Members to review their Evidence of Coverage for more information about filing an appeal The right to get information about Bravo Health plan Providers drug coverage and costs Members have the right to get information from us about our plan and operations This includes information about our financial condition the services we provide about our health care Providers and their qualifications and about how Bravo Health compares to other health plans Members have the right to find out from us how we pay our doctors To get any of this information Members should be directed to call Member Services Members have the right to get information from us about their Part D prescription coverage This includes information about our financial condition and about our network pharmacies To get any of t
19. exceptions allowed or required by law such as release of health information to government agencies that are checking on quality of care The laws that protect Member privacy give them rights related to getting information and controlling how their health information is used Bravo Health is required to provide Members with a notice that tells them about these rights and explains how Bravo Health protects the privacy of their health information For example Members have the right to look at their medical records and to get copies of the records there may be a fee charged for making copies Members also have the right to ask plan Providers to make additions or corrections to their medical records if Members ask plan Providers to do this they will review Members request and figure out whether the changes are appropriate Members have the right to know how their health information has been given out and used for non routine purposes If Members have questions or concerns about privacy of their personal information and medical records they should be directed to call Member Services Bravo Health will release a Member s information including prescription drug event data to Medicare which may release it for research and other purposes that follow all applicable Federal statutes and regulations The right to see Participating Providers get covered services and get prescriptions filled within a reasonable period of time Members will get most
20. expenses for the record and transcript If both Parties desire a copy then such fees and expenses will be equally shared between the Parties Limitation of Other Proceedings Each Party agrees that it will not file nor will it cause any other individual or entity to file any suit motion and petition or otherwise commence any legal proceeding which must be submitted to arbitration pursuant to the Agreement Upon the entry of an order dismissing or staying any such action or proceeding in a court the Party that filed such action or proceeding shall promptly pay to the other Party the attorney s fees costs and expenses incurred by such other Party prior to the entry of such order TZ 09 988 1 Suruurdoq SAINJILIJ 9N010d09 S0 JOJ YSTI POSBOIOUI YUM UIWIOM JOJ SuruooJog c9 og ye Suruuidoq Suru 1os sunno y siso10doojsQ Jop o pu OG 938 uouioA 107 AJIA Jop o pue op 932 uouloA JOJ Z AIDA Kudesourur A poxouis 1949 SALU OYM SIpO SL S9 pose usw JO SuruooJ1og Aydeisouosenjn jeurwopqy e us inouy on1oy peuruopqy K I 9 X UOHnEUTUIEXO searg SIS Q aseg q 9s VSd siseq ose Aq ose Suru oos poer pes e qeous ded I BUIUDIIOS I9DUBD OJLJISOIJ OL 988 o dn SILOK 2934 AIOAD 1Se9 1V pue Wexd Mpd 93u uojure JA Kouonboaq 92ugu9jure A YNLIH K amp ouonboaq WILOH KJUO SIBIA KJUO so euroq SIeo QT ADAJ 19 5004 euoequdip snutjo L sop ISP OY o
21. he she can use a special form to give someone they trust the legal authority to make decisions for them if they ever become unable to make decisions for themselves Members also have the right to give their doctors written instructions about how they want them to handle their medical care if they become unable to make decisions for themselves The legal documents that Members can use to give their directions in advance in these situations are called advance directives There are different types of advance directives and different names for them Documents called living will and power of attorney for health care are examples of advance directives If Members decide that they want to have an advance directive there are several ways to get this type of legal form Members can get a form from their lawyer from a social worker from Bravo Health or from some office supply stores Members can sometimes get advance directive forms from organizations that give people information about Medicare Regardless of where they get this form keep in mind that it is a legal document Members should consider having a lawyer help them prepare it It is important to sign this form and keep a copy at home Members should give a copy of the form to their doctor and to the person they name on the form as the one to make decisions for them if they can t Members may want to give copies to close friends or family Members as well If Members know ahead of ti
22. hen heres oe RRO fedet te Bs eli NN aaah aos 24 Participating Provider Claim Reconsideration Process c ccecsesssessceesceecescescesecaecsaecsaecaaecaeecseceaeeseeeseeeaeeseeenseeneenaeenaeenaes 25 Claim Adjustment Reason Codes s i ate A ads 26 NATIONAL PROVIDERJDENTIFIER NDD ie doga cascade cach et ra a w eee eee te cenhonteecanscsecessvsdescusesahessesveseosdatesossesceteenesurs 31 HIERARCHICAL CONDITION CATEGORIES HCCOD 33 SAMPLE EXPLANATION OF BENEFITS EOB STATEMENT AND PAYMENT CHECLK 34 PRIOR AUTHORIZATION 35 General Rules sa aasan 35 Authorization Rules by Place of Service iii ibid ne e 36 Eum 36 Inpatientu 37 Outpatient I IL E 38 Ambulatory Surgery Center u yy nasha a duin tutes tieu e ei e au ES 40 Home Health Services s sr e ede ec ee ted ee fe e e eade Re Ettore eii end eS 40 Preventive Care Pt 41 Healthvand Welles oe t eerte a p WE ee at dee tte dte ee ido 42 Medicines and Tijectibles iio E ire idonea ii atiende t
23. hrs PROFESSIONAL SERVICES RADIOLOGY RADIATION THERAPY THERAPY REHABILITATION Endoscopy Procedures Gastroenterology 91000 91299 Hyperbaric Oxygen Therapy Interventional Radiology Intracardiac Electrophysiological Procedures 93600 93668 Neurological Testing 95812 96120 Out Patient Therapy see therapy for auth rule Pain Management Epidural 64400 64530 ASC approval after 3rd inject Performed by Anesthesiologist Pulmonary Testing 94010 94799 Regulated Space Maryland only Sleep Studies Surgery Thoracic Stress Echo Vestibular Function Test 92531 92548 Wound Management Hearing Exams Non Participating Providers except Anesthesiologists Refer to Pain Management Non Participating except chiropractors CT Scans MRA MRI ALL Nuclear Medicine including Nuclear Cardiology PET Scans Stress Echo Intensity Modulated Radiation Therapy IMRT Prior authorization is required only for elective admission A course of therapy occurring as part of an inpatient confinement that has met medical necessity criteria and been authorized does not require separate authorization Cardiac Rehabilitation Occupational Therapy after 1st 12 visits Physical Therapy after 1st 12 visits Pulmonary Rehabilitation Speech Therapy except evaluation 39 Ambulatory Surgery Center Pl
24. including prognosis Hyperlipidemia treatment plan physical activity including limitations Obesity resumption of occupation and sexual activities Emphasize risk factor reductions Category II risk factors Discuss accessing the emergency medical system Menopausal complications Develop action plans for aspirin and sublingual nitroglycerin Obesity including any contraindications Stress Depression This table of suggested guidelines has been developed from the AHA ACC Secondary Prevention for Patients with Coronary and Other Vascular Disease revised 2005 clinical guidelines It is intended to provide guidance to practitioners to reduce risks associated with CAD increase awareness of CAD and to optimize disease management It contains guidelines only and should never supersede clinical judgment The practitioner in conjunction with the patient or responsible party should decide whether these or other recommended services should be performed more frequently less frequently or not at all As with all services provided to Bravo Health Members the clinical judgment and the discussion around it should be documented in the medical record 63 OUTPATIENT MANAGEMENT OF COPD Screening Diagnosis Symptoms Chronic cough throughout the day Any pattern of sputum production Dyspnea that is progressive persistent worse on exercise worse during respiratory infections Repeated episodes of acute bronchitis History o
25. listed in the tables require authorization as noted In Office Place of Service 11 32 33 DURABLE MEDICAL EQUIPMENT Diabetic Shoes Diabetic Supplies initial set up only DME Purchase All Medicare Approved gt 200 Per Line Item All Prosthetics except mastectomy bras colostomy supplies indwelling Foley catheters Rentals All Repairs amp Maintenance All Diabetic Education Training Except Senior Partners Dialysis Self Training Nutritional Education Classes 97802 97804 Diabetes and Renal LABORATORY Labs ALL except these labs performed in Physician s Office 81000 81002 81003 81007 81025 82010 82270 82272 82570 82947 82962 83026 83036 83721 84478 84520 84703 85013 85014 85108 85610 87449 87804 87880 EDUCATION Providers will be reimbursed for the lab draw 36415 for all other labs tests not listed above MEDICATIONS AND INJECTIBLES Infusion Therapy except exclusion list see pages 43 44 Injectibles except Flu Pneumococcal Tetanus and Hepatitis B see attachment pages 43 44 IMMUNIZATIONS except Influenza Tetanus Hepatitis B and Pneumovax Immunizations for Travel OUT PATIENT SERVICES Enhanced External Counter Pulsation ECP G0166 limited to 35 visits per 12 month period Hyperbaric Oxygen Therapy Interventional Radiology Thoracic Stress Echo RADIOLOGY CT Scans MRA MRI ALL Nuclear Medicine including Nuclear Cardiolo
26. 1AJ9S STUL SALYA NOILVZIMOHLNV SALVA LSOd HIT lqesimquur Ajoyeredas JOU ST pue 3481 9seq IY ur popngout SI eSeo rui Sul ALVY 4SVA NI GH OTONI HOVHTIN OTT pejerduioo poy spun y UJIM ww sry JYrutqns oseo d SLINO HOIAYAS O M CHLLINGNS 601 QOUBISISSE JOJ WEIJL 99IAJ9S GIVd ATSNOIA add SOT I pIAOId Ino JOBJUOD pue SPIODII INO MOTADI ISBIA pessooogud K snolASJd u q seu wwe SIU oyeI WIP Jod 9 ur p pn oUut SI IMAS STY 10 JUJUAtLd Sul ALVY WHIG Wad LV GIVd bot U x gt IO U d gt SAY x 87 UOISIDIP JU U IM SIUBPIODIR UT PISSIDOIA IQ JIM Ww oY polopuer u q seu uorsro p SSIDOYA NI ASIAM OJIHA vez oy UsUM uorssmupe SITY uo spiooes TEeorpajai pajsanbarl sey ju unried G sados ug peoH mo 3SBI JOIAIOS JJUOJSNO Y JO JNS IY Se possoooJdoJ SEM WEO STUL ANSSISWIVIO HOIANWSS YANOLSNO EEZ QOIAIOS JO sed P1100 YIM WWP STU JUUQNSII oseo d SOd LOWNNOO HLIM LINANS Tez 3SBI JOIAIOS JJUOJSNO Y JO JNS IY Se possoooJdoJ SEM WHE SUL ANSSI HLAV HOIAYAS AAWOLSNS oez UOISIIP Teodde ue uo poseq wwe Ioud e 0 o8uguo e s1u s id i Weoo stu TVWAddV CANUNLAAAO ZZ eotoAur 9jerIdo1dde y UJIM turpo o STU JUIQNSII ISed HOIOANI HLIM WIVTO LINENS ezz ayeI SSOJ dOJS PAJILVIJUOO SU UT p pn out ST IOIAIOS STUY JOJ JUDWIOSINGUITOY ALVA SSO IdOLS NI CHANTONI zez 9jeJ sso d
27. 51011041252 e npouos 0 reo BUI siequiour JO JopIAOJd pojepouruioooe oq 0 e q oq amp eur uonejrodsue1 juoS1 Ju unurodde oj sord S Rp 9014 poysonbol oq p nous uoryeyodsuesy sjoquieui 199 9S OARIG 103 sjueunurodde JopiAo1d Suredronred wo pue 0 peprAo1d SISQUIIA 91913119 ENG preorpojAjo1eorpojo NOLLV 2TOdSNV lt LL ZOTH 8S7 998 o1 HdO NOISIA 6TE9 ESL 998 3uo qq 10 S TV LNWG L St 1 9 998 q eoud10 ASNAV dONVISSOS HLIVSH TVILNHIA sorjsouseiq 1son SALIOJLIOgET So oujeg eorum SHOIASIHS ASIOIVSIOSV T LNHILVdLLOO soles oje1edos Aq poprAoid are o oq UMOYS soorAJos ML SIDIAYAS AAVTTIONV S DPS9E SAYLZ o qv iap eorA19S 104 2e4 ojeAMq AWOQIT TOLO P9b 998 ALL ALL 1957 496 008 SOSTAIOS JSQUISJA 68L S 888 YIQISITA poyewojyny 971 L9p 998 sJoquiow urd Joy UONJLUNOJUI Ju ur ed oo pue AJIJIgI8IJo s ptAo1d soora1eg JOQUISIN NOLLVOIJISHA ALI TIqIDTI TH AGIND AONAUAAAY MOINO 8007 utoopA q ng H AYVIHIAdOYd Y IVILNHGIAJNOO uwunipog unedoy vy91f qrH q doH gy dog usng oo unedoy lt r91 f p ad sts etq q doy v doH uo veon 5 OT9T WI g dog LJe bIoD 0091f 1d sisA erq q doy snuej2Tnp Aipeuog 00c1f KTOJ e220ooSuruo A sorqey OTA UoJpe o q OOTIL oesA oq e99osoum uq sorqey OTA UuoJpeoo q v601f INI LG DISH oxpejq odeq OvTOTf
28. 9 V eSejs 1opun sounseour TV Kdeuou oup1o o osio1oxo poonpar on31e pue IpeoIq Jo SSAUJIOUS oseosip PLAM TEINJINIJS umouy yA sjuonjeg Sq 189138 JH Jo sulojdurks jo jueuido oAe qq JH Jo suroyduiAs JUOJINO JO 101d UJIM oseosip JA emionns O IBLIS Sjusnjed ojeudoudde ut SIODAIO Q PI9 Sjuored ojeudoudde ur sioltqtuut OV V 93 s Jopun s rnse ur V Ade L ASLASIP Ie DA EA OITJLUIOJdUTASY AH MOJ 2 HAT Jour Sur opoure1 AT IW snotA 1d GUM sju ned Bq AH JO suio3duis JO SUSIS noy mq oseosip MLA LINJINIJS g 23vIS OSBISIP yeoy TLINJINIJS ur UOLJIGIGU YOY ouroJpu amp s oroqujour Jonuoo esn SNIP Wor ayeyu ouoo e oSe1noosiq 9sioloxo Je n391 93e 1mo9ug S1opiosrp pidi worl uonessoo Supjouus a3e mo9ug uorsuoj1od q aIL Ade L WO XHd W suixojorpieo Sutsn soned JO KyIsago snjr our sojoqerp euioqpu amp s or oqejour oseosip e KreuoJ00 uorsuojiod amp q QA sjuoneq 34 AH Jo sutoldu s JO oseosip yeay eIMonys JNOUJIM mq ounyrey 11090 107 ASH 4314 JY V 93u S Ayano yeorsXyd Aue uo AJIJIgLUT ue ur Sun nS 1 oseosrp OLIPILO UJIM SJu nud 1S 1 ye surojdui s o19A9S AT SSE O ured eurgue Jo eouds p uonejid ed onsiyey sosneo jrAnoe AILUIPIO ULY sso SOI 3e OTJLJIOJUIOGJ Aja noe eorsAud Jo uorejrui POJJILU ur ZUNS ISPISIP MIPILI YIM sued omevozdur s ApojeJopojA TIT SSE ured peurgue Jo eouds p uoneyidjed on3138 ur sjn
29. AdXH CANTADO LON IpI ued sty JOPUN S9OTAJIS p949A00 JOU JIE SSNIP poJojstutuipe JIS XM NIWGV ATAS GANAAOSD LON OVI QOIAIOS YOVI 10 s SIcuo po q YIM JUUIQNSII 9SBI H CATIA ADAVHO ON 6 I siequinu QAN 9poo sniq euonewN uir JUQNSa1 9sea d SAIHAWON DAN HLIA LINENS ZET S IAIJIPOU oyetidoidde UJIM 3ruiqnsad aseolg AMICON O M GQXLLIWSOS 9 I IIIqd poziwo t ue UJIM 3ruqnsoJ4 SLATI qarLsunOWM TNA CAZINALI SET A 91e1edos LINGV HO SNH ZA NI M LISIA N4 bel Pp3SINQUITSI pue p lltq oq JOUULVO UOISSTUPL juonedur ue Jo simoy gz UTY IM sys wooy DUISIDUIH IOPIAOIJ 3U9J9glIp 0 PINSSI SEM OQIAJ S STU JOJ 9 g UO UONJEZIJOUJNE au IHCIAOJd INIATAHIO NOH HLNV ZET QOIAIOS JO o ep oyeredos VILA SUIMOYS Iq POEP YIIM ww sry JUQNSII se d SALVA HOJAYAS TIVLAC ACIAONd OFT ponad 98e32A09 IY UTUJIM SI 918p SDALIS DUI osneoog SIDUJIBY JOTUIS 0 WEO STU 3ruqnsoJ oseo d SUANLAVd NOINSS OL LINENS S8CI SDIAJOS JO oyep JU UO 1IQUIIJA UYIE9H OA81gG e JOU sem JUOT ed stu HOIAYAS HO ALVA NO DITA LON ZI pezuoujne SOIAIOS JO 19quinu JY SPIDIXI DITATIS STUL NOILVZIMOHLNV SQWHOXH pal yunoure juatur ed 09 19QUIIJA Y SI SUL ALIISVIILINSILVd AVdOO TVINGA CI ued 1yg u q STY Jopun p Aoo JOU OIE SUIO I IDUITUIAUOO juamed WALI SONSINSANOO INSILVd OZI jueurj1edoe SI TAJAS uj eoH Ino Aq paruop u q oAeu sAep e1idsou s yL SAVA TVLIGSOH CHINA YN STI uoneziuoujne u JO sep uomneardxo 3uj 19378 P9J9PUII SEM 99
30. Admissions All Sub acute Admission All RADIATION THERAPY Intensity Modulated Radiation Therapy IMRT Prior authorization is required only for elective admission A course of therapy occurring as part of an inpatient confinement that has met medical necessity criteria and been authorized does not require separate authorization Emergency Room Urgent Care Place of Service 20 amp 23 No Authorizations are required Outpatient Hospital Place of Service 22 EDUCATION Diabetic Education Training Except Senior Partners Dialysis Self Training Nutritional Education Classes 97802 97804 Diabetes and Renal PABORSTONE Labs ALL except these labs that may be performed in Physician s Office 85018 82947 82962 81000 81002 81003 81005 86308 86403 86406 MEDICATIONS AND INJECTIBLES Infusion Therapy except exclusion list see pages 43 44 Injectibles except Influenza Pneumococcal Tetanus and Hepatitis B see attachment IMMUNIZATIONS except Influenza Tetanus Hepatitis B and Pneumovax Immunizations for Travel OUTPATIENT SERVICES Allergy Testing 95004 95199 Audiologic Function Test 92551 92597 Blood Transfusions Bronchoscopy Cardiac Catheterization Chemotherapy includes all IM SQ and IV injections Colonoscopy Diagnostic Enhanced External Counter Pulsation ECP G0166 limited to 35 visits per 12 month period Electroencephalogram EEG w video monitoring 48
31. Ambulatory Services a The PCP is responsible for obtaining pre authorization for services requiring pre authorization and for any referral made out of network 53 b The Provider may make their requests via facsimile phone or letter for pre authorization before scheduling the service c The Medical Director reviews any request that does not meet Bravo Health s criteria d All Member requests for second opinions and recommendations for second opinions will be provided within the network whenever the opportunity exists Bravo Health does not require second opinions for procedures e Except for eligibility and benefit coverage denials all denial determinations are made at the Medical Director level f Member eligibility is noted Benefit level s indication of other insurance and limitations exclusions are noted g Prior authorization guidelines clinical practice guidelines medical necessity criteria are utilized as part of the review Guidelines will be provided to physician upon request h A written description identifying the information that is collected to support decision making is maintained i An appropriate licensed medical professional supervises all the review decisions j Physician consultants from the appropriate specialty areas of medicine and surgery are utilized if the reviewing Medical Director deems necessary k Each request will be approved denied or an alternative Covered Service may be suggested
32. D HEALTH PRACTITIONERS CREDENTIALING CRITERIA REQUIRED INFORMATION 1 Completed Bravo Health Texas Standard or CAQH application with a signed and dated Bravo Health Certification and Attestation form a If you answer yes to any of the questions supply all additional information b Ifyou answer yes to the malpractice history question please supply for each case RP pex Date of alleged malpractice A brief description of the nature of the case and alleged malpractice A statement describing your role in the case Current status of case including any settlement amount 2 3 4 5 6 7 8 Current and complete professional liability information on the application and provide a copy of your current malpractice insurance face sheet Current and complete hospital affiliation information on the application and a copy of your current appointment or reappointment letter If no hospital privileges and your specialty warrants hospital privileges a letter from you detailing your coverage arrangements and a letter from the physician who will admit for you Five years of work history month year format documented on the application or on current curriculum vitae with any gaps of more than 6 months explained and gaps of one year or more explained in writing A signed and dated Provider Agreement Upon acceptance an executed copy will be returned to you for your files Completed and signed W 9 form Bravo Health conduc
33. ESS Participating Providers are prohibited from balance billing Bravo Health Members including but not limited to situations involving non payment by Bravo Health insolvency of Bravo Health or Bravo Health s breach of its Agreement Provider shall not bill charge collect a deposit from seek compensation or reimbursement from or have any recourse against Members or persons other than Bravo Health acting on behalf of Members for Covered Services provided pursuant to the contracted Provider s Agreement The Provider is not however prohibited from collecting co payments co insurances or deductibles for non covered services in accordance with the terms of the applicable Member s Benefit Plan In the event a Provider refers a Member to a non Participating Provider without pre approval or provides Excluded Services to Member Provider must inform the Member in advance in writing 1 of the service s to be provided 11 that Bravo Health will not pay for or be liable for said services and 111 that Member will be financially liable for such services In the event the Provider does not comply with the requirements of this section Provider shall be required to hold the Member harmless as described above MEMBER CONFIDENTIALITY At Bravo Health we know Bravo Health Members privacy is extremely important to them and we respect their right to privacy when it comes to their personal information and health care We are committed to p
34. LNOVINS OL Gadvad NG TITE Ke3s Teotsins Teorpaui e se passoooid ST urmro o SIU AVC DANS CAN OL Q38GV3O Na OTE S9poo VSV UJIM WE sty JUIQNSII oseo d Sopoo VSV UJIM poNHTUGNS oq JSNUI swe BISIYISIUY 4009 VISAHLSANV CITVA GIAN 80 Aes K1j9ur9 9 e se paSSIDOIH ST ur o sru L AYLINITAL OL GAdVaD NG 90 Ureno SUISINU pos e se possooo1d ST umo SIUL DNISYAN CATTIS OL AUAVAD NG soe epoo aunpoooud pasun oy Jloddns 0 Sp10991 eorpoui YIM wre STU JUUQNSII 9sea d SMOGSOONd ALSINA ZOE SUI9 I 9S9U JOJ sos reyo SH IAVHO OL LON TIE GAZINALI 88 PaTTIG 2113 Jo Tejo su Tenbs jou soop Pq pozru 94 uo 8J0 Sul WJ p3193 4o2 E JUUIQNSII ISLIAd peziioujne MACIAONd AVI LSANO NON I8C 21d u q IABY soolAI9Ss y sso un AKlojelogeT json Aq poeprAoJd oq 3snu sados Atoyeloqe T J9j1enb GAHOVAI NANIXVA ATAHLAVN 642 SIU JOJ o qe IeA ore siu u q e3uep euonrppe ON 3901 u q seu WNUIXLRU ejuep Apiayrenb ou 9poo pyd 91eudoudde oui UJIM wwe sty JUIQNSII 9seo d ONG ONISSIN SAZ ed T g po3221100 YIM JUUQNSII ISPIA JAL THA LOSWNOONI 027 Jolie SIUBINSUL reuinid y wog SIJOUIF Jo uoneue dx ue YIM JUIQNSII ISPIA GaLsanoaa JOY 892 Jorn1reo Areuind oy Aq peur juowAed y s1u s id i junoure stu INHNAVd IHIMAVO AAVNINd 49 S9poo LdO YIM Ww sty JUUQNSII oseo d S34d00 LAO HLIA TIAA 9S7 sapos oyeridoidde y AAVOIGAW TIE SIDIAYES GOVI SSZ YUM oTeorpay 03 joeurp WP Sty IQ se d eTeoTpo
35. N OHAHAOO LON 6ST Uefd SIU JOPUN S9OTAJIS PIJIAOD JOU 318 ESIDADI UOT EZI IJ9 S 0 PAJEJAI S OSIAI9S TVSNSHAWN ZITINALS CHAGAOD LON 8ST ue d sty 1opun SIDAS D 19A029 JOU 918 A8ULVUO K S Y 0 poje o1 SIDIAIIS HONVHO X4S CHAHAOO LON SI ueld sty JOPUN SIOIAIOS po49AO00 JOU 318 OAT EOI squoned e Aq p9ISPUII SIDIALIS HALLVIHA AH ADAVHO G3ISIAOO LON SST ueld sty 19pun paJ2Aoo JOU 9 18 SasTeYO WIOOY 6ALId WOON ALVAId Q3NHAOO LON PST ued sty 1opun JOIAIOS PoJJAOO JOU SI SUISINN NA s7yeALIg ASAAN ALNA ALVA OHAHAOO LON EST ued sty 19pun sur lr PAJJAOO jou ore sj1o0ddns 3004 LNOdd S LOOA Q3WHAOO LON ISI ueld sty Jopun swa pa13A09 JOU ore s ous dIpedoy WO SAOHS OIGHdOHLYO Q3N38AOO LON OST UBId sty JOPUN SIMS p949A00 jou JIE SOOTAIOS SUISINU IU JMA DNISYAN ANIL TINA OHAHAOO LON 6pT ued sty JOPUN SIOIALIS po49A00 jou JIE S9ITAJAS ujedounjeN OAS HLVdONNLVN IHAHAOO LON 8bT ued sty JOPUN SIOIAIOS p949A00 JOU JIE SEIU PAAPAA IVAN GANHAITAC CHAHAOO LON LbT ued sty Jopun SIOIAIOS p949A00 JOU DIV SODTAIOS JoyeUIOWIOY OAS AAMVNANOH CHAHAOO LON SVI ued sty Jopun SIOIAIOS p949A02 JOU JTE SODTAIOS eIpo1lsno HAVO TVIQOLSnO Q3NHAOO LON trI ued sty JOPUN SIMAS p949A00 JOU JTE SOOTAIOS O9I 9UISO 7 OLLHINSOO GHAYHAOO LON tI ued sty Jopun DOTAIOS pa3J2AO9 e jou ST oynjoundnoy FANLONNdNOV HAHAOO LON Zvi ued Sty JApUN Ss OMIAI9S PIJIAOI JOU SILE SJUIUIJEIM ejueuliodx g TVINANIJ
36. NSII ISBI H SLINN 40 IHAWON ONISSIN 94 pezuoujne 949 9Y 01 Surp1oooe p ss oo d TAAHT LNSPESHHIG LV CHTIIMS TL useq sey WEP SHL pezuoujne sem ey 9AA MS 94 Uey jusJ9grp SI Pa iq 9A9 MAS UL 3po9 sINpsooid JUJJINO Y YIM JUIQNSII oseo d PONUTJUODSIP u q seu pejq poo sinpsooid Sur 41009 HANAHOOJd AINNILNOOSIA 9 pezuneuiseue sem Juarjed y aur JO YISU9 IY 9JLITPUI 0 SLINN AWIL VISHHLSANV ONISSINW 19 UITETO JU JUUIQNSII ISPIA SHUN IWY PISDUISIUE JO SUI ersoujsoue INOUJIM p llrtuqns SEM WEP au Sjrun owy erisaujsaue y Jo JUJWALd y sjuasaIdaJ 11931 IUN STULL SLINN ANIL VISHHLSANV 09 92IAISS JO SoyEp UJIM JUUQNSII ISBI H HOIAYAS HO ALVA ONISSIN 6 S9poo SOdOH UM ww sty JUIQNSII aseo d 4109 SOJOH O M CaLLINGNS 8 9781 seq IY UI PIPNIOUI ST 99IAISS SIU JOJ JUIVIISINQUIIA ALVY HSVA NI GACNTONI LE jueuiKed urorp Jod 99 ur p pn out SI JOMIS STY JOJ JUIVIISINQUIIY WIC Yad NI CHAN TONI 9 9poo 140 DIA e YIM JIUIQNSa1 9se d S3Gd00 IdO O M CALLINENS S QOIAIOS JO TIVLAC O M G3S LLIWSOS ee oyep YOwd JOJ SIDIAJIS o1floads pue soS1euo oy SULMOUS Jq p lre1 9p Y YIM wwe STU JUUQNSII oseo d s Iaquinu poo sniq Teuoren UJIM wwe STU JUIQNSII 9se d SAHAWON DAN O M GaLLINGNS ZE uonezriioulne au Jo 9Jep uonegidxo Iy Joye D3I9Du 91 SEM 99IAISS STYL GGMIdXH HLAV SZ eui peop Suny JU 19378 paqjruiqns sem UTEJO CAYIAXA LINIT AWIL ONTTIA zz SIU oorAIes JO oyep dU JO S RP OST UM pojrumqns oq JSNU si
37. Sp OYA 9ui YORU JOU SIOP WWP oY uo PASY ONC UL oyep 3234400 Y YPM JUIQNSII IST d ep ISIBUISTP JODIJODUT UL YIM PIJJUIQNS SEM WE SUL ALVA ADAVHOSIC LOHAAOONI CIO enp sr JUSUIISINQUILSA oyeredas ou pue 000 T Uey ssa ST porq Wy au 000 T gt LSOO LINN S Sjrun JO 19qumu 31109 943 YIM 1rtuqns asea d SLINN HO IHAWON LOSNNHOONI 09S SDIAJOS JO Soyep ogIO9ds UJIM Ww sty 3ruqnsoJ oseo d SALVA ONIOSdS HLIM TIA SOS 9 QB TeAe ore sjngouoaq TeUOT Ippe ou pue GHAHOVAI XVI ANIVIGOd ANILNOA CGv peuoeal u q sey Teoh Iepuo eo I9A9 SJISTA p JO SIDIAIIS AlyeIpod unnoi JOJ jgeueq umnurxeul UL lqelreAae ore S 9UIQ eUOT Ippe ou pue poprAoJd u q seu spre suurssq JOJ JY9UIQ WINWIxew UL CaHOVaY WANIXYN CIV ONBIVSH ISt UNUTXBUur SAVHA C AJHAH ATVA ANO SHSSVIO OSb JJ9UIQ su spoooxo sosse S JO Ied siu SIB9 om JSA9 JIJJUJg PAISAOD E SI sosse 8 oka Jo ed JUN uonezuoujne Iod 9JINboJ sure13o1d Suresunos uoressoo Supiours NVADOYA NOLLVSSHO DNDIONS SOb de199 y JO 92ueApe ur paroidde aq JSNU de19y3 uonrnnu eotpala AdVYAHHL NOLLPLLON TVOIGHN vob 9 QB TeAe 918 sjrouoq euonrppe ou pue poprAoJd u q seu saoralos 2189 u eou G3HOV9M ZO poa12A00 JOJ SUOTJE9O poAo1dde uejd o sdupunoir uonejiodsue unnoi ZT Jo JIJAUJg UWNUIXLU ayy NONIXVN NOLLVLJOISNVAL yuowAed w rp tod 1uonedur 94 UL p pn out ST IOIAIOS STUY JOJ JUISVIISINQUIIA NATA dd LNALLVdNI NI GHCNTONI ZIE Ae1s 9jnoe qns e se passa90 1d ST Wo SIUL A
38. TX 78229 Provider Services 1 800 291 0396 Sales Inquiries 1 866 790 9079 TTY 1 800 964 2591 for the hearing impaired www bravohealth com
39. ablish baseline weight FLUID MANAGEMENT Encourage daily weights on the same scale at the same time each day Report weight gains of gt of 5 Ibs in a week Establish monitor daily fluid intake limits avoid excessive fluid intake Instruct on fluid restriction if indicated MEDICATION EDUCATION Develop a patient medication schedule including drug doses Review effects of medications on guality of life and survival Discuss probability of side effects and what to do if they occur Discuss availability of lower cost medications or financial assistance Influenza flu vaccine annually IMMUNIZATIONS Pneumococcal vaccine initially repeat as per CDC recommendations Utilization Management Committee will review Guidelines for new scientific evidence or national standard changes prior to distribution to Providers annually 58 CHF PHARMACOLOGICAL TREATMENT OPTIONS RECOMMENDATIONS ACE Inhibitors Angiotension Coverting Enzyme Need to change font to match others ACE Inhibitors should be prescribed for patients with left ventricular systolic dysfunction with EV 40 unless contraindicated or not tolerated ACE Inhibitors should be continued indefinitely The recommended dose of ACE Inhibitors for heart failure are the larger doses used in the clinical trials demonstrating improvement in survival Contradictions to ACE Inhibitors include shock angioneurotic edema significant hyperkalemia scrum potassi
40. ace of Service 24 OUTPATIENT SERVICES Interventional Radiology Pain Management Epidural 64400 64530 ASC approval after 3rd inject Performed by Anesthesiologist RADIATION THERAPY Intensity Modulated Radiation Therapy IMRT Prior authorization is required only for elective admission A course of therapy occurring as part of an inpatient confinement that has met medical necessity criteria and been authorized does not require separate authorization Home Health Services Place of Service 12 DURABLE MEDICAL Diabetic Shoes EQUIPMENT Diabetic Supplies initial set up only required purchase Medicare Approved gt 200 Per Line Item Prosthetics except mastectomy bras colostomy supplies indwelling Foley catheters Rentals Repairs amp Maintenance EDUCATION Diabetic Education Training Dialysis Self Training Nutritional Education Classes 97802 97804 Diabetes and Renal HOME HEALTH SERVICES Aide Primary Care Physicians PCPs may see Dialysis in Home Members in their home without prior authorization Infusion Nurse Occupational Therapy Physical Therapy Specialist Physician Home Visits except Podiatry Speech Therapy Wound Management PREVENTIVE CARE The following Preventive Health Care Services DO NOT require authorization Preventive Care Abdominal Aortic Aneurysm Ultrasound A one time screening ultrasound for people at risk like p
41. acholine injection 10 CC inj chloride neb J0132 Acetylcysteine injection J7631 Cromolyn sodium inh J1460 Gamma globulin 1 J7505 Monoclonal solud CC inj antibodies J0135 Adalimumab injection J7330 Cultured J1550 Gamma globulin 10 Q4079 Natalizumab chondrocytes implnt CC inj injection J0180 Agalsidase beta injection J9100 Cytarabine hcl 100 J1470 Gamma globulin 2 J9261 Nelarabine injection MG inj CC inj Q4093 Albuterol inh non comp J9110 Cytarabine hcl 500 J1480 Gamma globulin 3 Q4087 Octagam Injection con Initial auth only MG inj CC inj Q4094 Albuterol inh non comp J9098 Cytarabine liposome J1490 Gamma globulin 4 J2357 Omalizumab u d Initial auth only CC inj injection J7620 Albuterol ipratrop non J0850 Cytomegalovirus J1500 Gamma globulin 5 J2355 Oprelvekin injection comp imm IV vial CC inj J9015 Aldesleukin single use J9130 Dacarbazine 100 mg J1510 Gamma globulin 6 Q4086 Orthovisc inj vial inj CC inj J0215 Alefacept J9140 Dacarbazine 200 MG J1520 Gamma globulin 7 J9263 Oxaliplatin inj CC inj J9010 Alemtuzumab injection J7513 Daclizumab J1530 Gamma globulin 8 J9265 Paclitaxel injection parenteral CC inj J0205 Alglucerase injection J9120 Dactinomycin J1540 Gamma globulin 9 J9264 Paclitaxel protein actinomycin d CC inj bound J0256 Alpha 1 proteinase J1645 Dalteparin sodium Q4088 Gammagard Liquid J2425 Palifermin injection inhibitor injection J0270 Alprostadil for injection J0882 Darbepoetin alfa Q4092 Gamunex injection J2469 Pa
42. all not agree to do so unless the requesting party has shown good cause as to why the additional or expanded discovery is necessary On motion by either Party and for good cause shown the arbitrators shall have the power to enter and impose any appropriate protective orders limiting use and disclosure of any information submitted during or related to the arbitration In addition the arbitrators shall abide by any protective orders agreed upon by the Parties 7 Evidence Any arbitration pursuant to this Section shall be conducted by the Arbitrators under the guidance of the Federal Rules of Evidence The Arbitrators however shall not be required to conform strictly to such Rules in conducting any such arbitration The Arbitrators shall conduct such evidentiary or other hearings as they deem necessary or appropriate and thereafter shall make their determination within ten 10 days of any evidentiary hearing or motion The parties may offer such non duplicative evidence as is relevant and material to the dispute and shall produce such evidence as the arbitrators may deem necessary to an understanding and determination of the dispute An arbitrator or other person authorized by law to subpoena witnesses or documents may do so upon the request of a Party or upon the arbitrators own motion The arbitrators shall be the judges for the duplicative nature relevance and materiality of the evidence offered and as noted above the Federal Rules of E
43. appointment of an Arbitrator Each Arbitrator must have a minimum of ten 10 years of legal experience or professional experience in the healthcare industry Procedure for Selection of Third Arbitrator The two 2 Arbitrators appointed or selected as set forth in Section 6 4 shall appoint a third Arbitrator as soon as practicable or if they do not do so within forty five 45 calendar days after notice is given to the Parties of the appointment of the second Arbitrator any Party may apply to the Chief Judge of the United States District Court of Texas for the appointment of an Arbitrator After the appointment of the third Arbitrator the Arbitrators shall hold a preliminary conference with the Parties within thirty 30 days to define and narrow the issues and claims to be arbitrated The arbitrator may at the preliminary conference establish the extent of and schedule for the production of documents and other information identify the form of evidence to be presented and limit discovery 67 5 68 Scheduling and Timing of Arbitration The arbitrators must begin the formal arbitration hearing within one hundred twenty 120 days of the date the last arbitrator is appointed The arbitration hearing must be completed within sixty 60 days following the close of discovery The parties and arbitrators shall use their best efforts to ensure that the arbitration hearing proceeds in a timely fashion without unnecessary delay unnecessary dela
44. aprao1g Suredronged JOJ swe TV WITE O JOLId 0 UOTJDIIIOS e sjuosoJdaJ UTEJI STU WIVTO YORId OL NOLLOSNNOO IZ 9poo 9 DOIAIOS JO IDEJA pea e UJIM Ww STU 1Yruiqns 9seo d HOIJAYAS AO HOVId GTIVANI 61 epoo SISOUSEIP 6GOI PILA Y YIM ww sry JUUQNSII ISPIA 4109 SISONDVIC GI IVANI 8I 9poo pI A Y YIM ww sty JUIQNSII oseo d PITeA Jou SI porq IPod ounpoooud Sul 4109 FANGAOONd GIIVANI LI spioS9i TEOIPSUL UJIM Ww sty JUUQNSII ISPIA GHAMNOJA SAYODAY TVOIGSN 9T Jusudinba sty NINO SOW ST YOU TVINGY ANG SI 10 l qelreAe ore sjgouog euonIppe ON sujuotu I 3e poddeo st 1uoeuidmbo eorpeur o qe1np JOJ ejusy eotdsoH ur p llo1u ST 3uoned oY IGOIp lN 03 Wp STU puqns se d HOIdSOH NI CATIOYNA INHILVd VI pepue a3B12A09 UJJLAH OALIgJ S ISQUIAJA IY 1937 P9J9PUII SEM NAJ S STUL NV Id M ALTISIOITA SALVALSOd 6 ULAH OABIG ui 9J8P AnO3JJ9 S ISQUIIA IY 01 JOLId PIIDPUII SEM 99IAISS STUL NV Id HLIM ALITIGIOITA SALVA 4 Yd 8 Ao CaLSNVHXa L BUISINU po D S POY AJEIPIJA e UT pomad yyauaq tad s ep 001 JO umurxeui 94 Spasoxa WETO STYL PHHNG SAVA NISAAN CaTIDIS SOOTAIOS SOU JOJ Y UO UONYLZIOYJMEL OU SI 219U L CaZIMOHLNV LON SOIANSS osSenSuveT eru G uordrioSs Gq PoD sex L s po S uosvoy 1yu urmsn pvV Wre LC ueld sty 1opun PAJJAOO Jou are soAndooeg1uoo UONdIJOS Id UoN IAHOVALNOO XA NO
45. are oxygen Initiate oxygen therapy for patients with Stage IV Very Severe COPD if 1 PaO is lt or 55mm Hg or SaO is lt or 88 with or without hypercapnia or 2 PaO is between 55mm Hg and 60 mm Hg or SaO is 89 if there is evidence of pulmonary hypertension peripheral edema suggesting CHF or polycythemia Smoking cessation all stages COPD Yearly Influenza vaccination all stages COPD Pneumococcal Vaccine One dose for persons under 65 who have chronic disorders of the pulmonary systems One dose for unvaccinated persons age 65 and older One dose revaccination for persons age 65 and older if they received the vaccine greater than or equal to 5 years previously and were less than 65 years at time of primary vaccination Increase bronchodilator therapy Consider antibiotic therapy for bacterial infection Consider corticosteroids if no improvement in symptoms Administer O as needed Increase social support Improve exercise tolerance Indications for Hospital Admissions Insufficient home support newly occurring arrhythmias significant co morbidities onset of new physical signs cyanosis peripheral edema failure of exacerbation to respond to initial medical treatment severe background COPD marked increase in intensity of symptoms such as development of resting dyspnea This table of suggested guidelines has been developed from the American Diabetes Association 2007 Standards of Medical Care in Diabetes Dia
46. arrangement and c If the physician does not have hospital privileges due to any reason other than a strictly voluntary relinquishment by the physician the physician s application will be reviewed by a Bravo Health Medical Director and forwarded for review to the PACC 6 Primary care physicians must have coverage arrangements with a Bravo Health Participating physician to assure that services are available on a twenty four hour a day seven days a week basis Te Practitioners must disclose for Bravo Health Credentialing Committee review all claims or suits alleging malpractice that have been filed against him or her or appealed or settled by the physician or his or her insurance carrier in the past five 5 years 8 Practitioners who currently or have ever been excluded from Medicare and or Medicaid participation is not eligible for participation with Bravo Health If a physician is accepted into Bravo Health and then is excluded from Medicare and or Medicaid participation that physician will be terminated 17 10 11 12 13 14 15 16 18 Practitioners must hold and maintain a current federal narcotics license It must include all DEA schedules that the physician prescribes It is recommended that this license include all of the following DEA Schedules 2 2N 3 3N 4 and 5 Pathologists and diagnostic radiologists may be exempted from this criterion Physicians must have and maintain malpractice insurance of a
47. art and continue indefinitely in all patients who have had myocardial infarction acute coronary Goal syndrome or left ventricular dysfunction with or without heart failure symptoms unless All patients post MI contraindicated J Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated Blood Pressure Identify and treat reversible causes Goal Accurate BP measurements with appropriate size cuff at every visit lt 140 90 mm Hg or Advocate amp monitor lifestyle changes weight control physical activity alcohol moderation if lt 130 80 mm Hg if moderate sodium restriction emphases on fruits vegetables and low fat dairy products Diabetes or Renal Insufficiency Pharmacological management goals All patients on optimal dose of drug therapy for insufficiency adequate hypertension control see Seventh Report of the Joint National Committee on Prevention Detection Evaluation and Treatment of High Blood Pressure JNC 7 ASK Identify use of all tobacco products at every visit Cigarette Smoking ADVISE Strongly urge and educate users on the importance of quitting at every visit ASSESS Determine the patient s willingness to quit Goal ASSIST Counsel the patient and help to develop quit plan and set quit date Complete Cessation Prescribe pharmacotherapies found to be effective unless contraindicated Combination treatment with sustained release bupropin an
48. aw including lack of required substantiating documentation for non Participating Providers and suppliers or particular circumstances requiring special treatment that prevents timely payment from being made on the claim If additional substantiating documentation involves a source outside of Bravo Health the claim is not considered clean The following standard CMS required data elements must be present for a claim to be considered a Clean Claim This applies to both electronic and paper claims Professional Claims e Patient name Patient demographic information Member identification number Rendering Provider name Payee name and address Provider signature Explanation of Benefits from the primary carrier when Bravo Health is the secondary payor If the services were not rendered in an office or home setting list the name and address of the facility where services were rendered in Box 32 Provider federal tax identification number Date of service All appropriate diagnosis codes ICD9 CM codes Procedure code for each service rendered CPT 4 or HCPCS Codes All appropriate modifiers for each service rendered Amount billed for each procedure 23 Place of service code NPI number Type of service Days and units Anesthesia time in minutes Include the following information for all injectible drugs 1 Average Wholesale Price AWP reimbursed Providers the National Drug Code NDC Number and the NDC unit s associated with each drug 2 A
49. betes Care 29 S4 S42 2006 It is intended to provide guidance to practitioners to reduce risks associated with diabetes increase awareness of diabetes and to optimize disease management It contains guidelines only and should never supersede clinical judgment The practitioner in conjunction with the patient should decide whether these or other recommended services should be performed more or less frequently Clinical judgment and discussion should be documented in the medical record Utilization Management Committee will review Guidelines for new scientific evidence or national standard changes prior to distribution to Providers annually 64 PHARMACEUTICAL MANAGEMENT Bravo Health provides a pharmacy benefit to all of our Members This benefit consists of a three tier formulary with a fourth tier for specialty injectible medications All prescriptions require the Member to pay a co payment based on the medication s formulary status Our formulary can be found on line at www bravohealth com Click on Providers then Provider Forms and Information You may also request a printed copy of the formulary by contacting our Provider Services Department at 1 888 353 3789 Bravo Health s formulary requires that some medications require prior authorization before they can be dispensed Please call 1 800 753 2851 for prior authorization The formulary lists these medications with the designation PA If you would like a copy of the criteria t
50. can a Provider apply for an NPI There are several methods that a Provider can apply for a NPI number 1 Phone 1 800 465 3203 TTY 1 800 692 2326 2 E mail customerservice npienumerator com 3 Mail NPI Enumerator P O Box 6059 Fargo ND 58108 6059 31 NOTE If a Provider wishes to obtain a copy of the NPI application form they must call to obtain an application form No e mail or mail requests for applications will be accepted Reminder to Providers A Provider may apply for an NPI using only one of the ways described above Make sure that the Provider has a correct Social Security Number SSN and Federal employee identification number when applying How do I bill with an NPI number The NPI number should be placed in the following boxes on the appropriate claim form CMS 1500 Place the NPI in Block 24J UB92 Place the NPI in Block 56 Additional questions on how to bill an NPI number e Refer to www cms gov e Medicare Claims Processing Manual o Chapter 26 o Completing and Processing Form CMS 1500 Data Set 32 THE IMPORTANCE OF HIERARCHICAL CONDITION CATEGORIES HCC Effective January 1 2004 CMS implemented a risk adjustment model in which reimbursement to Medicare Advantage organizations such as Bravo Health is based on hospital inpatient hospital outpatient and office based Provider encounter data This model predicts health cost expenditures by calculating the disease burden of the population A Member s
51. ction surveys or samplings c Physicians and Allied Health Professionals must agree to Bravo Health administrative protocols Physicians Allied Health Practitioners must recognize that information from the National Practitioner Data Bank NPDB and confirmation of the validity of the practitioners board preparedness or certification State License Federal DEA Certificate and malpractice insurance information must be forthcoming and will be considered prior to credentialing ADDITIONAL REQUIREMENTS If the applicant is accepted for participation in Bravo Health the following additional requirements will apply l The physician or allied health professional must continually maintain and comply with all Bravo Health policies and procedures According to the Provider s Contract physicians or oral surgeons must notify Bravo Health in writing within five 5 days of any changes in his or her status relative to the established credentials criteria or any other matter that could potentially affect a continued contractual relationship with Bravo Health such as significant or prolonged illness leave of absence suspension or modification of privileges any change in physical or mental health status that affects practitioner s ability to practice or any other action that materially changes the practitioner s ability to provide service to Members A physician or oral surgeon who maintains more than one office after acceptance must have all
52. d Galveston Guadalupe Harris Jasper Jefferson Liberty Medina Montgomery e Orange e Must not have End Stage Renal Disease ESRD at the time of enrollment ELIGIBILITY VERIFICATION All Participating Providers are responsible for verifying a Member s eligibility at each and every visit Please note that Membership data is subject to change CMS retroactively terminates Members for various reasons When this occurs the Bravo Health claim recovery unit will request a refund from the Provider The Provider must then contact CMS eligibility to determine the Member s actual benefit coverage for the date of service in question You can verify HMO Bravo Classic Bravo Healthy Heart Bravo Gold or Bravo Select Member eligibility in three ways o Online through Emdeon or other office management software o By calling Provider services at 1 888 353 3789 o Through our Interactive Voice Response IVR System at 1 866 467 3126 The IVR System is available 24 hours a day 7 days a week To verify Private Fee For Service Bravo Liberty Member eligibility o Call 1 866 464 0701 bravo Classic RXBIN 610014 RXPCN MEDDPRIME RXGrp ELDERHLTH Issuer 80840 Processor PAID ID 99999999 G BF BNF 0 35 70 Name SAMPLE A SAMPLE PCP Name SAMPLE SAMPLE y a PCP Phone 999 999 9999 Me dica R rescription Drug Coverage PCP 0 Specialist 35 Emergency Room 50 Behavioral Health Corphealth 866 671 4537 H4528001 MEMBER HOLD HARML
53. d Bravo Health will present these opportunities and implement interventions 49 HEALTH SERVICES Bravo Health utilization management staff base their utilization related decisions on the clinical needs of its Members the Member s Benefit Plan the appropriateness of care Medicare National Coverage Guidelines objective scientifically based clinical criteria and treatment guidelines in the context of Provider and or Member supplied clinical information and other such relevant information Bravo Health in no way rewards or offers incentives either financially or otherwise practitioners utilization reviewers clinical care managers physician advisers or other individuals involved in conducting utilization review for issuing denials of coverage or service or inappropriately restricting care If you have any further questions or comments please feel free to contact our Provider Services Department at 1 888 353 3789 Goals e To ensure that services are authorized at the appropriate level of care and are covered under the Member s health plan benefits e To monitor utilization practice patterns of Bravo Health s Contracted Physicians Contracted Hospitals and Contracted ancillary services e To provide a system to identify high risk Members and ensure that appropriate care is accessed e To provide utilization management data for use in the process of re credentialing Providers e To educate patients physicians contracting
54. d the facility will be instructed to provide the Member and or the authorized representative with notification of the termination of skilled benefits Emergency Services Bravo Health covers emergency services necessary to screen and stabilize Members without preauthorization in accordance with applicable law Bravo Health covers emergency services if a PCP or other authorized representative acting on behalf of Bravo Health has directed the Member to the Emergency Room In an emergency situation Members sometimes self refer without the knowledge of the Primary Care Physician or Bravo Health In such cases the medical records will be reviewed retroactively Final determination regarding whether an emergency situation existed will be subject to review and will be determined in accordance with applicable law The review is primarily used to promote high quality care assess whether there is access to Primary Care Physicians who are contractually obligated to provide care 24 hours a day 7 days a week is adequate and increase awareness of appropriate use of costly emergency care resources 55 Decision Time Frames Utilization review determinations are made in a timely manner and in compliance with applicable law Emergent authorization not required in accordance with applicable law e Urgent within 48 hours or next business day Expedited with 72 hours or as required by the health status of the Member e Routine within 14 days of
55. d accreditation mandates Healthcare Effectiveness Data and Information Set HEDIS HEDIS a standardized data set is developed and maintained by the National Committee for Quality Assurance NCQA an accrediting body for managed care organizations The HEDIS measurements enable comparison of performance across plans The sources of HEDIS data include administrative data claims encounters and medical record review HEDIS measurements include measures such as Comprehensive Diabetes Care Adult Access to Ambulatory and Preventive Care Glaucoma Screening for Older Adults Controlling High Blood Pressure and Breast Cancer Screening Plan wide HEDIS measures are reported annually and is a mandated activity for Health Plans contracting with The Centers for Medicare and Medicaid Services CMS All records are handled in accordance with Bravo Health s privacy policies and in compliance with the Health Insurance Portability and Accountability Act HIPAA Privacy Rule Only the minimum necessary amount of information which will be used solely for the purpose of this HEDIS initiative will be requested HEDISG is considered a quality related health care operation activity and is permitted by the HIPAA Privacy Rule see 45 CFR 164 501 and 506 Bravo Health HEDIS results are available upon request Contact the Health Plan s Quality Improvement Department 47 ON SITE ASSESSMENTS On site facility assessments are performed to as
56. d nicotine withdrawal products has been shown to be the most effective ARRANGE Follow up soon after quit date AVOIDANCE of exposure to environmental tobacco smoke at work and home 62 Cholesterol Primary Goal LDL C lt 100 mg dL If triglycerides are gt 200 mg dL non HDL C should be lt 130 mg dL Intensive cholesterol lowering therapy can significantly reduce the risk of major coronary events strokes and total mortality LDL C should be lt 100mg dL Further reduction of LDL C to lt 70 mg dL is The treatment of elevated LDL C involves therapeutic lifestyle changes TLC and Drug therapy Essential features of TLC are reasonable If baseline LDL C is gt 100 dL initiate LDL Reduced itake of saturated fats Cy of total calories and cholesterol lt 200 lowering drug therapy mg day ncreased intake of soluble fiber 0g day and plant stanols sterols Qg day Increase consumption of omega 3 fatty acids in the form of fish or in caspsule form 1g d Weight reduction management ncreased physical activity HMG CoA reductase inhibitors statins If on treatment LDL C is 2100 mg dL intensify LDL lowering therapy may LDL lowering drug combination If triglycerides are 2200 mg dL non HDL C should be 130mg dL and further reduction of non HDL C to 100mg dL is reasonable If triglycerides are gt 500mg dL therapeutic options to prevent pancreatitis are
57. d services as defined in their Evidence of Coverage EOC Each month Bravo Health sends Participating Primary Care Physicians a list of his her active Members The name of the Plan in which the Member enrolled will be listed on the roster Recently terminated Members may appear on the list Bravo Health encourages its Members to call their Primary Care Physician to schedule appointments However if a Bravo Health Member calls or comes to your office for an unscheduled non emergent appointment please attempt to accommodate the Member and explain to them your office policy regarding appointments If this problem persists please contact Bravo Health THE ROLE OF THE PRIMARY CARE PHYSICIAN PCP Each Bravo Health Member must select a Bravo Health Participating Primary Care Physician PCP at the time of enrollment The Primary Care Physician is responsible for managing all the health care needs of a Bravo Health Member as follows e Manage the health care needs of Bravo Health Members who have chosen them as their Primary Care Physician e Ensure that Member receives treatment as frequently as is necessary based on the Member s condition e Develop an Individual Treatment Plan for each Member e Submit accurately and timely encounter information for clinical care coordination e Comply with Bravo Health s pre authorization procedures e Refer to Bravo Health Participating Providers Comply with Bravo Health s Quality Management a
58. d to Plan for purposes of administration To the extent permitted by law Plan shall have the right to inspect at all reasonable times any medical records maintained by Provider pertaining to Plan s Members Provider agrees to maintain all patient records pertaining to treatment of Members for a period of ten 10 years Medical Records shall not be removed or transferred from Provider except in accordance with general Provider policies rules and regulations Providers agree to furnish Members timely access to their own records Bravo Health may audit a Provider s medical records for Bravo Health Members as a component of Bravo Health s quality improvement credentialing and re credentialing processes In accordance with AMA guidance and NCQA guidelines medical records must be legible with current details organized and comprehensive in order to facilitate the assessment of the appropriateness of care rendered Documentation audits are performed to assure that Primary Care Physicians maintain a medical record system that permits prompt retrieval of information They are also performed to assure that medical records are legible contain accurate and comprehensive information and are readily accessible to health care Providers Medical record review also provides a mechanism for assessing the appropriateness and continuity of health care services Applicable regulations mandate medical record review by Bravo Health Criteria indicators to be
59. dazole Inj Pulmozyme Targretin Gel Byetta Focalin Mucomyst Rapamune Tazorac Cream Camptosar Inj Forteo Myfortic Raptiva Testim 66 ALTERNATIVE DISPUTE RESOLUTION 1 Binding Arbitration Except as otherwise provided in the Agreement the Parties agree that any controversy or claim including but not limited to any alleged class actions arising out of or relating to the Agreement or the breach thereof whether involving a claim in tort contract or otherwise that cannot be resolved by informal means shall be settled by final and binding arbitration as its exclusive remedy A party aggrieved by the alleged failure neglect or refusal of another to arbitrate under the Agreement for arbitration may petition the applicable United States District Court of Texas for an order directing that such arbitration proceed in the manner provided for in the Agreement The Parties expressly agree however that the right of either party to terminate the Agreement pursuant to the Agreement and Bravo Health s right to withdraw from a service area is absolute and shall not be subject to arbitration All arbitration proceedings shall take place in the applicable State in which Provider is to provide Covered Services under the Agreement Rules for Arbitration The Parties agree to adopt the Rules of Procedure for Arbitration Rules and the Code of Ethics for Arbitrators Code of the American Health Lawyers Association Alternativ
60. des Philadelphia amp Mid Atlantic MUST use Quest Labs Pittsburgh e Can use participating hospitals and Quest Labs Texas Can use Clinical Pathology Lab CPL or Quest Labs Lab services performed at skilled nursing and long term care facilities do not require pre authorization D D O a D D 0 JE NON PARTICIPATING All non Participating providers require prior authorization PROVIDERS except Chiropractor Radiologist and Anesthesiologist or ER Podiatry Routine Refer to specific plan benefits Non Routine Refer to Medicare Coverage Guidelines Professio Modifier 26 professional component does not require an authorization for Participating or Non Participating Providers Radiology Authorization Bravo Contact NIA at 1 800 642 2804 for all procedures requiring authorization Pennsylvania Senior Partners Contact 215 606 6336 Mid Atlantic amp Texas Contact 1 888 454 0013 All Regions Requests may be faxed to 1 866 464 0707 Transportation Benefits vary according to plan See Quick Reference Guide and Benefit Grid for details Vision Pennsylvania Contact Davis Vision 1 800 584 3140 Texas Contact OptiCare 1 866 258 4102 Mid Atlantic C Network Contact Bravo Health for Customer PRIOR AUTHORIZATION RULES BY PLACE OF SERVICE The following tables list outlines the Bravo Health authorization procedures by place of service Services
61. described in their Evidence of Coverage To let Bravo Health know if they have any questions concerns problems or suggestions regarding their rights responsibilities coverage and Bravo Health operations h To notify Bravo Health Member Services and their Providers of any address and phone number changes as soon as possible i To use their Bravo Health plan only to access services medications and other benefits for themselves ADVANCE MEDICAL DIRECTIVES All Providers contracted directly or indirectly with Bravo Health may be informed by the Member that Member has executed changed or revoked an advance directive At the time service is provided the Provider should ask the Member to provide a copy of the advance directive to be included in his her medical record If the PCP and or treating Provider cannot as a matter of conscience fulfill the Member s written advance directive he she must advise the Member and Bravo Health Bravo Health and the PCP and or treating Provider will arrange a transfer of care Participating Providers may not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive However nothing in The Patient Self Determination Act precludes the right under state law of a Provider to refuse to comply with an advance directive as a matter of conscience BENEFITS AND SERVICES All Bravo Health Members receive the benefits an
62. e Dispute Resolution Service collectively referred to as AHLA The AHLA Rules and Code for Arbitration shall apply to any arbitration under the Agreement unless otherwise specifically stated or supplemented in the Agreement In the event of any conflict between the AHLA Rules and Code for Arbitration and the Agreement the provisions of this language and the Agreement shall control Demands for Arbitration and Selection of Arbitrators The demand for arbitration shall be in writing and shall be served in the manner prescribed in Section 7 9 of the Agreement The demand for arbitration shall set forth a detailed statement of the issue and facts supporting the arbitration demand shall specify the matters to be arbitrated including identification of the Section or Article of the Agreement in dispute and shall identify the name and address of the Arbitrator chosen by the Party making such demand The other Party to the dispute shall appoint an Arbitrator shall give written notice of such appointment in accordance with Section 7 9 to the other Party and shall specify the name and address of such Arbitrator within forty five 45 calendar days after receipt of the demand If such Party fails to appoint an Arbitrator and notify the other Party as herein provided within such forty five 45 calendar day period the Party making the arbitration demand shall have the right to apply to the Chief Judge of the United States District Court of Texas for the
63. e is clearly a very low rate of serious cardiac events during cardiac rehabilitation Weight Management Goal BMI 18 5 to 24 9kg m2 Waist circumference Men lt 40 inches Women lt 35 inches Assess body mass index and or waist circumference on each visit and consistently encourage weight maintenance reduction through an appropriate balance of physical activity caloric intake and formal behavioral programs when indicated to maintain achieve a body mass index between 18 5 and 24 9 kg m2 If waist circumference is gt 35 inches in women and gt 40 inches in men initiated lifestyle changes and consider treatment strategies for metabolic syndrome as indicated The initial goal of weight loss therapy should be to reduce body weight by approximately 10 from baseline With success further weight loss can bet attempted if indicated through further assessment gardening Influenza Vaccine Patients with cardiovascular disease should have an influenza vaccination annually Education Goal Improve patient Knowledge amp Enhanced outcome Assess patients baseline understanding Category I risk factors Elicit their desire for information Identify and treat aggressively Use ancillary personal and professional patient education Hypertension programs Smoking Involve family Members Diabetes Invest time to improve functional capacity and survival Sedentary lifestyle Incorporate patient specific information
64. e that each will be limited to a maximum of twenty five 25 including subparts written interrogatories and or written document requests and or written requests for admissions Responses to written discovery are due within thirty 30 days of service Upon motion by the aggrieved party the arbitrators may enter any appropriate orders for non compliance with discovery requests against the other party up to and including preclusion of the presentation of certain evidence not produced in a timely fashion The parties may agree to reasonable extensions to respond to the other s discovery requests so long as the extension does not extend the overall discovery period beyond ninety 90 calendar days following the preliminary conference Each party will be limited to no more than five 5 party opponent depositions and the parties agree to make requested employees available for deposition within forty five 45 days of such a request If either party believes a deposition has been requested in bad faith or for the purposes of harassment delay or otherwise either party may move for an appropriate protective order and the arbitrators shall rule on such protective order Either party may also move for additional depositions or deponents should the issues reasonably require and the arbitrators shall rule on such request The arbitrators shall strictly enforce these discovery limits With respect to any motions to extend or expand discovery the arbitrators sh
65. ed for are in the medical record and there is evidence that the practitioner reviewed these reports There is explicit notation in the medical record of follow up plans related to consultation abnormal laboratory and imagining study results Chronic or unresolved problems from previous visits are addressed in subsequent visits There is no evidence that the patient is placed at risk by a diagnostic or therapeutic procedure There is evidence of patient significant other teaching There is evidence that medical care is offered in accordance to Bravo Health clinical care guidelines The medical record contains appropriate notation concerning use of alcohol cigarettes and substance abuse There is notation regarding follow up care calls or visits There is a separate medical record for each patient The documentation is consistent with ICD 9 codes Medical records are easily located and retrieved Forms used for documentation are consistent in all records There is a completed immunization record in accordance with the organization s adult preventive guidelines Chart is orderly Preventive screenings services are recommended There is documentation of a discussion of a living will or advance directives for patients 65 years of age or older or patients with life threatening conditions Clinical findings evaluations are documented Provider must meet these requirements for medical record keeping If opportunities for quality improvement are identifie
66. ede du Es 43 Prior Authorization Request Form tec ay a et e aite ee aa yh ka a as ie e a NL ha a deed 45 QUALITY IMPROVEMENT cae ietnca vs etras e a Q oeae vein ee in kakao es e E e tweveseecesteuosestetstoastes 46 Quality Improvement Programi eR GA AR ek eo AA RR A ie S 46 Healthcare Effectiveness Data and Information Set eene ener etra sss 47 ON SITE ASSESSMENTS costos oracion eae aeee te niae e ni acido acacia candelaria 48 SEA e EUR Ne Ete v M tee ub e rte pete ee dente ate RU te ates 48 Medical Record Review 5a cce ete Sana a E RR REN ER CATH QURE 48 HEALTH SERVICES uya aa 50 GC p 50 Clinical Review Gnudelifies n ere e ee ert ea el rae EN UR e ee e E Ue RUN RE TNT ate 50 Prospective Review Process c ceres ee ce eT e E ean RR UR REN AER EO EE e Bes AN RTI AERIS 51 Decision Time Frames eoe o n eap ad tes RN UR RR ue aee rt UN OR RU AREAS 51 Concurrent Review e REO RV Ae OR REI aed RR EAR COR RENE REED e D UR EI RS 53 Retrospective Review scu ec eU ERU T ER I EGO non 53 Referrals to Non Contracted Providets nasce RT A Rt E e Bens UN MR WERE A 53 Ambulatory Services n tese bon e EIU I A E OQ UE GN IRR UE DR ES QU Ee we 53 Discharge Planning a aaa reo Ran adeant eaedem tau ea 54 Case Management nete Egi reo Q Qan aha MER Feet Rie ee Net tae cae aeree uD sa pa uye 55 Skilled Nursing Cate tens tete e ta ceteri S etse te
67. edical Director Determination Certified Not Certified Medical Director Date 45 46 QUALITY IMPROVEMENT PROGRAM Bravo Health is committed to providing access to quality healthcare for all Members in all product lines through the continuous study implementation and improvement of care to our Members Quality Improvement OT assumes that there is no permanent threshold for good performance Our Members expect and should be provided a comprehensive and therapeutic health care delivery system that is always evolving and improving The Quality Improvement Department accomplishes this by integrating analyzing and reporting on data from across the Plan as well as other data sources The QI Department prioritizes quality initiatives based on relevance to the Plan QI works with internal Bravo Health departments to manage plan resources in the most cost effective manner to maximize patient health outcomes The following is a brief overview of the QI Department s functions The QI Department works on internal and external reporting of quality of care and risk management concerns Substantial QI Risk Management is presented to the Quality Improvement Committee QIC to formulate corrective action plans and monitor the results The QI Department assists Senior Management and the Medical Director in the coordination of the Quality Improvement activities The QIC is charged with providing oversight identi
68. embers can also get help from their SHIP Bravo Health Members have the following responsibilities 12 Along with rights Members have responsibilities by being a Member of Bravo Health Members are responsible for the following To become familiar with their Bravo Health coverage and the rules they must follow to get care as a Member Members can use their Bravo Health Evidence of Coverage and other information that we provide them to learn about their coverage what we have to pay and the rules they need to follow Members should always be encouraged to call Member Services if they have any questions or complaints To advise Bravo Health if the Member has other insurance coverage To notify Providers when seeking care unless it is an emergency that Member is enrolled with Bravo Health and present their plan enrollment card to the Provider To give their doctors and other Providers the information they need to care for the Member and to follow the treatment plans and instructions that they and their doctors agree upon Members must be encouraged to ask their doctors and other Providers questions whenever they have them To act in a way that supports the care given to other patients and helps the smooth running of their doctor s office hospitals and other offices To pay their plan premiums and any co payments they may have for the covered services they receive Members must also meet their other financial responsibilities that are
69. en at low risk and once every 12 months for women at high risk and for women of child bearing age who have had an exam that indicated cancer or other abnormalities in the past three years Pneumococcal Vaccine Generally once per lifetime Prostate Cancer Screening Digital Rectal Examination once every 12 months Prostate Specific Antigen PSA Test once every 12 months Routine Physical Exams 41 Health amp Wellness ForEver Fit Texas Health Education Mailings Smoking Cessation Includes counseling for two cessation attempts within a 12 month period for Members diagnosed with smoking related illness or are taking medicines that may be affected by stop smoking tobacco Counseling for each cessation attempt includes up to four face to face visits 42 PRIOR AUTHORIZATION MEDICINES AND INJECTIBLES The following list of drugs requires authorization under the Medicare Part B Benefit Short Description HCPCS Short Description HCPCS Short Description HCPCS Short Description Code Code Code J0129 Abatacept inj J0735 Clonidine Q2009 Fosphenytoin 50 mg J9230 Mechlorethamine hcl hydrochloride inj J0130 Abciximab injection J0770 Colistimethate J1458 Galsulfase inj J7669 Metaproterenol non sodium inj comp unit dose J7608 Acetylcysteine inh sol u J0800 Corticotropin J1560 Gamma globulin gt J7674 Meth
70. enroll in a specific plan and e Providers may not offer anything of value to induce a prospective Member to select them as their Provider PROVIDER CREDENTIALING AND PARTICIPATION Providers must be credentialed by Bravo Health according to the following guidelines Provider New to plan not previously credentialed Status Practicing in a solo practice Procedure Requires a signed contract and initial credentialing which may include a site visit depending upon Provider s specialty New to plan not previously credentialed Joining a contracted group practice Requires initial credentialing however a site visit is not be required regardless of specialty Already contracted and credentialed Leaving a group practice to begin a solo practice Does not require credentialing however a new contract is required and a new office location may require a site visit depending upon Provider s Specialty Already contracted and credentialed Leaving a group practice to join another contracted group practice Does not require credentialing and no site visit is required regardless of specialty Already contracted and credentialed Leaving a group practice to join a non contracted group practice The Provider s participation is terminated unless non contracted group signs a contract with Bravo Health Primary Care and OB GYN offices require site visits PROVIDER amp ALLIE
71. entricular thrombus Use of Warfarin in conjunction with aspirin and or clopidogrel is associated with increased risk of bleeding and should be monitored closely Patients with true aspirin allergy laryngospasm anaphylaxis should receive Clopidogrel ACE Inhibitors Start and continue indefinitely in all patients with left ventricular ejection fraction lt 40 and in those with hypertension diabetes or chronic kidney disease unless contraindicated Renin Angiotensin Among lower risk patients with normal left ventricular ejection fraction in whom cardiovascular risk Aldosterone System factors are well controlled and revascularization has been performed use of ACE inhibitors may be Blockers considered optional Angiotensin receptor blockers e Use in patients who are intolerant of ACE inhibitors and have heart failure or have had a myocardial infarction with left ventricular ejection fraction lt 40 e Consider in other patients who are ACE inhibitor intolerant Aldosterone Blockade Use in post myocardial infarction patients without significant renal dysfunction creatinine lt 2 5mg dl in men lt 2 0mg dl in women or hyperkalemia Potassium should be lt 5 0MEq L who are already receiving therapeutic doses of an ACE inhibitor and Beta Blocker have a left ventricular ejection fraction lt 40 and have either diabetes or heart failure Refer to the Clinical Practice Guideline for the Outpatient Management of CHF in Adults di St
72. eople who have smoked Bone Mass Measurements Dexascan Every 24 months more often if medically necessary Cardiovascular Testing Electrocardiogram and cardiovascular blood screenings to check cholesterol and other blood fat lipid levels Colorectal Screening Fecal Occult Blood Test once every 12 months if age 50 or older OR Flexible sigmoidoscopy generally once every 48 months if age 50 or older for those not at high risk 120 months after a previous screening colonoscopy OR Screening Colonoscopy generally once every 120 months high risk every 24 months 48 months after a previous flexible sigmoidoscopy No minimum age Colorectal Screening Barium Enema once every 48 months if age 50 or older high risk every 24 months when used instead of a sigmoidoscopy or colonoscopy Diabetes Screening Fasting Plasma Glucose Test Member may be eligible for up to two screenings each year see definition for coverage Influenza Vaccine once a year in fall winter Glaucoma Test once every 12 months indicated for those at high risk for glaucoma Hepatitis B Vaccine Three shots are needed for complete protection Indicated for those at medium to high risk for Hepatitis B Medical Nutrition Therapy Services For Members with diabetes or kidney disease and your doctor refers you for the service Mammogram once every 12 months for Members 40 years and older Pap amp Pelvic Exams Once every 24 months for wom
73. ervice is a Covered Service and pay your clean claims for Covered Services using the Members medical records Medical records and claims are generally used to review treatment and to do quality assurance activities It also allows Bravo Health to look at how care is delivered and carry out programs to improve the quality of care Bravo Health s Members receive This information also helps Bravo Health manage the treatment of diseases to improve Bravo Health s Members quality of life Bravo Health s Members have additional rights over their health information They have the right to e Send Bravo Health a written request to see or get a copy of information that we have about them or amend their personal information that they believe is incomplete or inaccurate If we did not create the information we will refer Bravo Health s Member to the source such as you e Request that we communicate with them about medical matters using reasonable alternative means or at an alternative address if communications to their home address could endanger them e Receive an accounting of Bravo Health s disclosures of their medical information except when those disclosures are for treatment payment or health care operations or the law otherwise restricts the accounting MEMBER RIGHTS AND RESPONSIBILITIES Bravo Health Members have the following rights The right to be treated with dignity and respect Members have the right to be treated with dig
74. evaluated must include but are not limited to the following 1 SO O ON UE P 10 11 12 13 14 15 16 17 18 19 20 The specific time of return is noted In days weeks months or as needed 22 23 Only authorized staff have access to medical records 25 26 27 21 24 28 29 30 31 Demographic personal data are noted in the record complete patient name date of birth home address and phone number sex marital status insurance and Member identification number An emergency contact person s name address and phone number or that there is no contact person is noted in the medical record Each page of the medical record contains patient s name or Bravo Health identification number All entries are legible signed and dated Significant illness medical and psychological conditions are indicated on the medical list Prescribed medications including dosage date of initial and or refill prescriptions are listed Allergies and adverse reactions to medications are prominently noted in the record Appropriate past medical history in the medical record History and physical are included in the record The working diagnosis are consistent with the findings Treatment plans are consistent with the diagnosis and is noted on every visit note There is documentation that the Member participated in the formulation of the treatment plan All diagnostic and therapeutic services for which a Member was referr
75. evated filling pressures a third heart Digoxin sound ventricular dilatation or depressed ejection fraction Useful drug in heart failure patients with atrial fibrillation with rapid ventricular rates Anti Coagulants Patients with heart failure and atrial fibrillation should be treated with Warfarin unless contraindicated in present systematic embolization Anticoagulation with Warfarin should be considered in patients with severely impaired systolic function and Warfarin high risk thromboemboli Considered administration of spironolactone at low dose 12 5mg to 25mg daily for patients receiving standard Aldosterone therapy who have severe heart failure caused by left ventricular dysfunction Antagonist Patients should have a normal serum potassium level and adequate renal function Spironolactone Monitor serum K levels at regular intervals and after any change in dosage Not routinely recommended but indicated in atrial fibrillation Antiarrhythmics Due to its low incidence of proarrhythmic effects in general amiodarone is the preferred drug when antiarrhythmic therapy is indicated in patients with heart failure for supraventricular tachycardia not controlled by Digoxin or beta blocker or patients with life threatening ventricular arrhythmia that are not candidates for implantable cardiac defibrillators Useofantiarrhythmic agents should not be used for the suppression of ventricular premature beats or no
76. f exposure to tobacco smoke occupational dusts and chemicals Smoke from home cooking and heating fuel Classification by Severity Stage 0 At Risk Stage 1 Mild COPD Stage 2 Moderate COPD Stage 3 Severe COPD Stage 4 Very Severe COPD Patient Education Prevention of Complications It is important to obtain a thorough history to screen for risk factors especially cigarette smoking occupational exposure and outdoor indoor pollution The most important risk factor for COPD is cigarette smoking The diagnosis should be confirmed by spirometry if patient has symptoms At initial assessment and periodically determine risk factors and causes of exacerbations Initiate and monitor cigarette and smoking cessation At initial assessment and annually According to the GOLD standards spirometry can be used to monitor disease progression but to be reliable the intervals between measurements must be at least 12 months apart Additional tests for the assessment of a patient with Stages II IV Bronchodilator Reversibility Testing CXR ABG Chronic cough and sputum production Avoidance of risk factors Lung function is normal Annual Influenza Vaccine FEV gt 80 FEV FVC lt 70 Mild airflow limitation and usually but not always chronic cough and sputum production FEV FVC lt 70 50 lt FEV lt 80 predicted Worsening airflow limitation and usually the progression of symptoms with shortness of breath developing on exer
77. fibrate or niacin before LDL lowering therapy and treat LDL C to goal after triglyceride lowering therapy Refer to NCEP III guidelines for details Screen all CAD patients for diabetes type 1 DM increases CAD risk three to ten fold Diabetes Type2 DM increases CAD risk two fold in men and four in women nitiate lifestyle and pharmacotherapy to achieve near normal HbA Ic Goal Begin vigorous modification of other risk factors e g physical activity weight management blood HbAlc lt 7 pressure control and cholesterol management as recommended above Coordinate diabetic care with patient s primary care physician or endocrinologist Refer to the Clinical Practice Guideline for Diabetes Care Exercise training improves exercise tolerance symptoms psychological well being lipid profiles and Physical Activity cardiac outcomes To guide exercise prescription assess risk preferable with exercise tolerance test Goal For all patient encourage of 30 60 minutes of moderate intensity aerobic activity such as brisk At least 30 minutes walking supplemented by an increase in daily lifestyle activities household work gardening Tdays week Encourage resistance training 2 days per week minimum 5 days For moderate to high risk patients recommend medically supervised Cardiac Rehab programs Physicians and patients are sometimes concerned about the safety of exercise training in patients with CAD although ther
78. fication prioritization and coordination of all quality improvement activities related to the care and service of our Members The QI Department coordinates with various internal departments on mandatory Centers for Medicare and Medicaid Services CMS audits such as Healthcare Plan Effectiveness Data and Information Set HEDIS and The Health Outcomes Survey HOS QI also contributes to Bravo Health s annual CMS site visit and quality reviews by the Pennsylvania Department of Health The QI department works to maintain optimal health outcomes for our Members through annual review of best practice standards Preventive standards are derived from The United States Preventive Services Task Force Standards USPSTF which are derived from the American Diabetes Association the American Cancer Society as well as other nationally recognized organizations Guidelines are revised and modified to reflect the latest in preventive best practices If you have any questions about Bravo Health s Quality Improvement Program or would like a comprehensive description of The QI Program QI Program Annual Goals or a list of activities towards achieving those goals please feel free to contact Bravo Health s Quality Improvement Department at Bravo Health Inc 3601 O Donnell Street Baltimore MD 21224 Information will be provided upon request QUALITY IMPROVEMENT PROGRAM A Goals e Coordinate all quality management audits and quality improvement
79. gy PET Scans Stress Echo RADIATION THERAPY Intensity Modulated Radiation Therapy IMRT Prior authorization is required only for elective admission A course of therapy occurring as part of an inpatient confinement that has met medical necessity criteria and been authorized does not require separate authorization Occupational Therapy after 1st 12 visits Physical Therapy after 1st 12 visits Pulmonary Rehabilitation Speech Therapy except initial evaluation Inpatient Place of Service 21 31 51 61 Note Emergency and urgent admissions do not require prior authorization Medical necessity criteria will be applied after facility s notification to Bravo Health Authorization for claims payment will only be granted to those meeting medical necessity criteria The following services do require authorization as outlined below DURABLE MEDICAL EQUIPMENT Diabetic Supplies initial set up only DME Purchase All Medicare Approved gt 200 Per Line Item All Prosthetics except mastectomy bras colostomy supplies indwelling Foley catheters Rentals All Repairs amp Maintenance All 37 INPATIENT SERVICES Acute Hospital Admissions All Acute Rehab Admissions All Behavioral Health Hospital Admissions CompCare or Corphealth See Behavioral Health Elective Admissions All Long Term Acute Care Hospital Admissions LTACH All Skilled Nursing
80. hat Bravo Health uses to determine coverage status for these medications please visit our website You may also request a printed copy of these criteria by contacting our Provider Services Department Step Therapy Bravo Health requires step therapy on the following 2 classes Proton Pump Inhibitors and Lipid lowering agents The first line therapy for the proton pump inhibitor class will be either generic Omeprazole or Zegerid If you require any other medications for your Members in this class prior authorization will be required For the lipid lowering class first line medications are Lovastatin Simvastatin and Pravastatin If you require any other medications in this class for your patients they will require prior authorization As always remember to prescribe generics to our Members Generic medications offer the lowest co payments and don t require you to fill out any paperwork or receive callbacks from the retail pharmacies asking you to switch to a formulary medication If you do prescribe a brand name drug that has a generic equivalent the pharmacy will automatically switch the drug to the generic medication If the Member requires the brand name drug due to a medical failure or allergic reactions to a generic medication you must contact Bravo Health to seek prior authorization for the brand name medication 65 PART D PHARMACY PRIOR AUTHORIZATION The following drugs DO NOT require prior authorization under the Part D benefit
81. he power to award punitive or exemplary damages As used herein punitive or exemplary damages include but are not limited to multiple damage awards and any award of attorneys fees regardless of whether these types of damages are based on statute or common law Notwithstanding the above in the event that either Party wishes to obtain injunctive relief such as a permanent or temporary restraining order such Party may initiate an action for such relief in a court of competent jurisdiction in the State of Texas The decision of the court with respect to the requested injunctive relief shall be subject to appeal only as allowed under applicable state or federal law However the courts shall not have the authority to review or grant any requests or demands for damages The judgment and award of the arbitrators shall be accompanied by detailed written findings of fact and conclusions of law At any time within one year after the award is made any party to the arbitration may apply to the United States District Court of Texas for an order confirming the award 69 9 10 11 70 Confidentiality of Arbitration Except in connection with the enforcement of such award or as otherwise may be required by law all aspects of such arbitration proceeding will be held in strict confidence by the Parties and arbitrators and shall not be disclosed to any third party without the prior written consent of the disclosing Party The parties agree that a
82. his information staff should direct Members to call Member Services How to get more information about Members rights Members have the right to receive information about their rights and responsibilities and if Members have questions or concerns about their rights and protections they should be directed to call Member Services Members can also get free help and information from their State Health Assistance Insurance Program SHIP In addition the Medicare program has written a booklet called Members Medicare Rights and Protections To get a free copy Members should be directed to call 1 800 MEDICARE 1 800 633 4227 TTY is 1 877 486 2048 Members can call 24 hours a day 7 days a week Or Members can visit www medicare gov on the web to order this booklet or print it directly from their computer What can Members do if they think they have been treated unfairly or their rights are not being respected If Members think they have been treated unfairly or their rights have not been respected there are options for what they can do e If Members think they have been treated unfairly due to their race color national origin disability age or religion we must encourage them to let us know immediately They can also call the Office for Civil Rights in their area e For any other kind of concerns or problem related to their Medicare rights and protections described in this section Members should be encouraged to call Member Services M
83. hospitals ancillary services and specialty Providers about the company s goals for providing quality value enhanced managed health care e To improve utilization of Bravo Health s resources by identifying patterns of over and under utilization that can be improved upon Clinical Review Guidelines Bravo Health has approved the following guidelines to be used for determining medical necessity and the appropriateness of care InterQual Criteria Guidelines ISP ISX ISD and SAC Utilization Management Policies and Procedures Technology Assessment Medicare National Coverage Decision Guidelines ASAM for Chemical Dependency and current literature and regulatory requirements for Mental Health Services MHN e Evidence of Coverage consistent with the contract definition of Medical Necessity Utilization Review decisions approving or denying payment of a service shall be based on the medical necessity and appropriateness of requested service the Member s individual circumstances and the appropriate contract language concerning benefits and exclusion All criteria utilized are available to any healthcare Provider upon written or verbal request 50 Bravo Health and delegated utilization review entities will involve actively practicing Providers in its development of criteria and in the development and review of procedures in applying the criteria Clinical criteria will be reviewed regularly and shall be modified as required to ref
84. iew information that is confidential protected and restricted under State and Federal Peer Review Laws The practitioner will be notified in the event that information obtained from other sources varies substantially from that provided by the physician and he or she will be given the opportunity to clarify and or correct this information prior to the finalization of the credentialing re credentialing process The practitioner has the right upon request to be informed of the status of their credentialing or re credentialing application The practitioner can contact their Provider Recruiter or the Bravo Health Credentialing Department at 866 442 7499 to make such a request Bravo Health Texas Inc conducts its credentialing and re credentialing processes in a non discriminatory manner and does not base its decisions for applicant participation solely on an applicant s race ethnic national identity gender age and sexual orientation or the types of procedures or types of patients the practitioner specializes in All decisions are based in the aforementioned criteria Bravo Health Texas Inc upon written request from a health care Provider that is applying to be credentialed or a physician who is already credentialed shall disclose the relevant credentialing criteria outlined above Bravo Health Texas Inc will not exclude from credentialing or terminate a health care Provider who has a practice that includes a substantial number of patie
85. iew is the process of continual reassessment of the medical necessity and appropriateness of acute inpatient care during a hospital admission in order to ensure Covered Services are being provided at the appropriate level of care These reviews are conducted telephonically Bravo Health is responsible for final authorization 2 The Concurrent Review process is performed telephonically by a licensed nurse The Bravo Health nurse confers with the attending Provider or other hospital staff Case Managers Social Workers Discharge Planners etc regarding the acute stay and any discharge planning needs and where appropriate speaking with the patient and or family 3 A Medical Director reviews any in patient days that do not meet medical necessity criteria and issues a determination All days which do not meet medical necessity criteria are discussed with the facility utilization staff and attending Provider and or PCP when appropriate or available In those instances where the admitting Provider does not agree with the determination the attending is encouraged to contact Bravo Health s Medical Director to discuss the appropriateness of the continued hospitalization The Medical Director then makes a determination to approve or deny the admission or days in question The Hospital s Utilization Review Department will be notified via facsimile of the daily log and or verbally regarding the status of the case and all denials All determinations to den
86. ion F APPLICABLE IMPORTANT INFORMATION REGARDING APPEAL RIGHTS IS ATTACHED Sample Bravo Health Payment Check Bravo Health Texas Inc 65 320 CHECK NO 0058522 7551 Callaghan Road Suite 310 San Antonio TX 78229 AMOUNT PAY Sixty Nine amp 49 100 dollars TO THE Get Well Medical Care P A ORDER OF PO BOX 3012 San Antonio TX 78229 1234 Wachovia Bank N A Philadelphia PA 19102 34 PRIOR AUTHORIZATION GENERAL RULES The following table outlines the general Bravo Health prior authorization and care direction procedures Ambulance Place of Service 41 No Authorization Required for 911 ambulance service Only Medicare covered ambulance services Routine Ambulance NOT COVERED Behavioral Health Inpatient amp Outpatient Pennsylvania amp Mid Atlantic Contact CompCare 1 800 541 3647 Texas Contact Corphealth 1 866 671 4537 Chiropractic The only codes covered to chiropractic care are 98940 98941 98942 98943 Clinical Trials Must Notify Plan Original Medicare Plan pays for clinical trials with 20 coinsurance to the Member Pennsylvania amp Mid Atlantic Contact Doral Dental 1 800 341 8478 Texas Contact StarDent 1 866 753 6319 Laboratory Lab services provided by any lab other than those listed below require pre authorization except for certain procedures that can be performed in outpatient settings See appropriate place of service guide for a list of co
87. lect current medical standards PROSPECTIVE REVIEW PROCESS Bravo Health requires prospective review of non urgent non emergent procedures that require the use of a facility other than the office InterQual internally developed clinical guidelines CMS guidelines National Decision Coverage Guidelines and Health Plan benefits contract and coverage guidelines are used to help make medical necessity determinations Decision Time Frames 1 Prospective review decisions on outpatient and inpatient elective procedures will be determined and communicated electronically or in writing to Bravo Health the Member and the healthcare Provider within 14 days of receipt of the request Bravo Health or the Member may extend this period an additional 14 days if the delay is in the best interest of the Member If the service requested can adversely affect the Member s life or function an expedited determination may be made within 3 days of the request or as soon as required by the health status of the Member Prospective Utilization Review decisions shall be communicated via telephone and or in writing to the requesting Provider and Member in accordance with the Standard Maximum Time Frames identified below Emergent Authorization not required using prudent layperson standards Urgent within 48 hours or as soon as the Member s health requires Expedited within 72 hours or as soon as the Member s health requires Routine within 14 days Au
88. leted internship residency training prior to January 1 1980 AND has ten year s of experience in his her trained specialty then the physician may be credentialed and listed in that designated specialty and is considered to be grandfathered 5 For physician listings in Bravo Health provider directories e Upon initial credentialing if a physician is board certified in his her primary specialty and has the appropriate fellowship training or board certification in his her subspecialty then the physician may be credentialed and listed in both the primary specialty and the subspecialty e Upon initial credentialing if a physician is not board certified in his her primary specialty then he she may not be listed in his her subspecialty The physician will be credentialed and listed only in his her primary specialty for which he she has the appropriate residency training as outlined in 4 above If the physician s designated specialty includes the provision of services in a hospital setting then a The physician must demonstrate active privileges at a state licensed acute care hospital that is currently contracted with Bravo Health or part of the evolving network or b The physician must provide to Bravo Health a written explanation as to why he she does not have hospital privileges and an acceptable method of hospitalizing Members Both the applicant and the Bravo Health contracted admitting physician must submit documentation of the
89. lid injection J3487 Zoledronic acid acetonide implt J9027 Clofarabine injection J1652 Fondaparinux sodium J7504 Lymphocyte immune globulin 44 D bravo Pri or Authorization Request Please fax to 1 866 464 0707 Type of Request Member Name PCP Requesting Provider Phone Referring To Service Requested Type of Service Service Description Procedure Description Date of Procedure facility Provider Diagnosis Codes Comments For Office Use Pre Cert Specialist Or call 1 888 454 0013 extension 336336 TX Bexar Harris El Paso Elective Expedited Date Time Rec d ID DOB Office Contact Person Fax e mail Specialty Facility ASC Out Patient Hospital In Patient Office Procedure DME Home Health PT OT ST Medications Medical Surgical Participating Provider Facility Non Participating Provider Facility Reason if requesting non par Procedure Codes Suppporting Clinical Information Attached Yes No If no was additional Information requested Yes No Date Requested M
90. lied Health Professionals must have graduated from an approved professional degree program for the specialty they are applying for participation Physicians must have completed a full residency training program accredited by one of the agencies listed below in the specialty designated as the individual s principal type of practice American Osteopathic Association AOA or the American Dental Association Commission on Dental Accreditation or the American Medical Association AMA Physicians and Allied Health Professionals must have and maintain a current and unrestricted license to practice medicine granted by each State where he or she has an office listing with Bravo Health Any Provider whose license is in a probationary status is not eligible for Membership 4 Physicians credentialed for participation with Bravo Health that are not board certified must have completed an approved residency training program with the following exception noted below If not board certified the credentialing staff will verify the physician s residency Residencies will be verified through the AMA or AOA physician master profile for the specialty being requested or by writing the residency program itself For podiatrists the residency will be verified by writing the residency program itself Board certification and residency verifications are completed within 180 days of being presented to the PACC Exception If a physician is not board certified but has comp
91. lonosetron HCl esrd use J0275 Alprostadil urethral J0881 Darbepoetin alfa J7310 Ganciclovir long act J2430 Pamidronate suppos non esrd implant disodium 30 MG J2997 Alteplase recombinant J9150 Daunorubicin J9201 Gemcitabine HCl J2504 Pegademase bovine 25 iu J0207 Amifostine J9151 Daunorubicin citrate J9300 Gemtuzumab J2503 Pegaptanib sodium liposom ozogamicin injection J0288 Ampho b cholesteryl J0894 Decitabine inj J9202 Goserelin acetate J9266 Pegaspargase singl sulfate implant dose vial J0285 Amphotericin B J0895 Deferoxamine Q4090 HepaGam B IM J9305 Pemetrexed injection mesylate inj Injection J0287 Amphotericin b lipid J9160 Denileukin diftitox J9225 Histrelin implant J9268 Pentostatin injection complex 300 meg J0289 Amphotericin b liposome J1190 Dexrazoxane HCl Q4083 Hyalgan or Supartz J9600 Porfimer sodium inj injection inj J0348 Anadulafungin injection J1162 Digoxin immune fab J3470 Hyaluronidase J2783 Rasburicase ovine injection Continued on next page 43 J7198 Anti inhibitor J0470 Dimecaprol injection 33473 Hyaluronidase Q4095 Reclast injection recombinant inj J7197 Antithrombin iii injection J1212 Dimethyl sulfoxide J1740 Ibandronate sodium J2993 Reteplase injection 50 50 ML inj J7511 Antithymocyte globuln J9170 Docetaxel J1742 Ibutilide fumarate Q4089 Rhophylac injection rabbit injection J0364
92. me that they are going to be hospitalized and they have signed an advance directive take should a copy with them to the hospital If Members are admitted to the hospital the hospital will ask them whether they have signed an advance directive form and whether they have it with them If Members have not signed an advance directive form the hospital has forms available and will ask if the Member wants to sign one Remember it is a Member s choice whether he she wants to fill out an advance directive including whether they want to sign one if they are in the hospital According to law no one can deny them care or discriminate against them based on whether or not they have signed an advance directive If Members have signed an advance directive and they believe that a doctor or hospital has not followed the instructions in it Members may file a complaint with their State s Board of Medicine The right to make complaints Members have the right to make a complaint if they have concerns or problems related to their coverage or care Appeals and grievances are the two different types of complaints Members can make If Members make a complaint Bravo Health must treat them fairly 1 e not discriminate against Members because they made a complaint Members have the right to get a summary of information about the appeals and grievances that have been filed with Bravo Health in the past To get this information Members should be directed to
93. n sustained ventricular tachycardia which is either asymptomatic or perceived as palpations Use of most calcium channel blockers is not recommended unless needed for hypertension or rapid response of atrial Other fibrillation Monitor Serum K Complied From evels on a regular basis Consider low potassium duet and avoid foods high in potassium um Guidelines for the Evaluation and Management of Heart Failure Report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines Committee on Evaluation and Management of Heart Failure Circulation 1995 92 2764 84 reviewed 2005 2 US Department of Health and Human Services Agency for Health Care Policy and Research Heart failure evaluation and care of patients with left ventricular systolic dysfunction Rockville The Agency 1994 Clinical Practice Guideline No 1 AHCPR Publication No 94 0612 3 Heart Failure Society Guidelines A Model of Consensus and Excellence Pharmacotherapy 20 5 495 522 2000 4 Institute for Clinical Systems Improvement Inc Health Care Guidelines Congestive Heart Failure in Adults November 2000 Utilization Management Committee will review Guidelines for new scientific evidence or national standard changes prior to distribution to Providers annually 59 09 Y919 21 711 4unida1 139 310 s eumofeye 9119 d9y ye ALAL ouropm3 1x9 114 VHV OOV x P1090 eorpour ot ur pojuoumoop og p nous 1 punoze uorss
94. nd Utilization Management programs Use appropriate designated ancillary services Comply with emergency care procedures Comply with Bravo Health access and availability standards as outlined in this manual including after hours care e Bill Bravo Health on the CMS 1500 claim form or electronically in accordance with Bravo Health billing procedures e When billing ensure that coding is specific enough to capture to acuity and complexity of a Member s condition and ensure that the codes submitted are supported by proper documentation in the medical record e Comply with Preventive Screening and Clinical Guidelines e Adhere to Bravo Health s medical record standards as outlined on page 49 of this manual THE ROLE OF THE SPECIALIST PHYSICIAN e Provide specialty services e Collaborate with Bravo Health Primary Care Physician to enhance continuity of health care and appropriate treatment e Provide consultative and follow up reports to the referring physician in a timely manner e Comply with access and availability standards as outlined in this manual including after hours care e Comply with Bravo Health s pre authorization process e Comply with Bravo Health s Quality Management and Utilization Management programs e Bill Bravo Health on the CMS 1500 claim form in accordance with Bravo Health s billing procedures e When billing ensure that coding is specific enough to capture to acuity and complexity of a Member s condi
95. ng address Bravo Health Claim Reconsideration Team P O Box 26038 Baltimore MD 21224 Bravo Health will review your request and respond within 60 days of receipt of the request If our original claim adjudication decision is reversed in whole or in part the claim will be reprocessed and paid within 60 days If our original claim adjudication decision is upheld we will respond in writing and include a reason for the reconsideration denial If you disagree with the outcome of the claim reconsideration process or for any dispute other than claim reconsideration you may pursue dispute resolution as described on page 67 of this Manual and in your Agreement with us You do have the right in most instances to file an appeal on behalf of a Bravo Health Member provided the Member has specifically authorized you to act on his her behalf A copy of the Member s written authorization must accompany the appeal 25 9c UOngzuoujne IY Jo 9J8P AnO 9JJ9 IY 1oJ 9q PIJIPUII SEM SOIAIOS STUL SALVA NOILVZIMOHLNV SALVGaad COT S9poo VSV UJIM WWE SITU JUIQNSII oseo d Sopoo VSV JIM pejiruimqns oq ISNU sure ersoujsouy SHUOD VISAHLSANV IdO HLIM TIIH ZOT s poo SISOUSEIP oyeridoidde UJIM JUUIQNSII oseo d SISONDVIC DNISSIN 16 3DIAJIS JO JOLTA 1231100 IY U IM JUUIQNSII ISBI A SOIANSIS HO HOVIA LOHAAOONI 78 p uro ds s3run Jo 19QUINU y UJIM JUQ
96. nity respect and fairness at all times Bravo Health must obey laws against discrimination that protect Members from unfair treatment These laws say that Bravo Health cannot discriminate against Members treat Members unfairly because of a person s race disability religion sex sexual orientation health ethnicity creed age or national origin If Members need help with communication such as help from a language interpreter they should be directed to call Member Services Member Services can also help Members in filing complaints about access such as wheel chair access Members can also call the Office of Civil rights at 1 800 368 1019 or TTY TDD 1 800 537 7697 or the Office for Civil Rights in their area The right to the privacy of medical records and personal health information There are federal and state laws that protect the privacy of Member medical records and personal health information Bravo Health keeps Members personal health information private as protected under these laws Any personal information that a Member gives Bravo Health when they enroll in our plans is protected Bravo Health staff will make sure that unauthorized people do not see or change Member records Generally we will get written permission from the Member or from someone the Member has given legal authority to make decisions on their behalf before we can give Member health information to anyone who is not providing the Member s medical care There are
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98. nsure that coverage is available 24 hours a day seven days a week PCP offices must be able to schedule appointments for Bravo Health Members at least two 2 months in advance of the appointment A PCP must arrange for coverage during absences with a Bravo Health Participating Provider in an appropriate specialty which is documented on the Provider Application and agreed upon in the Provider Agreement Primary Care Access Standards Appointment Type Access Standard Urgent Within 24 hours Non Urgent Non Emergent Within 48 hours Routine and Preventative Within 4 weeks On Call Response After Hours Within 30 minutes for emergency Waiting Time in Office 30 minutes or less Specialist Access Standards Appointment Type Access Standard Urgent Within 24 hours Non Urgent Non Emergent Within 48 hours Elective Within 4 weeks High Index of Suspicion of Malignancy Less than one 1 week After hours Access Standards All Participating Providers must return telephone calls related to medical issues Emergency calls must be returned within 30 minutes of the receipt of the telephone call Non emergency calls should be returned within a 24 hour time period A reliable 24 hours a day 7 days a week answering service with a beeper or paging system and on call coverage arranged with another Participating Provider of the same specialty is preferred Behavioral Health Access Standards
99. nts with expensive medical conditions 20 PROVIDERS DESIGNATED AS PRIMARY CARE PHYSICIANS PCPs Bravo Health recognizes the following physician types as PCPs e Family Practice e General Practice e Geriatric Medicine e Internal Medicine Bravo Health also recognizes Infectious Disease physicians as a PCP for Members who may require a specialized physician to manage their specific healthcare needs CHANGES IN ADMINISTRATIVE MEDICAL AND OR REIMBURSEMENT POLICIES From time to time Bravo Health may amend alter or clarify its policies Examples of this include but are not limited to regulatory changes changes in medical standards and modification of Covered Services Specific Bravo Health policies and procedures may be obtained by calling our Provider Services Department Bravo Health will communicate changes to the Provider Manual through the use of a variety of methods including but not limited to Annual Provider Manual Updates Letter Facsimile E Mail Provider Newsletters Providers are responsible for the review and inclusion of policy updates in the Provider Manual and for complying with these changes upon receipt of these notices NOTIFICATION REQUIREMENTS FOR PROVIDERS Participating Providers must provide written notice to Bravo Health 60 days in advance of any changes to their practice or if advance notice is not possible as soon as possible thereafter These changes should be communicated to the Bravo Health Pro
100. offices participate for the purpose of providing health care to patients If the relationship between the physician or oral surgeon and Bravo Health should be terminated at any point for any reason other than a voluntary termination a one year period will elapse prior to eligibility for reapplication Upon reapplication all the circumstances of the termination resignation must be revealed and will be considered INITIAL CREDENTIALING OFFICE SITE REVIEWS 1 Provider Relations staff shall conduct initial credentialing office site reviews using the Office Site Evaluation Form The Office Site Evaluation Form is divided into the following sections Physical Appearance and Accessibility Patient Safety and Risk Management Medical Record Keeping and Storage Appointment Avallability e Each section of the Office Site Evaluation Form addresses a review topic with questions to be answered YES NO or N A not applicable Each answer is scored and scores are added to generate an overall score for the office site Results of the office site review shall be reported directly to the reviewed office site Objective findings and recommendations for improvement of deficiencies shall be included in the report Any office site scoring below 80 will be given thirty 30 days in which to submit and ninety 90 days to complete a corrective action plan for identified deficiencies Upon completion of the corrective action plan a re
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102. ons with diabetes In persons without overt CVD over the age of 40 years statin therapy to achieve an LDL reduction of 30 40 regardless of baseline LDL is recommended In persons with overt CVD all persons should receive statin therapy to achieve an LDL reduction of 30 40 Retinopathy Dilated eye Annual Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination exam performed by an eye care specialist within three to five years after the onset of by an diabetes Persons with type 2 diabetes should have an initial dilated and Eye Care comprehensive eye exam shortly after the diagnosis of diabetes Subsequent dilated Specialist comprehensive eye examinations for persons with type and type 2 diabetes should be performed annually Nephropathy Micro Annual Perform an annual test for the presence of microalbuminuria in persons with type 1 albumin diabetes with diabetes duration of gt 5 years and in all persons with type 2 diabetes starting at diagnosis In persons with any degree of CKD protein intake should be limited to RDA 0 8g kg to reduce the risk of nephropathy Serum Creatinine Serum Creatinine should be measured at least annually for the estimation of glomerular filtration rate in all adults with diabetes regardless of the degree of urine albumin excretion The serum creatinine alone should not be used as a measure of kidney function but instead used to estimate GFR and stage the level of CKD Hyper
103. or all of their health care from Participating Providers that is from doctors and other health Providers who are part of Bravo Health Members have the right to choose a Participating Provider Bravo Health will tell Members which doctors are accepting new patients Members have the right to go to a women s health specialist such as a gynecologist without a referral Members have the right to timely access to their Providers and to see specialists when care from a specialist is needed Members also have the right to timely access to their prescriptions at any network pharmacy Timely access means that Members can get appointments and services within a reasonable amount of time The Evidence of Coverage explains how Members access Participating Providers to get the care and services they need It also explains their rights to get care for a medical emergency and urgently needed care The right to know treatment choices and participate in decisions about their health care Members have the right to get full information from their Providers when they go for medical care and the right to participate fully in treatment planning and decisions about their health care Bravo Health Providers must explain things in a way that Members can understand Members have the right to know about all of the treatment choices that are recommended for their condition including all appropriate and medically necessary treatment options no matter what they cost or whe
104. or attending Provider Bravo Health and enrollee of the denial and the Appeal process including time frames and methods for filing an Appeal e Generate a notice of adverse determination to the attending Provider and the Member within two 2 business days of the determination or within 14 days of receipt of the request whichever is less either via facsimile or in writing 5 Ifthe prospective review does not occur prior to the procedure e g the procedure was performed on an urgent basis a review will be conducted within twenty four 24 hours of notification of the procedure 6 Prospective or pre pre service authorization is valid for ninety 90 days from the date of issuance All prospectively reviewed treatment which is not begun within ninety 90 days from the date of issuance will require another pre service review 7 Pre service review procedures will include provisions for the identification of Members with special circumstances who may require flexibility in the application of screening criteria and for those for whom case management services would be appropriate 8 The information regarding the medical necessity for an approval of a prospective review request will be accepted from any source including but not limited to phone facsimile and or written correspondence and can be initiated by any of the following entities Provider Member or authorized representative of the Member 52 CONCURRENT REVIEW 1 Concurrent Rev
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107. peat office site review will be performed 6 The completed Office Site Evaluation Form will be placed in the practitioner s Credentialing file prior to review by the PACC Member Complaint or Quality of Care Concern 1 In response to a Member complaint and or Quality Improvement office site or a quality of care concern relating to office site issues Provider Relations staff shall conduct an office site review using the same Office Site Evaluation Form and procedures as at initial credentialing or a different data tool depending on the substance of the complaint 2 Results of office site review will be evaluated along with the complaint or quality of care concern by the Provider Advisory Credentialing Committee PROVIDER RE CREDENTIALING All Participating Providers must adhere to the re credentialing requirements established by Bravo Health The standard states that Providers must be formally re credentialed every three 3 years It is imperative that Providers complete the re credentialing process in order remain in good standing and continue to treat Bravo Health Members Non compliance with the re credentialing process in advance of the Provider s due date for re credentialing will result in termination from the Bravo Health Provider network PRACTITIONER S RIGHTS The practitioner has the right to review information submitted to Bravo Health in support of his or her credentialing re credentialing application except for peer rev
108. rative denial based on Covered Services eligibility etc b Only the Medical Director makes the decision for denial based on medical necessity but he she can also make a decision on administrative guidelines The Medical Director in making the initial decision may elect to suggest an alternative Covered Service to the requesting Provider A denial notice is issued documenting the original request that was denied and the alternative service and the process for appeal If the Provider agrees he she notifies the Member Notification of Denials 56 a The reason for each denial including the specific utilization review criteria or benefits provision used in the determination of the denial are included in the written notification and sent to Members and Providers b The criteria used to determine the coverage is available to the Provider and Member upon request C All denials for retrospective review are sent to Providers within five working days of making the decision CONTINUITY OF CARE Bravo Health s policy is to provide for continuity of and coordination of care among medical practitioners treating the same patient coordination between medical and behavioral care and to minimize potential continuity problems caused when a practitioner leaves a network and has patients in active treatment Any Member who is currently undergoing treatment upon the termination of a Provider for reasons other than those associated with quality of ca
109. re or a Member who is new to Bravo Health may be allowed to continue care with their current Provider for up to 90 days from the date the enrollee is notified by the plan of the termination or pending termination of a Contracting Provider Members undergoing active treatment for a chronic or acute medical condition will have access to such discontinued Provider through the current period of active treatment for up to 90 calendar days whichever is shorter Members in their second or third trimester of pregnancy have access to their discontinued practitioner through the postpartum period If Bravo Health terminates a Contracting Provider for cause Bravo Health will not be responsible for the health care services provided by the terminated Provider to the enrollee following the date of termination Members with previously scheduled treatments or procedures and Members in the middle of an episode of care may be allowed to continue care with their current Provider for up to 90 days from the date the Member is notified by Bravo Health of the termination or pending termination of a healthcare Provider 57 CLINICAL PRACTICE GUIDELINES OUTPATIENT MANAGEMENT OF CONGESTIVE HEART FAILURE IN ADULTS GOALS FOR DIAGNOSTIC Establish Ejection Fraction and document the Left without resulting Ventricular Dysfunction Determine underlying cause of heart failure EVALUATION Identify precipitating or aggravating correctable factors
110. ris muntha citur ametur ct tisha Pos Mu Matt sos os 55 Einlergency Setvi Ces coste itn o cet iste turf stet scuta i ep th iter etie oe hile goo akapa tee DE ones 55 Decision Time Frames titres do tot as tel e ete tore on ch toad Pha tS ses 56 AAA O 56 Rend ring Dentales tte aso colt ted soe ones hiis batte llas lo ten testes ces llos apa ra es AGA 56 Notification of Denials 2 1 EE S T m ett ua aaa o 56 CONNOR 57 CLINICAL PRACTICE GUIDELINES sscscccssovchconsscssdccscesescevevedcesssabsorucethesevseetsncerccosarsesvsedets coduorsvevaeceevecs ccdsoceesvuesedysevuesdusvavecevece e 58 Congestive Heart Fail re adden eerte e de dette e Te ede tede dede eet de RT ERR d ee aede d 58 CHF Pharmacological Treatment Options eere nn rennen tren trennen entere erret 59 Heart Failure Disease Classification esie e etes i etie eerte SAVO KO dettes de Yee dee e dece ee ERR eed ed 60 DiabeteS e 61 Coronary and Other Vascular Disease isses eee ii e E Ee Reed edd 62 COPD orahe maa n m leith we elt ea GPS p esp eh an eder ete e Pe ot RE OE OE E DRE i la 64 PHARMACEUTICAL MANAGEMENT si sssscssscssscosssssecesssecsscosesscsssesesestesessecvesscosstacasdctetesccsstessoasessesssestesesessecoessossustoss osised itos siS 65 SL eee eee Reng dade ae eee 65 PriOr AA da 66 ALTERNATIVE DISPUTE RESOLUTION
111. risk is measured by assessing the diagnostic characteristics ICD 9 of the Member rather than assessing what treatments CPT they have received Provider must document the Member s conditions and diseases accurately using ICD 9 codes and extend to the fifth digit where appropriate This is particularly true for high risk conditions where co morbidities make a significant difference in risk scoring Diabetes is a perfect example of where ICD 9 code 250 is not enough to establish the extent of diabetic complications such as neuropathy blindness and vascular disease Chronic conditions must be documented at least once a year to ensure correct risk stratification of the Member Ensure that all diagnosis codes are transferred to the CMS 1500 claim form when billing For complicated cases this may require additional CMS 1500 forms to document more than four diagnoses It is important that you document the diagnosis clearly and update the Member s problem list with each encounter Even visits for minor conditions in patients with persistent conditions should be first coded with the conditions for which the patient is seen and second with accurate co morbid codes for persistent conditions like diabetes and CHF This will ensure that we capture accurate information on your patients annually The Member s name should be recorded on each page of the medical record and the physician should sign and date each entry To meet CMS requirements and to initia
112. rotecting our Member s personal information Bravo Health does not give out any Member information to anyone without obtaining consent from an authorized person s unless we are permitted to do so by law Because you are a valued Provider to Bravo Health we want you to know the steps we have taken to protect Bravo Health s Members privacy This includes how we gather and use their personal information Bravo Health s privacy practices apply to all of Bravo Health s past present and future Members When a Member joins a Bravo Health Medicare Advantage plan the Member agrees to give Bravo Health access to Protected Health Information Protected Health Information PHT as defined by the Health Insurance Portability and Accountability Act of 1996 HIPAA is information created or received by a health care Provider health plan employer or health care clearinghouse that i relates to the past present or future physical or mental health or condition of an individual the provision of health care to the individual or the past present or future payment for provision of health care to the individual 11 identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual and iii is transmitted or maintained in an electronic medium or in any form or medium Access to PHI allows Bravo Health to work with Providers like yourself to decide whether a s
113. sess the quality of care and services provided by prospective or Participating Providers Structural elements of quality care and services are evaluated On site evaluations must be performed for all PCPs OB GYNs and high volume Behavioral Health Providers prior to initial credentialing and re credentialing Components assessed during an on site evaluation include but are not limited to the following Office Standards 1 Facility appearance cleanliness Patient care services Ancillary services 0 Medical records organization and maintenance according to CMS and NCQA Medical record documentation standards 11 Safety and emergency procedures 12 Member oriented educational material 13 Advance Directives and Treatment Planning 2 Access to services 3 Administrative organizational structure 4 Policy and procedure manuals 5 Personnel 6 Confidentiality 7 Fire safety emergency 8 9 1 Medical Record Review 48 Confidentiality of Records Participating Providers and Bravo Health agree that all Members medical records shall be treated as confidential to comply with state and federal laws regarding confidentiality of medical records However nothing shall limit timely dissemination of such records to authorized Providers and consulting physicians to governmental agencies as required and permitted by law to accrediting bodies to committees of Provider and Plan concerned with the quality of care and utilization an
114. so1 KJIADL eorsAud AreUIpIO 4831 W o qe110Ju10 Ayay eorsAud Jo uonejruig JUSIJS ur SUN NSOI oseosrp oerpaeo YIM spune d oNRBUIOJdUI S AIPIN II SSE ured eursue 10 esudsAp suoyeyidjed onsyey opun osneo zou s op Apay eorsAud KILUIPIO Ayayo eorsAud JO suonplyut SUN NSOI JNOUJIM mq oseosrp OLIPILO YIM sjuoTeg IHLUOJdUKSY I SSe NOLLVOMISSVTIO ASVASIG MOTIVA L3V3H NOLLVIOOSSY LAVAH MHOA MAN OUTPATIENT MANAGEMENT OF DIABETES Aspect of Monitor Frequency Target Recommendations Care Outcome Glycemic Quarterly Target hemoglobin Alc A1C should be individualized A reasonable goal for A1C Control or in relatively healthy adults with good functional status is 7 or lower For frail older Semi adults persons with life expectancy of less than 5 years and others in whom the risks Fix font so Annual of intensive glycemic control appear to outweigh the benefits a less stringent they all treatment goal may be appropriate match Obtain A1C test quarterly in persons whose therapy has changed or who are not meeting glycemic goals Obtain AIC test at least twice yearly if at goal and who have stable glycemic control Use of Point of Care Testing for A1C allows for timely decisions on therapy changes when needed Lipids LDL Annual lt 100 mg dl Lifestyle modification focusing on the reduction of fat and cholesterol intake weight loss if indicated and increased physical activity has been shown to improve the lipid profile in pers
115. t least 1 000 000 per incident and 3 000 000 aggregate or minimum amounts according to community standards Physicians must meet Bravo Health standards for medical office certification and medical record assessment if applicable to their specialty Physicians must demonstrate professional growth and development through continuing education demonstrated by obtaining 50 hours of Category I AMA recognized Continuing Medical Education CME credits every two years A current AMA Physician s Recognition Award will satisfy this criterion This requirement will be waived e In any year a physician becomes board certified or re certified or e Ifthe physician is in his her first year of practice Allied Health practitioners must demonstrate professional growth and development through continuing education units at the time of re credentialing If any practitioner is indicted for a felony or a crime including moral turpitude dishonesty or false statement or other acts that practitioner will be suspended and may be terminated if the outcome is a conviction a Physicians must exhibit understanding of and agree to Bravo Health policies relative to the provision of health care services including ancillary services and adherence to the HMO s utilization cost containment and quality assessment policies b Physicians must agree to cooperate with and or respond to Bravo Health investigations of Member complaints quality activities and or satisfa
116. tary of Health and Human Services adopt a standard unique identifier for health care providers called the National Provider Identifier The unique Health Identifier for Health Care Providers rule was published January 23 2004 with an effective date of May 23 2008 The National Provider Identifier Number The rule establishes a standard nationally assigned non intelligent Provider identifier required to be used in all electronic health care transactions This number will be a 10 digit numeric unique identifier with an International Standard Organization ISO check digit in the 10 position This check digit acts the same way your checking account numbers allow banking institutions to verify your account number A Provider will have one number only and the Provider will use this number for every health plan they submit electronic transactions too Once a Provider is enumerated with an NPI this number will not change ever The NPI remains with the Provider regardless of job or location change Who will have responsibility of issuing the NPI The National Provider System Fox Systems Inc has the sole responsibility for issuing all NPI s to every provider in the country This system is a comprehensive uniform system for identifying and uniquely enumerating health care providers at the national level The Department of Health and Human Services DHHS will have overall responsibility for oversight and management of the system How
117. te the risk adjustment chart and case management review process Bravo Health requires your cooperation in providing access to office medical records On a regular basis you will receive written notification from Bravo Health requesting a chart audit Please be assured that we will conduct these audits efficiently and professionally with minimal disruption to your office workflow In addition our certified coders or nurse coders will be glad to come to your office to work with you and or your staff to resolve any coding issues that may arise 33 Sample Explanation of Benefits Statement Bravo Health Texas Inc P8790028002 7551 Callaghan Road Suite 310 San Antonio TX 78229 Forwarding Service Requested TEST 1 0 3840 SP 0 370 Date 06 29 2006 it Vendor 9370 Get Well Medical Care P A Voucher Number 64687 PO BOX 3012 Check ID P6041 San Antonio TX 78229 1234 Check Number 058522 Explanation of Payment Member ID 449999999 Option BSEL Provider Acct No AB 458518 Member Name SMITH JOHN Claim Number 205062201700120 Provider Name William Physician From Date of To Date of Service Billed Allowed Copay Deductible Adjustment Interest Payment Reason Service Service Code Amount Amount Coinsurance Code 05 13 2008 05 13 2008 99213 253 00 94 49 25 00 0 00 0 00 0 00 69 49 Claims Totals 253 00 94 49 25 00 0 00 0 00 0 00 69 49 Vendor Totals 253 00 94 49 25 00 0 00 0 00 0 00 69 49 Remark Code Explanat
118. tension Blood Each visit If patient has hypertension then the target blood pressure should be less than 130 80 Pressure if it is tolerated Because older adults may have reduced tolerance for blood pressure reduction hypertension should be treated gradually to avoid complications Foot Care Foot exam Annual All persons with diabetes should receive an annual foot examination to identify high risk foot conditions This examination should include assessment of protective sensation foot structure and biomechanics vascular status and skin integrity Persons with neuropathy should have a visual inspection of their feet every office visit by a health care professional This table of suggested guidelines has been developed from the American Diabetes Association 2007 Standards of Medical Care in Diabetes Diabetes Care 29 S4 842 2006 It is intended to provide guidance to practitioners to reduce risks associated with diabetes increase awareness of diabetes and to optimize disease management It contains guidelines only and should never supersede clinical judgment The practitioner in conjunction with the patient should decide whether these or other recommended services should be performed more or less frequently Clinical judgment and discussion should be documented in the medical record Utilization Management Committee will review Guidelines for new scientific evidence or national standard changes prior to distribution to Providers annually 9
119. ter data should be submitted to Bravo Health s Claims Department If a Provider provides services that require prior authorization without obtaining prior authorization the claim for those services will be denied If appropriate Providers must include the following additional attachments to their claim submission e If Bravo Health is the secondary payer the primary payer s Explanation of Payment e For Institutional Claims a itemized bill for pharmacy charges or claims exceeding stop loss thresholds 24 PARTICIPATING PROVIDER CLAIM RECONSIDERATION PROCESS As a Participating Provider you have the right to initiate a Claim Reconsideration Request and seek to have Bravo Health review its claim adjudication decisions You have sixty 60 days from the date you received Bravo Health s claim denial or claim adjustment notice to request a review of our administrative decisions Your Claim Reconsideration Request must be in writing and include the following information 1 The name of the Member the Member s date of birth and the Member s Bravo Health identification number 2 Provider name and address A copy of the specific claim and our payment adjustment or denial notice 4 An explanation of the specific service and dates of service for which payment was adjusted or denied and using applicable Provider Agreement provisions your rationale for requesting a reconsideration uy Y our request should be sent to the followi
120. the receipt of the request Bravo Health recognizes the need for prompt handling of all referrals and will communicate directly with the requesting Provider s office all rendered decisions via telephone communication and or facsimile Denials Efforts are made to obtain all necessary information including pertinent clinical information from the treating Provider to allow the Medical Director to make coverage determinations The Medical Director Is avallable by telephone to the Provider to discuss determinations based on medical necessity A denial may occur a At the time of prospective pre service review The process for discussion of such denials between Bravo Health s Medical Director and the Provider of care will be documented by the UM department staff and processed according to the adverse decisions policy b At the time of concurrent review the health plan will notify the acute facility via facsimile or verbally within 24 hours after receipt of all clinical information needed to render a determination Denial notification is sent to the facility and patient only when in a non Contracting facility in writing at the end of the admission stay A copy of the letter is also sent by mail to the attending Provider notifying him her of any downgrade or denied determination c At the time of a request for authorization for a non Covered service Rendering Denials a The Utilization Management staff can make the decision for an administ
121. ther they are covered by Bravo Health This includes the right to know about the different Medication Management Treatment Programs Bravo Health offers and in which Members may participate Members have the right to be told about any risks involved in their care Members must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice of refusing experimental treatments Members have the right to receive a detailed explanation from Bravo Health if they believe that a plan Provider has denied care that they believe they are entitled to receive or care they believe they should continue to receive In these cases Members must request an initial decision Initial decisions are discussed in the Members Evidence of Coverage Members have the right to refuse treatment This includes the right to leave a hospital or other medical facility even if their doctor advises them not to leave This includes the right to stop taking their medication If Members refuse treatment they accept responsibility for what happens as a result of refusing treatment The right to use advance directives such as a living will or a power of attorney 10 Members have the right to ask someone such as a family member or friend to help them with decisions about their health care Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness If a Member wants to
122. thorization and or denial or alternative treatment is the end result of prospective review While prospective review is preferable and must occur prior to planned care e g elective admissions situations will exist when a prospective process is not feasible e g emergency admissions and or does not occur The Provider is responsible for the prior authorization of all scheduled admissions or services The Provider shall obtain prior authorization for admissions services on a prospective basis when possible and in a timely manner that ensures Member s access to medically appropriate care Bravo Health s Utilization Management UM Department is responsible for the prospective review of admissions services the authorization ensures that the Member receives the proposed treatment in the appropriate type of facility location The prospective review process shall occur only after the authorization for proposed treatment is obtained by the Provider when indicated by the Provider Agreement Without the Provider s approval an authorization number will not be issued The clinical information regarding the Member the severity of the Member s illness and the proposed plan of care are assessed and evaluated by UM The guidelines listed above are utilized for screening medical and surgical care for the first level review Examples of information needed include but are not limited to 51 Member name and identification number Location of ser
123. tion FEV FVC lt 70 30 lt FEV lt 50 predicted Further worsening of airflow limitation increased shortness of breath and repeated exacerbations which have an impact on patients quality of life FEV FVC lt 70 FEV lt 30 predicted or FEV lt 50 predicted plus chronic respiratory failure Severe airflow limitation quality of life is very appreciably impaired and exacerbations may be life threatening Patient education is an effective way to accomplish smoking cessation improve knowledge of disease and associated signs and symptoms and improve responses to acute exacerbations How to assess severity of an exacerbation PaO lt 60mmHg and or SaO lt 90 with or without PaCO gt 50mmHg when breathing room air indicates respiratory failure PaO lt 50 and PaCO gt 70 and pH lt 7 30 suggest a life threatening episode that needs close monitoring or critical management Short Acting Bronchodilator when needed Albuterol terbutaline metaproterenol ipratropium Tier 1 Proventil HFA Ventolin HFA Atrovent HFA Tier 2 Continue short acting Bronchodilators as needed Add treatment with one or more long acting bronchodilators Servent Spiriva Tier 2 Pulmonary Rehabilitation Short and long acting bronchodilators Pulmonary Rehabilitation Inhaled Glucocorticosteroids if repeated exacerbations Asmanex Flovent HFA Pulmicort Tier 2 Combo w long acting bronchodilator Advair Tier 2 Add long term c
124. tion and ensure that the codes submitted are supported by proper documentation in the medical record e Refer to Bravo Health Participating Providers only e Submit encounter information to Bravo Health accurately and timely e Adhere to Bravo Health s medical record standards as outlined on page 49 of this manual COMMUNICATION BETWEEN PROVIDERS e PCP should provide Specialist Physician with relevant clinical information regarding the Member s care Specialist Physician must provide PCP with information about his her visit with the Member in a timely manner PCP must document in the Member s chart his her review of any reports labs or diagnostic tests received from a Specialist Physician PROVIDER MARKETING GUIDELINES Bravo Health Participating Providers must adhere to the following guidelines with regard to any marketing activities e Ensure that any marketing activities are approved in advance by Bravo Health to ensure compliance with CMS guidelines e Ensure that any letters events health fairs etc are reported to and cleared in advance by Bravo Health e Ensure that any gifts or promotional items are cleared with Bravo Health in advance 14 e Providers may make available and or distribute Bravo Health marketing materials and display posters in accordance with and subject to Medicare Marketing Guidelines e Providers may not make available accept or distribute plan enrollment applications or offer inducements to
125. toxin a per unit Q4085 Euflexxa inj J9178 Inj epirubicin hcl 2 J3240 Thyrotropin injection mg J0587 Botulinum toxin type B J7194 Factor ix complex J1595 Injection glatiramer J1655 Tinzaparin sodium acetate injection J7626 Budesonide non comp J7193 Factor IX non J2505 Injection J7682 Tobramycin non unit dose recombinant pegfilgrastim 6mg comp unit dose J0594 Busulfan inj J7195 Factor IX J1817 Insulin for insulin J9350 Topotecan recombinant pump use J9045 Carboplatin injection J7189 Factor vila J1830 Interferon beta 1b J9355 Trastuzumab 25 MG J9050 Carmus bischl nitro inj J7190 Factor viii J7644 Ipratropium bromide J3285 Treprostinil injection non comp J0637 Caspofungin acetate J7192 Factor viii J9206 Irinotecan injection J3315 Triptorelin pamoate recombinant J9055 Cetuximab injection J1440 Filgrastim 300 mcg J1945 Lepirudin J3355 Urofollitropin 75 iu injection J0725 Chorionic J1441 Filgrastim 480 mcg J1950 Leuprolide acetate J3365 Urokinase 250 000 gonadotropin 1000u injection 3 75 MG IU inj J0740 Cidofovir injection Q4091 Flebogamma J9219 Leuprolide acetate 33370 Vancomycin hcl injection implant injection J0743 Cilastatin sodium injection J9200 Floxuridine injection J9218 Leuprolide acetate J3396 Verteporfin injection injeciton J9060 Cisplatin 10 MG injection J9185 Fludarabine J9217 Leuprolide acetate J1562 Vivaglobulin phosphate inj suspnsion injection J9062 Cisplatin 50 MG injection J7311 Fluocinolone J2020 Linezo
126. ts an office site visit at Primary Care and OB GYN offices This requirement is waived for new physicians joining an existing practice All applications for participation with Bravo Health will be reviewed by the designated Bravo Health Medical Director and Physician Advisory Credentialing Committee PACC Applications will be reviewed on an individual basis The criteria stated below are the minimum standards and meeting these criteria is not sufficient in and of itself for acceptance Bravo Health maintains the right to limit the Provider network according to its needs The credentials process is a vital part of the Bravo Health Quality Assessment program and is an essential tool to assure that the care delivered is of optimal quality using the resources available All information submitted to Bravo Health for both the initial credentialing and re credentialing processes will be considered by the PACC prior to making a decision regarding acceptance denial or termination CREDENTIALS CRITERIA 1 16 Physicians must have obtained a Doctor of Medicine Doctor of Osteopathy Doctor of Medical Dentistry or Doctor of Dental Surgery degree from a medical school accredited by one of the following the Liaison Committee on Medical Education or have obtained a certificate from the Educational Council for Foreign Medical Graduates ECFMG the American Osteopathic Association AOA or the American Board of Oral and Maxillofacial Surgery ABOMS Al
127. um gt 5 5mEq 1 symptomatic hypotension severe renal artery stenosis severe aortic stenosis and pregnancy Alternative Treatment to ACE Inhibitors Consider Angiotension Receptor Blockers ARB as alternative therapy only in ACE inhibitor intolerant patients due to persistent cough shock or angineurotic edema or add to ACE if beta blocker contraindicated Consider hydralazine isosorbide dinitrate combination therapy if renal insufficiency precludes ACE ARB therapy Beta Blockers Data supports long acting metoprolol carvedilol or bisoporlol indicated for clinically stable patients with left ventricular systolic dysfunction and mild to moderate heart failure symptoms that are on standard therapy which typically includes ACE Inhibitors diuretics as needed to control fluid retention and digoxin Start with low doses and gradually increase If tolerated beta blockers are also indicated in the treatment of high risk patients after an acute myocardial infarction Consider diuretic drugs for patients with fluid overload and edema Patients with symptomatic heart failure should be treated with a diuretic drug even when rendered free of Diuretics edema Diuretic drugs should be used in conjunction with an ACE inhibitor The dose and type of diuretic drug may change according to fluid status but generally will be needed indefinitely Consider digoxin in patients with symptomatic evidence of heart failure el
128. verage Sale Price ASP reimbursed Providers the applicable HCPCS code and HCPCS unit s Institutional Claims e Bill type Revenue codes and HCPCS codes Patient status code DRG code All appropriate diagnostic codes All appropriate diagnosis codes ICD9 CM codes Detailed billing for all pharmacy related revenue codes The detailed billing should include the name of the drug the National Drug Code NDC number and the units associated with each drug e Skilled nursing facilities should include a description of charges for example bed level blood glucose draw stick occupational physical speech therapy and radiology Specific CPT 4 Codes are also required based on the services rendered e NPI Number Claims must be submitted with all required information within 180 days of the date on which the service was rendered All claims submitted after the 180 day period will be denied for untimely filing For claims questions please contact Provider Services at 1 888 353 3789 A Provider Service Representative will be able to answer your questions concerning eligibility benefits and claims If a claim needs to be reprocessed for any reason the Provider Service Representative will work with the Claims Department to handle these cases Providers who are being paid under capitation and expect no additional payments still must submit claims in order to capture encounter data as required per your Bravo Health Provider Agreement This encoun
129. vice e g hospital or ambulatory surgery setting Primary Care Physician name Attending physician Date of service Diagnosis Surgery if applicable with CPT code Clinical information supporting the need for the service to be rendered po monaco gp 2 If the information regarding the Member the severity of the Member s illness and proposed plan of care meet the criteria for the establishment of medical necessity for inpatient care outpatient procedure or surgery or other required services needing prior authorization a length of stay is assigned This information is entered into the Electronic Data Record and approval is communicated to the Provider and the hospital within 2 days of the determination either via facsimile or in writing if denied 3 Ifthe information regarding the Member the severity of the Member s illness and the proposed plan of care do not meet the criteria for the establishment of medical necessity the attending Provider is advised that the case will be referred to the Medical Director for review UM Staff will advise the Provider that he she can contact the Medical Director for further discussion regarding the case The Provider will also be advised that the Medical Director will also attempt to contact him or her If the case is approved by the Medical Director UM will notify the attending Provider of the authorization 4 Inthe case of adverse determinations for the Member UM will e Notify the PCP and
130. vidence shall serve as guidance however strict conformity is not necessary The arbitrators should refuse to allow the introduction of any evidence that the arbitrators believe would result in the disclosure of confidential information which is privileged under any applicable statute or under applicable law including but not limited to information subject to a a peer review privilege b a patient physician privilege c an attorney client privilege or d any business proprietary or trade secret privilege All evidence shall be taken in the presence of the arbitrators and all of the Parties and the Parties counsel and other authorized representatives except where a Party is absent after due notice has been given or has waived the right to be present 8 Judgment and Award of Arbitrators The arbitrators shall render their decision and award upon the concurrence of at least two 2 of their number Such decision and award shall be in writing and shall be signed by all three 3 arbitrators Thereafter counterpart copies thereof shall be delivered to each of the Parties simultaneously In rendering such decision and award the arbitrators shall not add to subtract from or otherwise modify the provisions of the Agreement or any agreement entered into pursuant hereto The arbitrators shall have the power to grant and award only legal remedies in the form of monetary damages as provided by Texas law except that the arbitrators shall not have t
131. vider Data Maintenance Department via facsimile at 1 866 234 9418 or by e mail to PDM BravoHealth com The following is a list of changes that must be reported to Bravo Health e Practice address e Billing address e Fax or telephone number e Hospital affiliation e Tax Identification Number e Practice name e Providers joining or leaving the practice including retirement or death e Practice Mergers and or acquisitions e Adding or closing a practice location 21 CLOSING PATIENT PANELS When a Participating Primary Care Physician elects to stop accepting new patients the Provider s patient panel is considered closed If a Participating Primary Care Physician closes his or her patient panel the decision to stop accepting new patients must apply to all patients regardless of insurance coverage Providers may not discriminate against Bravo Health Members by closing the patient panels for Bravo Health Members only nor may they discriminate among Bravo Health Members by closing their panel to certain product lines Providers who decide that they will no longer accept any new patients must notify Bravo Health s Network Management Department in writing at least 60 days before the date on which the patient panel will be closed PROVIDER ACCESS AND AVAILABILITY STANDARDS A Primary Care Physician PCP must have their primary office open to receive Bravo Health Members five 5 days and for at least 20 hours per week The PCP must e
132. wary Kuy sonouiso1q Adereu eors uq Sueos Lad JUQUIOIBULIA Ued paspg jondsopy souuo8ms yuoyedyng ATRIL Ieuonednooo Surgeu Ie onN Suns l AnergoAsdomoN VIAWIIW i1p uduooO 22g snqv oouejsqns pue UYILIH LJUIA 221dsor ajnap uual Suo UOYONQOYI BUISANN bp2111 amoy qng 2Jnoy SUOISSIUIP Y yuoreduy IANI Adeisy ZO oueqiodAH AI 39utoH mouyFle H uuoH uonuss nd JoyUNO 2U19 XH4 pooueyug 007 lt wary Muy INA paspg jonidsopyy somp oo q DNSOU RI SULOS LD Sen eorum juonedjno Ade1ogjouroq Joeqpesjorg Juassaug uoN ooue nquiy Joje SI JOAOYOIYM ep ss ursnq 1x u JO SINOY tC UTUJIM uoneogrnou onbor suoissrupe JUISIOWII JUSSIL uoissmunpe oq 0 1oLid sKep oAg 3589 JE uonezroqne 10Lid oamboa SUOISSTUIPE IAPAA dAYINOAYA NOLLVZISOH ILOV HOT MEMBER ELIGIBILITY Anyone who meets the following criteria is eligible to enroll in one of Bravo Health s HMO Benefit Plans e Must be enrolled in Medicare both Part A and Part B e Must reside in one of the following Counties e Bexar e El Paso e Harris e Must not have End Stage Renal Disease ESRD at time of enrollment To enroll in one of Bravo Health s Private Fee For Service PFFS Benefit Plans the Member must e Be enrolled in Medicare Part A and Part B e Reside in one of the following Counties e Atascosa Bexar Brazoria Chambers El Paso Fort Ben
133. y is defined as a period of time that exceeds five 5 consecutive business days The Parties must ascertain the ability of each arbitrator to comply with this scheduling requirement as a condition of his her selection as an arbitrator If the arbitration hearing is not begun within this period either Party shall have the right to file suit a motion a petition or otherwise commence a legal proceeding in the United States District Court of Texas and shall have the right to refuse to participate further in any arbitration proceeding related to the same dispute Discovery In any such arbitration proceeding each Party thereto shall have access to the relevant books and records of the other Party and the power to call any employee agent or officer of any other Party for testimony and shall have all other rights to discovery afforded under the Federal Rules of Civil Procedure as well as the rules or laws applicable to the Federal District Court proceedings in Texas all of which shall be fully enforceable by the arbitrators or if they fail to effect such enforcement by the United States District Court of Texas Any discovery by the Parties to the arbitration shall be performed within a discovery period to be defined and limited by the arbitrators but in no event shall such discovery period exceed ninety 90 calendar days following the preliminary conference unless an extension is mutually agreed upon in writing by the Parties The parties agre
134. y TEUISHO jo yriqrsuodsa1 y sr We stul WIE UOTJBAJ9SQO UR S SUITED SIY JUIQNSII SLA uoneA19sqo se poziioyjne sem Ae s STUL NOLLVANSSHO SV LINANSIA ZSZ e s uone AISsqo Ue se passoo0id SI Wwe STU ALVA NOLLVAYASIO OL NG ISZ yuoo sex L s poS uosevsy JUJUIJSN py Wep 0 uorjezusunoop sunioddns euorppe YIM WE JU MIMA I IM JUIUIISINQUIII STU UJIM 9913BSIP ININISAPAV AYVADSNIVIO DO nod JI se ni MYE BUIPOD 3991107 pue JAPAN 0 Surpioooe PISINQUITII u q seu Wwe SIL juowAed uorjejides y ut p pn out ST wego sty JOJ JU9UIISINQUIIY HOLAYAS GSLLV LIdVO 2 juowAed uorjejides y ut p pn out ST wego sty JOJ JU9UIISINQUIIY SOIANHS CALVLIGVO NALSAS Of urteo passoooid AJSNOTAJJId e Jo 3uounsn pe ue SI SUL ININISAPAV 666 yu ur smquir OdV IY ut POpNIOU SI 99IAISS SIU 10 JUSVWIISINQUIIIA HOMd OdV NI GAANTONI 006 1J9U9Q TE U P S I9QUIIJA 94 JOPUN p Aoo JOU SI JOIAIOS STUL LIANA TVLNAC NI GHCNTONI LON 228 JUJUJVLOAJI S ISQUIIJA JU ssnosrp 0j u unied G S SIAI9S ug eog INO JIBJUOD aseolq SIDIAYAS HLTVAH LOVINOO 68 pejsneuxo useq aney s ep e1idsou juaryedu CGaLSNVHXG SAVA INHILVINI vI8 sAep e1idsou 1uonedur s u1 01 soydde Aed oo Teytdsoy JusTyedut aur XIddV SINANAVdOO LNHILVANI I9 Teoh JU JO SUJUOU S8 IY SULINP P9ISPUII 94190 JOJ TEJA puooss JY Jo TE ZI Aq 10 SO1ALOS ONTTIA ATHNIL AACIAONd
135. y or down grade a stay will be followed up with a formal letter Only a Medical Director is authorized to deny or downgrade days during an acute stay RETROSPECTIVE REVIEW Retrospective reviews are performed on all admissions to non Participating facilities where the Member has been admitted and discharged prior to Bravo Health s notification What about Participating facilities a Bravo Health allows 14 days after notification for facility to provide a verbal written or facsimile clinical review Bravo Health will issue a determination within 14 days of the notification based on the clinical information provided Clinical information submitted is reviewed according to criteria for medical necessity and are subject to Member eligibility at the time services are rendered b Retrospective review may occur for pre authorized services in order to facilitate claims payment Referrals to Non Contracted Providers Referrals to non Contracting Providers are approved only when the non Contracting Providers provide services that are not available within the network All referrals to non Contracting Providers must be reviewed and authorized by Bravo Health before services are performed There must be verification that the Provider of service is Medicare certified The Medical Director must review all referrals to non Contracted Providers The Director of Health Services may approve non Contracting Providers when deemed necessary by the Medical Director

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