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UPMC for Life Private Fee-for-Service (PFFS) Plan Terms & Conditions Below are materials to help familiarize you with the UPMC for Life Private Fee-for-Service (Medicare) plan. If you have any questions regarding UPMC Health Plan, please call UPMC for Life (Medicare) Provider Services at 877-539-3080.
Your cooperation makes a direct contribution to the success of Health Plan initiatives that deliver world-class health care and resources to our members. UPMC Health Plan is a Medicare Advantage Organizations (MAO) sponsoring PFFS plans that pay “the same as Medicare” to deemed suppliers. The amount due for DMEPOS competitive bid items will be reduced on July 1, 2008 and therefore, UPMC Health Plan has chosen to maintain a higher rate of reimbursement and maintain current rules related DMEPOS access. Last Update: 7/9/08 Administrative Guidelines The UPMC for Life Private Fee-for-Service (PFFS) plan is a Medicare Advantage health plan with a Medicare contract that is offered by UPMC Health Plan. UPMC for Life Private-Fee-for-Service (PFFS) is one of the Medicare Advantage plan options available from UPMC for Life. Members enrolled in the UPMC for Life Private-Fee-for-Service plan can obtain plan-covered health care services from any eligible provider who is willing to provide the services. The UPMC for Life PFFS plan provides medical services through eligible providers in the United States who are willing to provide services to PFFS enrollees. Providers must be licensed or certified by the state and currently acting within the scope of that license or certification in order to render services to a UPMC for Life Private Fee-for-Service member and have a Medicare billing number or be eligible to obtain one. Institutional providers must be Medicare-certified health care facilities. If a provider chooses not to provide services to PFFS members, the member must find another Medicare participating provider who is willing to provide services. For additional plan details, see the UPMC for Life PFFS Terms and Conditions. Providers who are not familiar with the Medicare Private Fee-for-Service plan are encouraged to learn about the provider “deeming process.” Please remember that if you do not wish to accept the terms and conditions explained in this document, you should not provide services to a UPMC for Life Private Fee-for-Service member. Providers must be licensed or certified by the state and currently acting within the scope of that license or certification in order to render services to a UPMC for Life Private Fee-for-Service member. In addition, providers may not render services if they are sanctioned. UPMC Health Plan will NOT cover or pay for any services rendered by a provider who has opted out of Medicare. Providers also are required to abide by Medicare and other federal health care program laws, regulations, and program instructions that apply to the services furnished. Upon request by UPMC Health Plan or CMS, providers must make medical records available. Provider Rights, Responsibilities, and Roles
Providers have a responsibility to:
Provider Role in Compliance UPMC Health Plan must comply with various laws, regulations, and accreditation standards in order to operate as a licensed health insurer. In order to meet these requirements, as well as combat cost trends in the health care industry such as fraud, abuse, and wasteful spending, UPMC Health Plan established its distinct Compliance Program. UPMC Health Plan’s Compliance Program serves to assist providers, staff members, management, and our Board of Directors with promoting proper business practices. Proper business practices include identifying and preventing improper or unethical conduct. Reporting Compliance Concerns and/or Issues UPMC Health Plan has established a Help Line for providers, staff members, and other entities to call in order to report compliance concerns and/or issues without fear of retribution or retaliation. The Help Line number is 877-983-8442, and it is available 24 hours a day, 7 days a week. Callers may remain anonymous. Compliance concerns include, but may not be limited to, issues related to the Health Insurance Portability and Accountability Act (HIPAA), the Gramm-Leach-Bliley Act, and the Americans with Disabilities Act (ADA). Responsibilities of Provider with Regard to Compliance
The success of UPMC Health Plan’s Compliance Program relies in part upon the actions taken by our providers. It is critical for our providers to be aware of the goals and objectives of the UPMC Health Plan Compliance Program, as well as of their responsibilities as providers. Provider Role in HIPAA Privacy & Gramm-Leach-Bliley Act Regulations All UPMC Health Plan policies and procedures include information ensuring that UPMC Health Plan complies with the Health Insurance Portability and Accountability Act (HIPAA) regulations and the Gramm-Leach-Bliley Act. Hospitals and providers subject to HIPAA are trained to understand their responsibilities under these privacy regulations – as is the staff at UPMC Health Plan. UPMC Health Plan has incorporated measures in all of its departments to make sure potential, current, and former members’ personal health information, individually identifiable health information, and personally identifiable financial information are maintained in a confidential manner, whether that information is in oral, written, or electronic format. UPMC Health Plan employees may use and disclose this information only for those purposes permitted by federal legislation (for treatment, payment, and health care operations); by the member’s written request; or if required to disclose such information by law, regulation, or court order. A form authorizing the release of personal health information is available from UPMC Health Plan’s Member Services Department or from the UPMC Health Plan website. This form complies with the core elements and statements required by HIPAA privacy rules. This form must be completed, signed, and returned to UPMC Health Plan before UPMC Health Plan will release information. All members – including commercial, UPMC for You, and UPMC for Life – receive UPMC Health Plan’s Privacy Statement and Notice of UPMC Health Plan Privacy Practices in their welcome kit materials. Members also receive a copy of the privacy information annually. These documents clearly explain the members’ rights concerning the privacy of their individual information, including the processes that have been established to provide them with access to their protected health information and procedures to request, to amend, restrict use, and receive an accounting of disclosures. The documents further inform members of UPMC Health Plan’s precautions to conceal individual health information from employers. UPMC Health Plan’s Notice of Privacy Practices is separate and distinct from the Notice of Privacy Practices providers are required to give to their patients under HIPAA. UPMC Health Plan’s Privacy Statement and Notice of Privacy Practices can be viewed at www.upmchealthplan.com. Provider Role in ADA Compliance Providers’ offices are required to adhere to the Americans with Disabilities Act (ADA) guidelines, Section 504 of the Rehabilitation Act of 1973, and other applicable laws. Providers may contact Provider Services at 877-539-3080 to obtain copies of these documents and other related resources. UPMC Health Plan suggests that providers’ offices or facilities comply with this act. The office or facility must be wheelchair-accessible or have provisions to accommodate people in wheelchairs. Patient restrooms should be equipped with grab bars. Handicapped parking must be available near the provider’s office and be clearly marked. Reporting Fraud and Abuse to the Health Plan UPMC Health Plan has established a hotline to report suspected fraud and abuse committed by any entity providing services to members. The hotline number is 866-FRAUD-01 (866-372-8301), and it is available 24 hours a day, seven days a week. Voice mail is available at all times. Callers may remain anonymous and may leave a voice mail if they prefer. TTY/TDD users should call 800-361-2629. Some common examples of fraud and abuse are:
Suspected fraud and abuse may also be reported via the website at www.upmchealthplan.com or the information may be e-mailed to If reporting fraud and abuse by mail, please mark the outside of the envelope “confidential” or “personal” and send to:
Information reported via the website, by e-mail, or by regular mail may be done anonymously. The website contains additional information on reporting fraud and abuse. Reporting Fraud and Abuse to the Centers for Medicare & Medicaid Services The Centers for Medicare & Medicaid Services has established a hotline to report suspected fraud and abuse committed by any person or entity providing services to Medicare beneficiaries. The hotline number is 800-HHS-TIPS (800-447-8477), and it is available Monday through Friday from 8:30 a.m. to 3:30 p.m. Callers may remain anonymous and may call after hours and leave a voice mail if they prefer. Emergency Services Members with an emergency medical condition should understand they have the right to summon emergency help by calling 911 or any other emergency telephone number, as well as a licensed ambulance service, without getting prior approval. UPMC Health Plan will cover care for an emergency medical condition with symptoms of such severity that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in:
The hospital or facility should contact Medical Management at 800-425-7800 on the next business day or within 48 hours after the emergency admission. Urgent Care Urgent care is defined as any illness, injury, or severe condition that, under reasonable standards of medical practice, would be diagnosed and treated within a 24-hour period and, if left untreated, could rapidly become an emergency medical condition. Members should contact their physician if they have an urgent medical need. UPMC Health Plan encourages providers to make same-day appointments available for their patients who call with unscheduled urgent health care needs. This improves the quality and continuity of patient care. If members are unable to contact their physician, and they believe they need care immediately, they should seek immediate medical attention. After such treatment, members should contact their physician within a reasonable amount of time. A reasonable amount of time is typically considered 24 hours, unless there are extenuating circumstances. Guidelines for Medical Record Documentation UPMC Health Plan requires providers to maintain medical records for their members in a manner that is:
The medical record must express the evaluation and treatment of the member in a legible and detailed manner to assist communication, coordination, and continuity of care, and to promote efficient and effective treatment. Consistent and complete documentation in the medical record is an essential component of quality patient care. UPMC Health Plan has adopted certain standards for medical record documentation. To meet these guidelines, a provider should do the following: Basic Information
Medical History
Treatment
Notations
In addition to the preceding guidelines, the records should reveal no evidence that a member was placed at risk by a diagnosis or therapeutic procedure. Referrals and Coordination of Care UPMC Health Plan relies on each provider to ensure the appropriate use of resources by delivering quality care in the proper setting at the right time. UPMC Health Plan’s approach to accountability is based on the belief that providers know what is best for UPMC Health Plan members. We rely on our providers to:
Providers are encouraged to coordinate a member’s care with other providers appropriate to the member’s benefit plan. Providers are responsible for determining the type of care the member needs and the appropriate provider or facility to administer that care. Inpatient Admissions Emergency Admission
The hospital or facility should notify Medical Management at 800-425-7800 within 48 hours or on the next business day following the emergency admission. Elective Admission To admit a UPMC for Life PFFS member for an elective admission, the admitting provider must obtain authorization prior to the admission by calling Medical Management at 800-425-7800. The admitting provider should work with the hospital to schedule the admission and any pre-admission testing. The member will be assessed a higher copay if prior authorization is not obtained. Inpatient Consultation and Referral Process If the admitting provider determines that a member requires consultation with a specialist, the admitting provider must refer the member to a specialist appropriate to the member’s benefit plan. The referral should follow the hospital’s locally approved procedures (e.g., consultation form and physician order form). The admitting provider and specialist jointly should determine how care should proceed. Coordination of care occurs through active communication among the admitting provider and the specialist. Pre-Admission Diagnostic Testing If testing is completed within 72 hours of the member’s admission, it is included with the admission. Otherwise, the testing can be billed separately. Pre-admission diagnostic testing includes:
Discharges Medical Management works with the hospital’s Utilization Management Department to coordinate discharge planning. A discharge planner is available to assist in coordinating follow-up care, ancillary services, and other appropriate services. Contact Medical Management at 800-425-7800 to speak to a discharge planner. Provider Services - Sample Identification Card Providers may contact UPMC Health Plan Provider Services at 877-539-3080 to check member eligibility, obtain answers to any questions they may have, or to obtain educational materials. This phone number appears on the member identification card. PFFS Plan ID Card
PFFS Rx Plan ID Card
Interactive Voice Response (IVR) System UPMC Health Plan’s Interactive Voice Response (IVR) System gives providers an immediate connection to claims and member eligibility information. IVR provides valuable claims information such as the status, received date, date of service, and total billed amount, as well as several other points of information. IVR allows providers to directly tap into UPMC Health Plan’s database of claims and member information in a quick and easy way. The telephone-based system understands and follows voice directions so there is no need to press numbers on a telephone keypad to respond. Providers may call 866-406-8762 to access IVR. This option is also available by calling Provider Services at 877-539-3080. To use this tool effectively providers must have the following:
In addition, Provider Services continues to be available to answer more complex inquiries. Summary of Benefits (Cost Sharing) To reference the correct Summary of Benefit below, ask the member if they are a member of an Employer Group or are a member of an Individual PFFS plan. If they are a member of an Employer Group, ask them to identify which one below. Employer Groups Individual Plans
Providers may identify a UPMC for Life Private Fee-for-Service member by reviewing the member’s identification card, which should be presented prior to services being rendered. When possible, verification of a member’s plan coverage should be made during the scheduling of the appointment to provide ample time to review the plan’s terms and conditions. Providers may view the terms and conditions online at www.upmchealthplan.com. Those providers who do not agree to accept the terms and conditions should not provide services to or bill a UPMC for Life Private Fee-for-Service member. Once a provider renders services to a plan member and accepts Medicare rates as payment in full, the provider is then considered deemed into the UPMC for Life Private Fee-for-Service network for said member. Deemed providers are subject to the terms and conditions of payment as outlined at www.upmchealthplan.com. Members are responsible for any applicable copayments, coinsurance, or deductibles. Balance-billing/Hold Harmless Providers are not permitted, in any event, to bill, charge, or collect a deposit from members or persons, other than UPMC Health Plan, acting on behalf of the member for covered services. UPMC Health Plan will reimburse providers the current Medicare rate for covered services rendered to all members enrolled in our UPMC for Life Private Fee-for-Service plan. Providers will be paid in line with Medicare prompt payment requirements. Providers may obtain specific reimbursement information by calling Provider Services at 877-539-3080. Providers will accept such reimbursement as payment in full for covered services provided to those members and will not bill the member for covered services, except for any applicable copayments, coinsurance, or deductibles. Provider reimbursement may not exceed the Medicare fee schedule. UPMC Health Plan will utilize claim software and perform random audits to ensure that these standards are not exceeded. In addition, UPMC Health Plan will follow up on member complaints regarding balance-billing to identify any overpayments. Paper Claim Forms CMS-1500 and UB-92 These forms are for professional services performed in a provider’s office, hospital, or ancillary facility. (Provider-specific billing forms are not accepted.) Paper Claims Forms - UB-92 Forms (Uniform Billing Code of 1992) These forms are for inpatient hospital services or ancillary services performed in the hospital. (Hospital-specific billing forms are not accepted.) Deadlines UPMC Health Plan accepts new claims for services up to 365 days after the date of service for members. When UPMC Health Plan is the secondary payor, claims are accepted with the explanation of benefit (EOB) from the primary carrier. This claim must be received within 90 days of the primary EOB remittance date or up to the new claim timely filing limit, whichever is greater. Claims submitted after these deadlines will be denied for untimely filing. Members cannot be billed for UPMC Health Plan’s portion of the claims submitted after these deadlines; however, they may be billed for copayments, coinsurance, and/or deductibles. Claim forms should be submitted to the address below:
Diagnosis Codes Claims must be submitted with a diagnosis code, indicating the member’s medical condition or circumstances necessitating evaluation or treatment. The diagnosis codes submitted on claim forms must correlate to the documentation contained within the member’s medical record and reflect or support the reason services have been provided. Claims Resubmission Claims may be resubmitted if UPMC Health Plan has not paid within 45 days of the initial submission. These claims can be a photocopy or a reprinted claim. Late Charges On CMS-1500 forms When submitting late charges on a CMS-1500 form, please write “late charges” on the claim. This allows UPMC Health Plan to route the claims to the appropriate processing area. Late charges are subject to the timely filing limit. On UB-92 forms When submitting late charges on a UB-92 form, please submit the appropriate bill type in box 4. Claims Documentation Requirements
Rejected claims—those with missing or incorrect information—cannot be resubmitted. A new claim form must be generated for resubmission. Required Fields on a CMS-1500 Claim Form The following CMS-1500 claim form is standard in the insurance industry; however, UPMC Health Plan requires providers to fill out only those fields noted in the figure below. Each field is explained in the numbered key that follows this illustration. CMS-1500 Claim Form
Explanation of Required Fields in CMS-1500 Claim Form If a numbered field is not included, it is not required by UPMC Health Plan in order to process a claim.
Required Fields on a UB-92 Claim Form The following UB-92 claim form is standard in the insurance industry; however, UPMC Health Plan requires providers to fill out only those fields noted in the figure below. Each field is explained in the numbered key that follows this illustration. UB-92 Claim Form
Explanation of Required Fields in UB-92 Claim Form If a numbered field is not included, it is not required by UPMC Health Plan in order to process a claim.
Place-of-Service Code Table All providers are required to submit CMS-1500 claim forms with CMS standard two-digit place-of-service codes entered in Box 24B. Forms submitted without these codes will be rejected with no adjudication and returned to the provider for resubmission. This policy applies to all lines of business. Commonly Used Place-of-Service Codes
Claims Coding For provider and ancillary services, UPMC Health Plan reimburses on a fee-for-service basis. Providers agree to accept the current Medicare rates for covered services, less deductibles and coinsurance, as payment in full for covered services provided to UPMC Health Plan members.
Providers are not permitted to balance-bill members for the difference between the provider’s charge and the reimbursement. UPMC Health Plan annually updates all fee schedules with CPT-4 and HCPCS code additions and deletions. Coverage policy follows Centers for Medicare & Medicaid Services (CMS) guidelines whenever appropriate. All provider claims are subject to coding review edits based on CMS Correct Coding Initiative (CCI) guidelines or UPMC Health Plan payment policies. Providers may view CCI edits at www.cms.hhs.gov/physicians/cciedits/default.asp. The practices listed on the next page are considered improper and inappropriate and will be subject to UPMC Health Plan system edits. Coding Practices Subject to Review
Unlisted Codes Procedures When appropriate, a provider may need to bill for a procedure that does not have an existing CPT/ HCPCS code. The provider should use the “miscellaneous” or “not otherwise classified” codes that most closely relate to the service provided. When billing for “unlisted” or “not otherwise classified” codes, providers may be asked to supply supporting documentation. Medications “Unlisted” or “not otherwise classified” drugs must be submitted with applicable HCPCS codes. The claim must include a description of the item/drug supplied, correct dosage, and the National Drug Classification Code number (NDC#). Modifiers Physician Modifiers Frequently used modifiers are listed in the following table. For a complete list of modifiers, refer to the CPT manual and the HCPCS Level II manual. Physician Modifiers
Providers should only use modifier 50 when the exact same service/code is reported for each bilateral anatomical site. Bilateral procedures that are not identified as bilateral in the description must be reported with modifier 50. Providers should report such procedures as a one line item with a unit number of one. Providers should use modifier 59 when billing a combination of codes that would normally not be billed together and are only appended to the procedure that is designated as the distinct procedural service. This modifier should be used when there are no other existing modifiers available and as required for medical record documentation. Anesthesia Modifiers Anesthesia claims for all members should be billed with the correct codes from the American Society of Anesthesiologists (ASA)—(00100–01999)—which are included in the CPT manual. Services performed for UPMC for Life members by a Certified Registered Nurse Anesthetist (CRNA) are eligible for reimbursement and can be billed in conjunction with anesthesiologist’s charges, provided the appropriate modifier is used. Anesthesia Modifiers Appropriate anesthesia modifiers also should be billed, including, but not limited to, the following:
Home Medical Equipment Modifiers Home medical equipment (HME) modifiers include, but are not limited to, the following:
Code-Specific Policies Surgical Procedures Providers must note surgical procedures performed during the same operative session by the same provider on a single claim form or electronic equivalent. Billing on separate claim forms may result in delayed payments, incorrect payments, or payment denial. Helpful Tips for Paper Claim Submission UPMC Health Plan has composed the following guidelines for paper claim form submission. Following the advice listed below may reduce the occurrences of incorrect reimbursement and subsequent claims resubmission.
Electronic claims can be submitted through clearinghouses such as Zirmed and Gateway EDI, etc. Provider Appeals and Grievances If a provider disagrees with a decision by UPMC Health Plan to deny coverage of care or services, the provider has the right to appeal that decision. Appeals fall into three categories: administrative, medical necessity, and expedited. Resubmitting a corrected claim due to minor error or omission is not an appeal. Corrections or resubmissions of claims due to minor errors or omissions should be sent to the customary claims address. A request for an administrative or a medical necessity appeal must be submitted in writing within 30 business days of the denial notification. The request must include the reason for the appeal and a copy of the medical record or other supporting documentation. The request for appeal should clearly state why and on what basis the provider wishes to appeal. To answer any additional questions about the right to appeal or how to file an appeal, providers may call Provider Services at 877-539-3080. Administrative Appeal Administrative appeals involve claims that have been denied for reasons other than those related to medical necessity. Therefore, administrative denials are not reconsidered based on medical necessity. Some examples are:
The following procedure outlines the administrative appeal process: 1. Provider sends a written appeal to UPMC Health Plan. The provider sends a written appeal to UPMC Health Plan at the following address stating the reason the claim was denied (from the Explanation of Payment) and any supporting documentation as to why the provider believes the decision should be reversed.
2. Committee reviews the denial. A Committee of UPMC Health Plan employees, including nurses and a medical director, decides administrative appeals. The Committee reviews such appeals only once. 3. Committee makes decision. The Committee makes a decision within 60 business days. All decisions are final. If the administrative denial is upheld, the provider is notified in writing of the result within 10 business days of the decision. If the administrative denial is reversed, the claim is adjusted within 30 business days of the date of the decision. Medical Necessity Appeal Two levels of appeal are available to providers regarding denials based on medical necessity. Each is described in this section. First Level Appeal 1. Provider sends a written appeal to UPMC Health Plan. Within 30 business days of the denial notification, the provider sends a written appeal to UPMC Health Plan at the following address:
2. Physician reviews the appeal. A UPMC Health Plan physician reviewer who was not involved with the initial determination reviews the appeal. 3. Physician reviewer makes a decision. Within 30 business days, UPMC Health Plan physician reviewer determines whether any additional information has been presented that supports a reversal of the denial. If the medical necessity denial is upheld, the provider is notified in writing of the result within 10 business days of the decision. If the medical necessity denial is reversed, the claim is adjusted within 30 business days of the date of the decision. Second Level Appeal 1. Provider submits a request for a Second Level Appeal. A provider who does not agree with the outcome of a medical necessity appeal can submit a request for a Second-Level Appeal following the procedure listed in First Level Appeal. 2. Physician reviews the appeal. A peer physician or physician of the same specialty of care that is being appealed reviews the dispute and makes a decision. Also, a UPMC Health Plan physician reviewer who was not involved with the previous determinations reviews the appeal. 3. Committee makes decision. A Committee comprised of UPMC Health Plan staff, a UPMC Health Plan physician, and an independent peer physician of the same specialty reviews the dispute and makes a decision within 60 business days. 4. Provider receives notification of the decision. If the medical necessity denial is upheld, the provider is notified in writing of the result within 10 business days of the decision. If the medical necessity denial is reversed, the claim is adjusted within 30 business days of the date of the decision. Provider Appeal on Behalf of a Member If UPMC Health Plan denies any part of a member’s request for coverage or payment of a service, the member may ask UPMC Health Plan to reconsider the decision. This is called an “appeal” or a “request for reconsideration.” If the member’s appeal concerns a decision UPMC Health Plan made about authorizing medical care, then the member and/or the member’s doctor will first need to decide whether the member needs a “fast” apppeal. Please call us at 877-539-3080 if you need help in filing an appeal on a member’s behalf. How do you file an appeal of the initial decision on a member’s behalf? Providers who do not have a contract with UPMC Health Plan must sign a “waiver of payment” statement that says that they will not ask the member to pay for the medical service under review, regardless of the outcome of the appeal. What if the member wants a “fast” appeal? The member, any doctor, or the member’s representative can ask UPMC Health Plan for a “fast” appeal by calling us at 877-539-3080. Or, you can deliver a written request to:
Or, the request may be faxed to 412-454-7320. Be sure to ask for a “fast” or “72-hour” appeal. If any doctor asks for a fast appeal for a member, or supports the member in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm the member’s health or ability to function, UPMC Health Plan will give a fast decision. What if the member wants a “standard” appeal? After UPMC Health Plan receives a standard appeal request, UPMC Health Plan has up to 30 days to make a decision, but will make is sooner if the member’s health condition requires. However, if UPMC Health Plan finds that some information is missing which can help the member, we can take up to 14 more days to make the decision. Vision Provider Resource Guide Vision Providers may submit claims for routine vision services to:
Please submit the CMS-1500 claim form for all vision services. Only use codes S0620 or S0621 for the routine eye exam service. For questions regarding claims, eligibility, or benefits, please contact OptiCare Managed Vision Provider Services at 1-866-921-7963. All claims for Medicare-covered vision services should be submitted to UPMC Health Plan. |
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