Provider Administrative Manual (PAM)

Welcome and thank you for participating in the Mount Carmel MediGold Health Plan network. We appreciate your partnership in delivering high-quality care and better outcomes for our members-your patients. Communication is key to any successful relationship, so we hope you find the contents in this manual helpful and let us know if we can do anything to make working with us easier.

Table of Contents

Section 1: Introduction

• About Mount Carmel MediGold Health Plan
• Important News and Updates to this Manual
• Provider Communications
• How to Contact the Plan
• Additional Resources

Section 2: Eligibility and Enrollment

• Eligibility
• Enrollment
• The Member's Primary Care Provider (PCP)
• Membership Identification Card

Section 3: Provider Policies and Protocols

• Compliance with Policy/Protocol
• Provide Timely Notice of Demographic Changes
• Prohibited Billing Practices
  • Balance Billing
• After Hours Care
• Delay in Service
• Medical Record Requirements
  • Follow Medical Record Standards
  • General Documentation Guidelines
  • Demographic Information
  • Member Encounters
  • Clinical Decision and Safety Support
• Risk Adjustment Information
  • Risk Adjustment Data Validation or Improper Payment Measures
  • Encounter Data Processing System
• Informing Members of Advance Directives
• Referrals and Prior Authorization Requests
• Member Rights and Responsibilities

Section 4: Quality Management

• Regulatory Requirements
• Healthcare Effectiveness Data and Information Set (HEDIS®)
• What are Medicare Star Ratings?
  • Star Measures
• Program Goals
• Program Activities
• Risk Management/Quality Concern Reporting
• Outcomes, Evaluations and Member-Based Studies
• Access and Availability
• Member and Provider Satisfaction

Section 5: Utilization Management

• Overview
• Medical Necessity
• Submission Process
• Prior Authorization
  • Prior Authorization Decision-Making Process
• Referrals 
• Hospital Notifications
• Concurrent Review
• Readmission Process
• Urgent Care and Emergency Services
• Notifications to Members
  • When to Deliver the NOMNC
    • Notice Delivery to Representatives
    • Exceptions
    • Alterations to the NOMNC
  • When to Deliver the DENC
    • An Important Message From Medicare About Your Rights (IM)
• Availability of Utilization Management Staff 
• Skilled Nursing Facilities (SNF)
  • SNF Prior Authorization and Admission Notification
  • Concurrent Review
    • Supporting Documentation
  • Tier Reimbursement Model
  • Benefit Period

Section 6: Case Management

• Overview
• Transitions of Care Program
• Disease Management Program
• Behavioral Health Program
• Chronic Care Improvement Program – Congestive Heart Failure
• CHF Telemonitoring Program (CHF)
• Nurse Advice Line
• Complex Case Management Program

Section 7: Medicare-Covered Drugs

• Medicare Part B Drugs
  • Definition
  • Benefit
• Medicare Part D Drugs
  • Definition
  • Benefit
• The Formulary
• Tiered Drug Benefit
• Medicare Part D Benefit Stages and Total Out-of-Pocket Costs
• Vaccines Covered Under Medicare Part D
• Provision of and Billing for SHINGRIX^©
• Part D Utilization Management Requirements
• Diabetic Glucose Monitors, Test Strips, and Supplies
• Self-Administered Drugs in an Outpatient Setting
• Non-Covered Part D Utilization Management Requirements
• Inflation Reduction Act

Section 8: Claims Processing Procedures and Guidelines

• Copayment and Coinsurance
• Annual Wellness Exam
• Annual Women’s Exam
• Diabetic Retinopathy Screening
• Essential Mount Carmel MediGold Health Plan Data Elements Required
• General Form Submissions
• Electronic Claim Submissions
• Paper Form Submissions
  • Tips for submitting paper claims 
• Remittance Advice
• Electronic Payment and Remittance Enrollment
• Corrected Claims Submission
• Request for Claims Review Form
• Claims Timely Filing Limitations
• Provider Portal 
• Transfer of Claims from Medicare Part B Carrier/MAC to Mount Carmel MediGold Health Plan
• Coordination of Benefits
• Secondary Payor
• Medicaid as a Secondary Payor
• Subrogation
• Workers’ Compensation

Section 9: Compliance

• Overview
• Monitoring and Auditing First Tier, Downstream and Related Entities (FDR) 
• Compliance Reporting

Section 10: Special Investigations Unit

• Fraud, Waste and Abuse (FWA)
• What is Fraud, Waste and Abuse?
• Examples of Provider, Pharmacy, or Vendor FWA 
• Disclosure of Ownership, Exclusion and Criminal Conviction
• How to Report FWA

Section 11: Network Participation Responsibilities

• Overview
• How to Become a Participating Provider with Mount Carmel MediGold Health Plan
• Mount Carmel MediGold Health Plan’s Code of Conduct
• Credentialing Process
  • Physician Credentialing
  • Initial Credentialing
  • Recredentialing
  • Facility Credentialing and Recredentialing
  • Summary Suspension
• Provide Official Notice
• Transition of Member Care Following Termination of Your Participation
• Performance Assessment
• Provisions of Access to Your Facility
• Physician Incentive Plan Regulation Compliance
• Remediation Policy
• Medicare Advantage Participation Provisions

Section 12: Member Grievance and Appeal Process

• Overview
• General Information on Medicare Appeals Procedures
• Who May File an Appeal
• Support for the Appeal 
• Assistance with Appeals
• Medicare Standard Organization Determination and Appeals Procedures
• Medicare Expedited/72-Hour Determination and Appeal Procedure
• Types of Decisions Subject to Expedited/72-Hour Review
• How to Request an Expedited/72-Hour Review
• How an Expedited/72-Hour Determination/Review Request will be Processed
• Mount Carmel MediGold Health Plan Grievance Procedures
• Quality Improvement Organization Immediate Review of Hospital Discharges
• Quality Improvement Organization Quality of Care Complaint Process

Last updated: 03/2024