PAM Section 3: Provider Policies and Protocols

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Compliance with Policy/Protocol

According to your provider agreement, you will comply with and be bound by Mount Carmel MediGold Health Plan’s policies and protocols, including those contained in this manual. Failure to comply with such policies and protocols will be reviewed by Mount Carmel MediGold Health Plan and may result in appropriate action in accordance with your provider agreement, such as denial of payment, financial penalties and modifications to your reimbursement or other terms of your agreement with us, or ineligibility to participate in recognition programs.

You are not permitted to bill our members for any amounts not paid due to your failure to comply with our policies and protocols.

Provide Timely Notice of Demographic Changes

You must notify us within 30 days of any changes to demographic and participation information that differs from the information reported with your executed provider agreement. These include, but are not limited to: tax ID changes (W9 required), office or remittance address changes, phone numbers, suite numbers, additions or departures of health care providers from your practice, ability of individual practitioners to accept our members or any other changes that affect availability to our members and new service locations.

If a provider is associated with a group that is delegated for credentialing, please verify that credentialing is not affected by contacting the Provider Service Center at 1-800-991-9907.

Prohibited Billing Practices

Balance Billing

Prohibited Billing of Qualified Medicare Beneficiary (QMB) Individuals and Medicare Assignment

Medicare-covered services, also covered by Medicaid, are paid first by Medicare because Medicaid is generally the payor of last resort. Medicaid may cover the cost of care that Medicare may not cover or may partially cover (such as nursing home care, personal care, and home- and community-based services).

Federal law prohibits all Medicare providers from billing QMB individuals for all Medicare deductibles, coinsurance or copayments. All Medicare and Medicaid payments the provider receives for furnishing services to a QMB individual are considered payment in full. The provider is subject to sanctions if you bill a QMB individual for amounts above the sum total of all Medicare and Medicaid payments, even when Medicaid pays nothing.

In addition, all Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries. Assignment means that the Medicare-allowed amount (Physician Fee Schedule amount) constitutes payment in full for all Part B-covered services provided to beneficiaries.

What to do:

Ensure that you are checking the eligibility of your patients. Some Medicare enrollees may qualify for both Medicare and Medicaid services. These members are called Dual Benefits Members.
You may confirm a member’s eligibility for Medicaid through Medicaid Information Technology System (MITS).

What not to do:

The QMB program is a state Medicaid benefit that covers Medicare deductibles, coinsurance and copayments, subject to state payment limits.
Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the state reimburses providers for the full Medicare cost-sharing amounts.
Further, all Original Medicare and MA providers—not only those that accept Medicaid—must refrain from charging QMB individuals for Medicare cost- sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions. Federal law bars Medicare providers from balance billing a QMB beneficiary under any circumstances.

See Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.

Non-Covered and/or Not Medically Necessary Services, Integrated Denial Notice (IDN) Required

If you have any reason to believe that Mount Carmel MediGold will not cover a service, in whole or in part, you must contact our Utilization Management team prior to performing the services and obtain a Prior Authorization determination. The Utilization Management team will review the request and, if the service is not covered under the member’s benefit plan and/or “medically not necessary,” issue an IDN to the member. The member must receive the IDN in advance of receiving the service and must have sufficient time to decide if they want to proceed with the non-covered and/or “medically not necessary” service, at which time the member could be billed.

Failure to obtain an IDN for a non-covered and/or “not medically necessary” service will result in an administrative denial, for which you may not seek any reimbursement from Mount Carmel MediGold Health Plan or the member.

You should know or have reason to know that a service may not be covered if:

The service is expressly excluded from coverage in the member’s Summary of Benefits and Evidence of Coverage.
We have provided general notice either that we will not cover a particular service or that particular services are only covered under certain circumstances.
We have made a determination that planned services are not covered and/or are “not medically necessary” services and have communicated that determination to you.

Member Responsibility: Nothing herein or in your agreement with Mount Carmel MediGold Health Plan prohibits you from collecting any coinsurance, deductible, or copayments specifically identified in the member’s Evidence of Coverage.

You may not bill our members for non-covered services if you do not comply with this policy.

After Hours Care

Our members are instructed to contact their PCP before any form of care is rendered. Therefore, the PCP may receive telephone calls outside routine office hours. It is incumbent upon you to determine whether the requested care is of an emergency nature. Every reasonable and medically appropriate attempt should be made to give advice and arrange for the member to be seen during regular office hours. As the provider, you should consider:

Meeting the member at the emergency room or directing the member to the nearest urgent care center or emergency room, where appropriate.
Meeting the member at your office.
Directing the member to your pre-arranged, network PCP on-call.

Delay in Service

Facilities that provide inpatient services must maintain appropriate staff, resources and equipment to ensure that covered services are provided to our members in a timely manner. A delay in service is defined as a failure to execute a physician order in a timely manner that results in a longer length of stay. A delay in service may result for any of the following reasons:

Equipment needed to execute a physician’s order is not available.
Staff needed to execute a physician’s order is not available.
A facility resource needed to execute a physician’s order is not available. Facility does not discharge the patient on the day the physician’s order is written. Payment to facilities may be affected for delays in service.

Medical Record Requirements

Follow Medical Record Standards

Medical record requests may be made by Mount Carmel MediGold Health Plan and/or its designated vendor for a variety of reasons. Requests for medical records may be necessary in any of the following circumstances:

Additional information is required before Mount Carmel MediGold Health Plan can process a claim.
A complaint or allegation of possible fraud, waste or abuse of the Medicare program which requires investigation.
Any complaint alleging possible quality of care, service or access to care.
Review of an established or new physician or practitioner is warranted, before or after a claim is paid, based on analysis of data.
Payment retraction.
Data collection for HEDIS.
Risk adjustment purposes that include, but are not limited to: verifying the accuracy of coding, ensuring all diagnosis codes are properly supported by relevant medical records, medical record review to identify any conditions not captured through claims or encounter data, and to comply with CMS requests for records when conducting any Improper Payment Measure audits or Risk Adjustment Data Validation (RADV).
CMS request for records (Mount Carmel MediGold Health Plan performs health care operations for CMS).
Additional information is required to support delegation oversight monitoring and auditing activities to ensure compliance with CMS guidelines.

In all cases, it is extremely important that requested records are provided to the proper entity within the timeframe specified.

It is understandable that there are concerns about patient confidentiality, but the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits disclosure of protected health information without a patient’s authorization when the information is necessary to carry out treatment, payment or health care operations.

When Medicare Beneficiaries enroll in one of our plans, they are informed of Mount Carmel MediGold Health Plan’s use of their protected health information to carry out health care operations. Providing the requested documentation does not violate HIPAA and does not require additional beneficiary authorization.

Your cooperation is a legal obligation as outlined in the Social Security Act, the law governing Medicare (Section 1842), as well as a contractual requirement of your participation in Mount Carmel MediGold Health Plan. CMS requires Mount Carmel MediGold Health Plan, as one of its contractors, to report suspected fraud. Failure to forward records that substantiate service may force Mount Carmel MediGold Health Plan to consider this action.

If you choose to charge the Plan for medical records, Plan shall reimburse physician for records requested by the Plan at the Medicare rate, plus postage when applicable. Payment shall be made by the Plan to physician upon the Plan’s receipt of the requested records.

General Documentation Guidelines

We also expect you to follow these commonly accepted guidelines for medical record information and documentation:

Date all entries and identify the author.
Make entries legible. If signatures are illegible, you may be required to provide an attestation or signature log.
Cite medical conditions and significant illnesses under history of present illness, past medical history, and/or assessment and plan.
Give prominence to notes on medication allergies and adverse reactions. Also note if the member has no known allergies or adverse reactions.
Make it easy to identify the medical history and include chronic illnesses, accidents
and operations.
For medication records, include name of medication and dosages. Also, list over-the- counter drugs taken by the member.
Code all ICD-10 codes to the highest specificity.
Document these important items:
- All member conditions that are currently being treated or monitored.
- Blood pressure.
- Height/weight and body mass index (BMI). Tobacco items, including advice to quit.
- Alcohol use and substance abuse. Immunization record.
- Family and social history.
- Preventive screenings and services.

Demographic Information

The medical record for each member should include:

Member name and/or ID number on every page.
Gender.
Age or date-of-birth.
Address.
Marital status.
Occupational history.
Home and/or work phone numbers.
Name and phone number of emergency contact.
Name of spouse or relative.
Insurance information.

Member Encounters

When you see our members, document the visit by noting:

Member’s complaint or reason for the visit.
Physical assessment.
Unresolved problems from the previous visit(s).
Diagnosis and treatment plans consistent with your findings.
Member education, counseling or coordination of care with other providers.
Date of return visit or other follow-up care.
Review by the primary physician (initialed) on consultation, lab, imaging, special studies and ancillary, outpatient and inpatient records.
Consultation and abnormal studies are initialed and include follow-up plans.

Clinical Decision and Safety Support Tools in Place to Ensure Evidence-Based Care is Provided

Examples of clinical decision and safety support tools include, but are not limited to:

ALT/AST laboratory test done if member taking statins.
Immunization tracking sheet.
Flow sheet for chronic diseases.
Member reminder system.
Electronic medical records.
E-prescribing.

Risk Adjustment Information

In 1997, CMS created a new payment methodology for Medicare Advantage plans. The new methodology uses the health status of Medicare beneficiaries to determine accurate payment rates.

Physicians and other health care providers play an important role in risk adjustment because CMS looks at provider encounter data (extracted by Mount Carmel MediGold Health Plan from claims) to determine payment rates. Encounter data you submit to Mount Carmel MediGold Health Plan must be accurate and complete.

Risk adjustment is based on ICD-10 diagnosis codes, not CPT codes. Therefore, it is critical for your office to refer to an ICD-10-CM coding manual and code accurately, specifically and completely when submitting claims to Mount Carmel MediGold Health Plan.
Diagnosis codes must be supported by the medical record. If it is not documented in the medical record, Mount Carmel MediGold Health Plan has the right to not submit the diagnosis code to CMS through EDPS or submit a delete through EDPS. Medical records must be clear and complete.
Never use a diagnosis code for a "probable" or "questionable" diagnosis. Instead code only to the highest degree of certainty.
Be sure to distinguish between acute vs. chronic conditions in the medical record and in coding. Only choose diagnosis code(s) that fully describe the member’s condition and pertinent history at the time of the visit.
Be sure that the diagnosis code is appropriate for the member’s gender.
Always carry the diagnosis code all the way through to the correct digit for specificity. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character where applicable. (Where place holders exist, "X" must be used for the code to be valid).
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.
To ensure complete and accurate diagnosis codes are submitted to CMS, Mount Carmel MediGold Health Plan will conduct internal data validation audits by reviewing a sample of provider medical records to ensure coding accuracy. You may be contacted by Mount Carmel MediGold Health Plan requesting medical records for data validation. In order for a chart to be valid the following criteria must be met:
- Complete patient demographic information
- Date of Service
- Valid Signature
- Illegible provider signature will require a signature attestation per CMS guidelines
Documentation must indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
Mount Carmel MediGold Health Plan will add any diagnosis codes documented within the record but they were not coded or coded to the highest specificity at the time of the visit. In addition, Mount Carmel MediGold Health Plan will delete any diagnosis codes that were coded at the time of Mount Carmel MediGold Health Plan is a registered trade name of Mount Carmel Health Plan, Inc., the visit but not fully supported within the medial record to CMS through EDPS.

Risk Adjustment Data Validation (RADV) or Improper Payment Measure (IPM)

In accordance with risk adjustment requirements, CMS performs Risk Adjustment Data Validation (RADV) or Improper Payment Measure (IPM) audits to validate the members’ diagnosis data that was submitted by Mount Carmel MediGold Health Plan drawn from provider claims submissions. These audits are typically performed annually. If Mount Carmel MediGold Health Plan is selected by CMS for an RADV or IPM audit or to validate submitted diagnosis information, you are required, as a participating provider to comply and timely submit requested medical records to substantiate the diagnosis data submitted.

Encounter Data Processing System (EDPS)

Mount Carmel MediGold Health Plan is required to submit accurate diagnosis information on all of its members to CMS through the Encounter Data Processing System (EDPS). For EDPS submissions, CMS will filter claims data according to their risk adjustment guidelines. This filtering logic may prevent some claims that have traditionally been paid by Mount Carmel MediGold Health Plan from being accepted by CMS for risk adjustment purposes. Because of this, there may be instances where Mount Carmel MediGold Health Plan will need to reach out to a provider to obtain missing or incomplete data that would be needed for Risk Adjustment submissions. Below are the CMS websites that provide technical information on EDPS guidance.

Informing Members of Advance Directives

The federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of incapacitating illness or injury through advance directives.

Under this federal act, physicians and other professional providers, including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to members on state laws about advance treatment directives, about members’ rights to accept or refuse treatment and about your own policies regarding advance directives.

To comply with this requirement, we also inform members of laws on advance directives through our Member Agreement and other communications. We encourage these discussions with your patients.

As long as the member can speak for him/herself, you must honor his/her wishes. If the member becomes so sick that he/she cannot speak for him/ herself, then this directive will guide you in treating the member and will save the member’s family, friends and other providers from any guesswork as to what course of treatment, if any, the member would have wanted.

There may be several types of advance directives to choose from, depending on state law. Most states recognize:

Durable Power of Attorney for Health Care (DPAHC): DPAHC form allows the member to appoint an agent (family, friend or other person) whom he/she trusts to make treatment decisions for him/her should there come a time the member is unable to make them for him/herself.
Living Wills: The living will is a document through which a member may inform his/her physician that, if the member has a terminal condition (no chance of recovery) and death will occur in a relatively short period of time, the member only wants a desired level of care provided. This document goes into effect only when a member is permanently unconscious or terminally ill and can no longer speak for him/herself.
Rights of the Terminally Ill Act: Members have the right to control decisions relating to their medical care when they are terminally ill. This includes the decision not to undergo procedures that extend life in case of a terminal illness. To do this, the member must make a written notice advising his/her physician to withhold or withdraw procedures that continue life in the event of a terminal condition. The member is encouraged to give this form to his/her physician and closest relative and it should be kept on file should the event ever occur.

You must document in a prominent part of the member’s medical record whether or not the member has executed an advance directive.

Referrals and Prior Authorization Requests

You are responsible for the care of your members whether you provide the care directly or indirectly. All medical care sought out of network (excluding emergent or urgent care) at your direction but not prior authorized, will be subject to Mount Carmel MediGold’s Remediation Policy. Prior authorization requests received after the date of service will not be processed.

All referrals and prior authorization requests for members seeking out of network services should be made by a network provider and will be validated during the medical necessity review during the Prior Authorization process.

See the Utilization Management Section in this manual for more details.

Member Rights and Responsibilities

We tell our members that they have the following rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you.

Members’ Rights

To be treated with dignity, respect and fairness at all times by Mount Carmel MediGold Health Plan and network providers.
Privacy of your medical records and personal health information.
To see network providers and get covered services within a reasonable period of time and within a reasonable distance from your home.
To know your treatment choices and to participate in decisions about your health care.
To use advance directives (such as a living will or a power of attorney).
To make complaints if you experience problems or have concerns related to your coverage or your care.
To obtain information about your health care coverage and costs.
To obtain information about Mount Carmel MediGold Health Plan and network providers.

Members’ Responsibilities

Be familiar with your coverage and the rules to follow to obtain care as a member.
Give your physician and other professional providers the information they need to care for you, and to follow the treatment plans and instructions that you and your providers have agreed upon.
Act in a way that supports the care given to other patients and does not prevent the provider or Mount Carmel MediGold Health Plan office from running smoothly.
Pay your plan premiums and any copayments/ coinsurance you may owe for covered services received.
Contact us with any questions, concerns, problems or suggestions.

Last updated: 03/2024