Provider Manual Agewell New York-Books Pdf

Provider Manual AgeWell New York
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Table of Contents, Key Contacts and Resources 5, I Dedicated Staff to Assist Our Participating Providers 5. II Directory of Important Phone Numbers and Addresses 7. III Website Information 8, Verifying Member Eligibility 8. I Verifying Member Eligibility 8, II Coverage Determination 8. III Member ID Card 9, IV Participant Eligibility 10. Member Rights and Responsibilities 11, I Member Rights 11.
II Member Responsibilities 12, III Non Discrimination 12. IV Patient Self Determination 13, Provider Role and Responsibilities 14. I Requirements for all Providers 14, II Role of Primary Care Provider PCP and Selecting a Provider 16. III Participation Guidelines 17, IV Responsibilities to your Patients 17. V Standards of Timely Member Access to Care 18, VI Referring to a Participating AgeWell NY Specialist 19.
VII Provider Education 19, VIII Provider Performance Standards and Compliance Obligations 20. IX Provider Compliance with Standards of Care 20, X Confidentiality and HIPAA 22. XI Closing of Provider Panel 23, Network Specialist Responsibilities 23. I Network Specialist Participation Guidelines 23, II Responsibilities to your patients 24. III Confidentiality and HIPAA 24, 2 H4922 AWNY Provider Manual 2017.
Utilization Management 24, I Medical Review Process 24. II Review of Request for Health Care Services 26, III Levels of Review 26. IV Review of the Utilization Management Program 27. V Quality Assurance and Medical Management 29, Provider Credentialing and Termination 30. I Provider Credentialing 30, II Application Process 31. III Initial Credentialing 31, IV Recredentialing 31.
V Off Cycle Credentialing 31, VI Provider Termination and Disciplinary Action 32. VII Appeal of Disciplinary Action 33, VIII Procedure For Provider Termination and Continuity of Care 33. IX Review Procedure 34, X The Hearing 35, Vendor Oversight 37. Corporate Compliance 38, Claims and Billing 39, I Instructions for Submitting Claims 39. II Claims Payment 40, III Claims Payment Reconsideration 40.
IV Corrected Claims Resubmission 40, V Filing Limit Appeal 41. VI Claims Status 41, VII Provider Preventable Conditions 41. 3 H4922 AWNY Provider Manual 2017, INTRODUCTION, AgeWell New York welcomes you as part of the provider network Our network of physicians and. community providers promote health and well being through the provision of high quality cost. effective health care in the home and the community It is our responsibility to collectively coordinate. and provide necessary health care services for our participants. You have joined a rapidly expanding network including over 9 000 licensed independent practitioners. and 40 hospitals committed to caring for the frail elderly chronically ill population AgeWell New. York has been serving this population since our inception in 2012 as a Managed Long Term Care Plan. MLTC AgeWell New York s Medicare Advantage Prescription Drug Plan MA PD and Special. Needs Products are designed to meet the needs of the Medicare or Dually eligible population. Medicare and Medicaid residing in the boroughs of Queens Brooklyn New York Manhattan. Bronx and the counties of Nassau Suffolk and Westchester. Our goal and guiding principles include, Offering plan benefits that improve access to appropriate care including assistance with. navigating an increasingly complex health care system. Shifting the focus of care from the institution to the home and community. Targeting and customizing interventions based on the needs of the participant. AgeWell New York s MA PD and Special Needs Plans provide benefits to eligible members. including Part D covered items Through its network providers AgeWell New York has access to an. adequate network of medical and supportive services All care is either provided directly by AgeWell. New York or coordinated through network providers, As a network provider you play a crucial role in assisting participants in meeting their goals by.
providing efficient high quality care and services We value your purpose and encourage that each. interaction you may have with our participants be filled with compassion and dedication to excellence. in service delivery, At AgeWell New York you are a valued partner in caring for our members your patients This manual. was designed to assist you in understanding the requirements of AgeWell New York in addition to. serving as a resource for any questions you have about our plans This manual serves as a. supplemental guide to the Provider Agreement Since changes in Medicare and Medicaid policies and. AgeWell New York operations are inevitable over time changes to policies herein are subject to. updates and modifications If AgeWell New York updates any of the information in this manual we. will provide bulletins as necessary and post the changes on our website www agewellnewyork com. You can also find a copy of this manual on the For Providers section of our website. AgeWell New York is proud of the relationship with our participating providers and is committed to. working with you to provide the support and assistance necessary to meet the needs of your patients. We look forward to a beneficial working relationship. 4 H4922 AWNY Provider Manual 2017, KEY CONTACTS AND RESOURCES. I Dedicated Staff to Assist Our Participating Providers. Provider Relations, Our Provider Relations Department is responsible for oversight functions related to maintaining. provider network ensuring network adequacy and access provider training and orientation. credentialing activities and continuous monitoring of provider network performance. The AgeWell New York Provider Relations Department is the primary connection between you and. our plan They are responsible for managing the plan s provider relationships that make up the health. care delivery system including individual practitioners groups hospitals skilled nursing facilities. medical equipment suppliers and other providers The main focus of the Provider Relations. Department is to assist you with all aspects of your plan participation. Your Provider Relations Representative will assist you by. Serving as a point of contact with the plan, Orienting you and your staff on the AgeWell New York policies and procedures. Providing ongoing education concerning changes in operational and regulatory procedures. Responding in a timely manner to any of your questions or concerns. Establishing provider connection to the AgeWell New York systems. Administering the credentialing recredentialing process. Provider Claims, AgeWell New York s Provider Claims Department provides claims processing and claims payment to.
ensure appropriate requirements are being met efficiently and effectively and in compliance with state. and federal regulations The Provider Claims Department is responsible for paying claims as defined in. the terms of your contract with AgeWell New York, Utilization Management. Our Utilization Management UM Department is the contact point for utilization management UM. and related functions to include prior authorization inpatient concurrent review clinical training and. related compliance programs as examples We support the utilization management function with. leading practice UM applications monitoring and reporting tools and techniques and professional. development of staff, Quality Management, The Quality Management Department oversees the following aspects of our participants healthcare. and service provision, Quality of care for our members. Member satisfaction including the evaluation of grievances and appeals. 5 H4922 AWNY Provider Manual 2017, Access and availability standards. Quality Management is also responsible for managing and training the appeals and grievances team. and complying with state and federal requirements related to processing appeals and grievances. Member Services, Member Services assists members with non urgent matters and provides excellent customer service.
and responsiveness to calls from public for information and or calls from prospective or current. The Member Services staff is responsible for, Providing telephone access through the member call center. Providing members with information about their health benefits. Assisting members to select or change a PCP or help them find a network provider. Fielding and responding to member questions and complaints. Clarifying information in the member handbook, Responding to communications received from members and providers. Pharmacy Benefits Operations and Management, AgeWell New York contracts with EnvisionRx a Pharmacy Benefits Management PBM Part D. organization that manages the pharmacy benefit including pricing paying pharmacies and determining. levels of coverage for certain drugs EnvisionRx is responsible for ensuring compliance with state and. federal requirements maintaining systems for seamless integration of member information into Care. Management Utilization Management Quality Assurance and other critical functions to support the. care management of members and improvement of health outcomes. Enrollment, Oversees and manages the activities of the clinical assessment functions of the plan including meeting. the initial assessment requirements Enrollment also works to ensure accurate member rosters and. fulfillment of member materials, 6 H4922 AWNY Provider Manual 2017.
Important Phone Numbers and Addresses, CLAIM SUBMISSIONS. Paper claims AgeWell New York P O Box 21536 Eagan MN 55121. Electronic claims Change Healthcare Emdeon Payer ID AWNY6. Provider claims call center 866 237 2140, Claims and Billing Inquiries 866 237 2140. PROVIDER RELATIONS, 718 484 5000, providers agewellnewyork com. 1991 Marcus Avenue Suite M201 Lake Success NY 11042. Claims Appeals AgeWell New York 1991 Marcus Avenue Suite M201 Lake Success NY 11042 Attn. Claims Appeals, Member Grievance Appeals AgeWell New York 1991 Marcus Avenue Suite M201 Lake Success NY. 11042 Tel 866 586 8044 Fax 855 895 0778 Attn Grievance and Appeals. Member Services Enrollment Eligibility Verification 866 586 8044 after option 3 press 1. Medical Management Including Prior Authorization 866 586 8044 after option 3 press 4. Pre Authorization fax line 1 855 527 5515, Transportation Services Non Emergency National Med Trans 855 639 6609.
Dental Services HealthPlex Provider Services 888 468 2183 Member Services 888 468 9868. Vision Services VSP 800 877 7195, Pharmacy Services. EnvisionRx Options Pharmacy Benefit Management Medicare Plans Special Needs Plans 844 782 7670. FIDA Medicare Medicaid Plan 855 889 0046, Interpreter Services. For assistance in coordinating interpreter services for those members in need of support with limited English. proficiency LEP or limited reading proficiency LRP 866 586 8044 Hearing and or visual Impairment. TTY TDD 1 800 662 1220, 7 H4922 AWNY Provider Manual 2017. III Website Information, Please take a look at our website www agewellnewyork com On our website you can find information. Supporting Forms, List of Services that Require Prior Authorization.
Provider Search, Online Eligibility and Claims Access. AgeWell New York Formulary, Provider Manual, Mandatory Provider Education Trainings and Attestations. EFT ERA Information, Reference Guide, Claims Submission Information. Provider Information Change Form, Provider Contact update Form. VERIFYING MEMBER ELIGIBILITY AND COVERED SERVICES, I Verifying Member Eligibility.
AgeWell New York will reimburse providers only for services rendered to currently eligible members. It is the responsibility of the provider to verify eligibility prior to providing services. You may obtain information on AgeWell New York member eligibility by calling the Member. Eligibility at 866 586 8044 Our hours are Monday through Friday from 8 00 am to 8 00pm EST. In order to verify a member s eligibility please ask to see the member s AgeWell New York ID card at. each appointment emergency visit or inpatient stay However the provision of service should not be. conditioned solely on the presentation of a member ID card Conversely the presentation of an ID. card does not guarantee eligibility or payment of benefits because a member s enrollment status can. change due to various reasons including disenrollment or loss of Medicaid or Medicare eligibility. Providers should verify member eligibility as outlined below. Call Member Services at 866 586 8044, Providers with eMedNY access may check the enrollment of Medicaid members on ePACES. where applicable, II Coverage Determination, AgeWell New York offers a wide range of benefits to its Members including inpatient hospital. physician services durable medical equipment and prescription drugs Network providers who are. uncertain if a particular service is covered or seeks approval for a service not covered may call. AgeWell New York for a coverage determination at 866 586 8044. 8 H4922 AWNY Provider Manual 2017, III Member ID Card. All AgeWell New York participants in our Plan are given an identification card sample below. Members should present their ID cards when they request any type of covered healthcare service This. card is for identification only and does not guarantee eligibility for coverage. 9 H4922 AWNY Provider Manual 2017, IV Participant Eligibility. LiveWell MA PD, Beneficiaries Prospective Members are eligible to join the plan as long as.
1 H4922 AWNY Provider Manual 2017 Provider Manual Medicare Advantage Prescription Drug MA PD Plan And Dual Special Needs Plans D SNPs 2 H4922 AWNY Provider Manual 2017 Table of Contents Key Contacts and Resources 5 I Dedicated Staff to Assist Our Participating Providers 5 II Directory of Important Phone Numbers and Addresses 7 III Website Information 8 Verifying Me

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