ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans
|
|
- Nicholas Daniels
- 5 years ago
- Views:
Transcription
1 ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans DEPARTMENT: Medicare Compliance POLICY TITLE: RELATED DEPARTMENTS: All POLICY #: 706 C VERSION #: 4 REVISION DATE: Identifying and Monitoring for Fraud Waste and Abuse 4/2016 EFFECTIVE DATE: PREPARED BY: PRODUCT: NEXT REVIEW DATE: 1/1/2013 Cathy Kajubi Medicare Advantage December 2016 Approved: David Finkel President, MedStar Family Choice Lesley Wallace Assistant Vice President, MedStar Family Choice PURPOSE This policy describes MedStar Family Choice s (MFC) efforts to identify, remediate and prevent instances of non compliance and Fraud Waste and Abuse (FWA) within its Medicare program. DEFINITIONS/ACRONYMS CMS Centers for Medicare & Medicaid Services FDR First Tier, Downstream, and Related entities FWA Fraud, Waste and Abuse MCO Medicare Compliance Officer MA Medicare Advantage MFC- MedStar Family Choice PDP Prescription Drug Plan
2 Employee: Any full-time, part-time, temporary, contracted or volunteer individual employed directly by MedStar Health or MedStar Family Choice involved in the administration or delivery of the Medicare benefit. First Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage (MA) Organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program. Downstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. Related Entity: Any entity related to an MAO or Part D sponsor by common ownership or control and: Performs some of the MAO or Part D functions under contract or delegation; o Furnishes services to Medicare enrollees under an oral or written agreement; or o Leases real property or sells materials to sponsor at a cost of more than $2,500. NBI MEDIC - National Benefit Integrity Medicare Integrity Contractor (NBI MEDIC) is the Medicare Part C and Part D program integrity contractor for the Centers for Medicare & Medicaid Services (CMS) under the National Benefit Integrity Medicare Drug Integrity Contract. The purpose of the NBI MEDIC is to detect and prevent fraud, waste, and abuse in the Part C (Medicare Advantage) and Part D (Prescription Drug Coverage) programs on a national level. POLICY All MFC employees and the employees of MFC s First Tier, Downstream, and Related entities (FDR) are responsible for assisting in the identification, investigation and reporting of instances of actual or suspected fraud, waste, and abuse through audits, data analysis, reporting, and other activities. PROCEDURE 1. Fraud waste and abuse can occur within many areas of an organization. It is the responsibility of all employees to identify and report suspected fraud waste and abuse activities. Employees should follow the appropriate policies and procedures for reporting fraud and abuse activities as outlined in the annual fraud waste and abuse compliance training. 2. Areas in which fraud waste and abuse can occur can include but are not limited to the following: Encounter Data Claims Submission Claims Processing Billing Procedures Underutilization Overutilization Customer Service Credentialing
3 Enrollment and Disenrollment Marketing 3. The Medicare Compliance Director will monitor on a frequent and routine basis reports in the areas of: Enrollment & Eligibility Member Services Complaints and Appeals Medical Claims Pharmacy Claims HIPAA Breaches Fraud Waste & Abuse 4. The Medicare Compliance Committee will review and recommend any additional reports that will assist in the identification and detection of fraud waste and abuse activities. 5. The Medicare Compliance Committee will review the results of auditing and monitoring activities on a quarterly basis or more frequently should serious issues be identified. 6. The auditing and monitoring activities will include the following: 7. An explanation/ evidence of a root cause analysis performed for any issues identified. Monitoring reports showing the outcomes of monitoring conducted on the identified issues. If monitoring occurred over a period of time, trending reports showing the trend of the issue (i.e., the issue is being or has been remediated over time or the issue is still occurring). Audit reports showing the results of any audits conducted for identified issues. Evidence/ explanation of any follow up done as a result of the monitoring/ auditing of the identified issue. An explanation of detailed corrective actions that were taken regarding the identified issues. A timeline indicating the corrective actions were fully implemented or, if not fully implemented, when the corrective actions will be completed. If corrective actions were not required, an explanation of rationale for not implementing corrective action. 8. The Medicare Compliance Director will submit quarterly reports and an annual report to the Medicare Compliance Committee to be shared with the Board of Directors. As appropriate, a NBI MEDIC referral will be created and submitted as well. The reports will summarize the overall fraud waste and abuse activity and any changes that are recommended in order to improve overall compliance. 9. As an additional resource in fraud waste and abuse detection, the Medicare Compliance Director and Medicare Compliance Officer will receive on a weekly basis reports from the Special Investigation Unit at UPMC. As the processor of MedStar Medicare Choice claims, UPMC performs FWA analytics on claims processed by UPMC. The UPMC Special Investigation Unit produces weekly activity reports as well as monthly reports of results.
4 10. The UPMC Health Plan Benefit Management Services (UPMC) utilizes an assortment of reporting tools and techniques to identify and evaluate potential fraud, waste and abuse (FWA) issues. Some of the tools are used by UPMC to identify and investigate FWA issues and create tips/cases where necessary or conduct risk assessments include : NHCAA SIRIS: The National Health Care Anti-Fraud Association (NHCAA) Special Investigations Resource and Intelligence System (SIRIS) is a database maintained by the NHCAA for the purpose of sharing intelligence and information related to healthcare fraud. The database includes information from all 50 states and from hundreds of healthcare insurance SIU s. The SIU reviews cases from states associated with each Evolent client for potential exposure. NHCAA Smart Briefs: The NHCAA also provides a daily known as a Smart Brief. Smart Briefs include prominent issues and news articles related to healthcare fraud. These issues are reviewed for new trends and possible exposure to each Evolent client. High Prescriber Utilization: The High Prescriber Utilization report is sent to the SIU on a monthly basis. The report includes summarization of narcotics usage for all prescribers and the member information included with that data. The data is analyzed and outliers are identified for further review. Based on that review a clinical auditor analyzes the data identified. StarSentinel Lead Generation Software: Star Sentinel is a lead generation software system powered by General Dynamics that allows the SIU to identify red flags, review potential outliers and review algorithms used to detect potential fraud, waste or abuse issues. Reviews of StarSentinel will be conducted on a regular schedule and in an as needed manner. High Dollar and Random Audit Claim Audits: Quality Audit department audits identify potentially questionable claim issues for review by the SIU. Quality Audit conducts prepayment review of high dollar claims for appropriate charges. Random audits are conducted of claims and questionable claims are provided to the SIU for review. 11. In addition to the claims processed by UPMC, all FDRs are responsible for providing FWA reports on a routine basis, but no less than quarterly. RECORD RETENTION Medical and business documents and records must be maintained in accordance with procedures and timeframes established by applicable laws, accreditation standards, and MedStar Health s Record Retention and Destruction Policy, whichever period is longer. For the Medicare line of business the record retention period is at least 10 years. Medical and business documents include paper documents such as letters and memoranda; computer-based information, such as or computer files on disk or tape; and any other medium that contains information about MedStar Health or its business activities. MedStar also requires that all FDRs meet or exceed this strict record retention requirement. RELATED DOCUMENTS/ATTACHMENTS Medicare Compliance Plan MedStar Code of Conduct Medicare Compliance Committee Charter
5 MedStar Family Choice Administrative Policy and Procedure: Medicare Compliance Fraud Waste & Abuse Education and Training REGULATORY REFERENCES: 42 CFR (b)(4)(vi)(F) Medicare Managed Care Manual, Chapter 21, Section 50.6 Medicare Advantage and Part D Fraud Handbook: Practical Techniques and Approaches on Detecting and Preventing Fraud (Version 1.0, March 2014) Medicare Advantage and Part D Program Integrity Basics (Version 1.0, August 2015) REVIEW AND REVISION HISTORY DATE REVISION REASON FOR CHANGE NO. 4/ Added additional information regarding auditing and monitoring 12/ Annual Policy Revision 3/ Annual Policy revision
ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans
ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans DEPARTMENT: Medicare Compliance POLICY TITLE: RELATED DEPARTMENTS: All POLICY #: 700C VERSION #: 3 REVISION DATE: Medicare
More informationChallenges for U.S. Attorneys Offices (USAO) in Opioid Cases
Challenges for U.S. Attorneys Offices (USAO) in Opioid Cases Overview On August 2, 2017, U.S. Attorney General Jeff Sessions announced a pilot program whereby a new federal data analysis program is being
More informationAmy Larrick Chavez-Valdez, Director, Medicare Drug Benefit and C & D Data Group
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 CENTER FOR MEDICARE TO: FROM: SUBJECT: All Part D Sponsors Amy Larrick
More informationChapter 18 Section 15. Department Of Defense (DoD) Applied Behavior Analysis (ABA) Pilot For Non-Active Duty Family Members (NADFMs)
Demonstrations And Pilot Projects Chapter 18 Section 15 Department Of Defense (DoD) Applied Behavior Analysis (ABA) Pilot 1.0 PURPOSE Under authority of 10 United States Code (USC) 1092, TRICARE will continue
More informationVaccine Starter Kit Program FAQs
Vaccine Starter Kit Program FAQs Program How does this program help Health Mart pharmacies provide vaccines for their customers? McKesson has designed a comprehensive program specifically for Health Mart
More informationAlcohol & Drug Practice
Alcohol & Drug Practice Vice-President, Health & Safety June 1, 2011 Purpose Cenovus recognizes that the use of alcohol and drugs can adversely affect job performance, the work environment and the safety
More informationCorporate Policies. Corporate Billing and Collection Policy Section:
MedStar Health Title: Purpose: Corporate Policies Corporate Billing and Collection Policy Section: To ensure uniform management of the MedStar Health Corporate Billing and Collection Program for all MedStar
More informationGUIDELINES: PEER REVIEW TRAINING BOD G [Amended BOD ; BOD ; BOD ; Initial BOD ] [Guideline]
GUIDELINES: PEER REVIEW TRAINING BOD G03-05-15-40 [Amended BOD 03-04-17-41; BOD 03-01-14-50; BOD 03-99-15-48; Initial BOD 06-97-03-06] [Guideline] I. Purpose Guidelines: Peer Review Training provide direction
More informationIntegrating HIPAA Into Your Compliance Program
Integrating HIPAA Into Your Compliance Program Fifth Annual National Congress on Health Care Compliance February 7, 2002 Glenna S. Jackson Vice President Compliance, MedStar Health Diane H. Meyer Chief
More informationPHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL
PHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 PHYSICAL MEDICINE AND REHABILITATION Table of Contents 30.1 Enrollment......................................................................
More informationDental Dialog. Highlighting news, programs, policies and tips for Aetna participating dentists. Fall aetna.com
Dental Dialog Fall 2017 Highlighting news, programs, policies and tips for Aetna participating dentists 43.22.802.1-FA A (10/17) aetna.com Dental Dialog Fall 2017 Inside this issue The opioid epidemic...
More informationPediatric Restorative Benefits: Potential for Fraud & Abuse
1 Pediatric Restorative Benefits: Potential for Fraud & Abuse Part 2 The Medicaid-Commercial Spectrum, Media Reports of Abuse, U.S. Senate Study, Quest for the Facts and a Plan of Action Craig Kasten Wednesday
More informationFall 2017 Provider Newsletter
Fall 2017 Provider Newsletter In This Issue Molina Healthcare s 2017 HEDIS and CAHPS Results...1 Molina Healthcare s Special Investigation Unit Partnering With You to Prevent Fraud, Waste, and Abuse...3
More informationRisk Classification Modeling to Combat Opioid Abuse
Risk Classification Modeling to Combat Opioid Abuse Improve Data Sharing to Identify High-Risk Prescribers of Opioids Christopher Sterling Chief Statistician NCI, Inc. www.nciinc.com 11730 Plaza America
More informationTaking Part B Therapy Beyond the $3,700 Threshold New Manual Medical Review Process Effective date October 1, 2012
Taking Part B Therapy Beyond the $3,700 Threshold New Manual Medical Review Process Effective date October 1, 2012 Presented by: Leigh Ann Frick, PT, MBA Vice President of Clinical Services Heritage Healthcare
More informationA newsletter for Molina Healthcare Provider Networks. Fall 2018
A newsletter for Molina Healthcare Provider Networks Fall 2018 In this Issue 2018-2019 Flu Season....1 Molina Healthcare s Special Investigation Unit Partnering with You to Prevent Fraud, Waste and Abuse...2
More informationManaging Opioid Overutilization Challenges
One Source. Lower Cost. Better Care. Managing Opioid Overutilization Challenges A LOOK AT REDUCING OPIOID OVERUTILIZATION BY 36 PERCENT Copyright 2017 MedImpact Healthcare Systems, Inc. All rights reserved.
More informationSeptember 22, National Association of Attorneys General 1850 M Street, NW, 12 th Floor Washington, DC Prescription Opioid Epidemic
National Association of Attorneys General 1850 M Street, NW, 12 th Floor Washington, DC 20036 RE: Prescription Opioid Epidemic On behalf of America s Health Insurance Plans (AHIP), thank you for your leadership
More informationMedicare Part D Overutilization Monitoring System
Medicare Part D Overutilization Monitoring System Lisa Thorpe, Division of Part D Policy Gary Wirth, Division of Clinical and Operational Performance Medicare Drug Benefit and C&D Data Group July 17, 2013
More informationAlign your brand with one of education s most highly respected and experienced organizations.
Christian Schools International Sponsorship Opportunities 2014-2015 Align your brand with one of education s most highly respected and experienced organizations. Sponsorship Opportunities Join Us. Founded
More informationProviderNews2015. a growing issue. Body mass index and obesity: Tips and tools for tackling
GeorgiA ProviderNews2015 Quarter 2 Body mass index and obesity: Tips and tools for tackling a growing issue For adults, overweight and obesity ranges are determined by using weight and height to calculate
More information340B Audit Experiences from 2015: What We Learned From Over 50 Audits
340B Audit Experiences from 2015: What We Learned From Over 50 Audits ROB NAHOOPII, PHARMD, MS, BCPS RICH BUCHER, JD, RPH TURNKEY PHARMACY SOLUTIONS Statement of Conflicts of Interest Rob Nahoopii Rich
More informationVaccine Coverage Requirements in the U.S.
Vaccine Coverage Requirements in the U.S. Richard Hughes IV and Emily Sobel 10.18.17 Avalere Health T 202.207.1300 avalere.com An Inovalon Company F 202.467.4455 1350 Connecticut Ave, NW Washington, DC
More informationThe Wisconsin Prescription Drug Monitoring Program
The Wisconsin Prescription Drug Monitoring Program DHS 2018 WI Opioid Forum April 12, 2018 Learning Objectives 1. How the WI epdmp supports healthcare professionals in making informed prescribing, dispensing
More informationCOMMUNITY HOSPICE & PALLIATIVE CARE NOTICE OF PRIVACY PRACTICES
COMMUNITY HOSPICE & PALLIATIVE CARE NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
More informationChapter 18 Section 2. EXPIRED - Department Of Defense (DoD) Cancer Prevention And Treatment Clinical Trials Demonstration
s And Pilot Projects Chapter 18 Section 2 EXPIRED - Department Of Defense (DoD) Cancer Prevention And Treatment Clinical Trials 1.0 PURPOSE The purpose of this demonstration is to improve TRICARE-eligible
More informationPatricia Ward Chief Budget Officer (919)
APRIL 2017 93.752 COOPERATIVE AGREEMENTS FOR STATE-BASED COMPREHENSIVE BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAMS State Project/Program: NC BREAST AND CERVICAL CANCER CONTROL PROGRAM Federal Authorization:
More informationCHAPTER 7 SECTION 24.1 PHASE I, PHASE II, AND PHASE III CANCER CLINICAL TRIALS TRICARE POLICY MANUAL M, AUGUST 1, 2002 MEDICINE
MEDICINE CHAPTER 7 SECTION 24.1 ISSUE DATE: AUTHORITY: 32 CFR 199.4(e)(26) I. DESCRIPTION The Department of Defense (DoD) Cancer Prevention and Treatment Clinical Trials Demonstration was conducted from
More informationAll Medicare Advantage, Prescription Drug Plan, Cost, PACE, and Demonstration Organizations Systems Staff
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 Medicare Drug Benefit and C & D Data Group DATE: February 3, 2014 TO:
More informationPHARMACY COMPLIANCE RISK AREAS FOR 2014
PHARMACY COMPLIANCE RISK AREAS FOR 2014 2014 San Juan Puerto Rico Regional Compliance Conference Darrell W. Contreras, Esq., LHRM, CHC-F, CHPC, CHRC 5 Risk Areas 1. Overbilling of Herceptin 2. Quality
More informationChapter 15 Section 1
Chapter 15 Section 1 Issue Date: November 6, 2007 Authority: 32 CFR 199.14(a)(3) and (a)(6)(ii) 1.0 APPLICABILITY This policy is mandatory for the reimbursement of services provided either by network or
More informationThe Wisconsin Prescription Drug Monitoring Program. WI PDMP Timeline. PDMP Overview. What is a PDMP? PDMPs Across the Nation. Wisconsin.
The Wisconsin Prescription Drug Monitoring Program Wisconsin Nurses Association Jail Health Care Conference May 21, 2018 WI PDMP Timeline PDMP Overview January 2013 WI PDMP operational April 2017 WI epdmp
More informationContracting for Dental Services: Increase Access to Care
Contracting for Dental Services: Increase Access to Care Irene V. Hilton, DDS, MPH Donald A. Simila, MSW, FACHE June 19, 2017 Objectives List scenarios in which health centers contract for dental services
More informationAppendix C NEWBORN HEARING SCREENING PROJECT
Appendix C NEWBORN HEARING SCREENING PROJECT I. WEST VIRGINIA STATE LAW All newborns born in the State of West Virginia must be screened for hearing impairment as required in WV Code 16-22A and 16-1-7,
More informationNEW MEXICO DEPARTMENT OF HEALTH Administrative Manual ADMINISTRATION
Chapter NEW MEXICO DEPARTMENT OF HEALTH Administrative Manual ADMINISTRATION EFFECTIVE: Policy REVISED: 4/13/9 draft NALOXONE DISTRIBUTION POLICY I. PURPOSE: This New Mexico Department of Health (NMDOH)
More informationCurbing Prescription Drug Abuse in Medicaid
Curbing Prescription Drug Abuse in Medicaid Joint Legislative Health Care Oversight Committee October 12, 2010 Dr. Lisa Weeks, BSPharm, PharmD Pharmacy and Ancillary Services Division of Medical Assistance
More informationPROVIDER CONTRACT ISSUES
211 East Chicago Avenue T 312.440.2500 Chicago, Illinois 60611 F 312.440.7494 www.ada.org TOP 10 CLAIM CONCERNS: ADA, NADP SHARE VIEWS ON DENTISTS CONCERNS The ADA Council on Dental Benefit Programs continually
More informationProvider Newsletter. MedStar Medicare Choice Pharmacy Benefits
Third Quarter 2017 MedStar Select/Medicare Choice Provider Newsletter MedStar Medicare Choice Pharmacy Benefits The pharmacy benefits manager for MedStar Medicare Choice is MedStar Medicare Choice Pharmacy
More information11/12/2015 THE LATEST ON THE 340B FRONT AGENDA MEGA GUIDANCE RELEASED. Mega Guidance released. Audit update from HRSA. Maintaining compliance
November 19, 2015 Connie Ouellette, Principal Carole Barker, Senior Consultant THE LATEST ON THE 340B FRONT berrydunn.com AGENDA Mega Guidance released Audit update from HRSA Maintaining compliance Areas
More informationSANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery
Page 1 of 9 SANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery Departmental Polley and Procedure Section Sub-section Alcohol and Drug Program (ADP) Effective: 7/11/2018
More informationRegulations & Standards for Hospice Managers
Regulations & Standards for Hospice Managers A Level I Module of the Hospice MDP Objectives Identify the difference between regulations, standards and guidelines Describe and discuss the regulations for
More informationChapter 4 Section Combined Heart-Kidney Transplantation (CHKT)
Surgery Chapter 4 Section 24.3 Issue Date: May 7, 1999 Authority: 32 CFR 199.4(e)(5) 1.0 POLICY 1.1 is a TRICARE benefit that requires preauthorization. 1.1.1 A TRICARE Prime enrollee must have a referral
More informationReport to the Social Services Appropriations Subcommittee
Report to the Social Services Appropriations Subcommittee Medicaid Coverage and Reimbursement for Outpatient Physical Therapy and Outpatient Occupational Therapy Prepared by the Division of Medicaid and
More informationBusiness Impact Analysis
ACTION: Final DATE: 05/23/2018 8:24 AM Business Impact Analysis Agency Name: Ohio Department of Medicaid (ODM) Regulation/Package Title: Dental services Rule Number(s): Rule 5160-5-01 with appendices A
More informationOverview. Provider Enrollment Requirements Member Eligibility Hearing Services Authorization and Billing Additional Information
Audiology Services Overview Provider Enrollment Requirements Member Eligibility Hearing Services Authorization and Billing Additional Information 2 Provider Enrollment 3 Alaska Medicaid Provider Enrollment
More informationIntroduction. Current status of 510(k) clinical data requirements. 1 Current Status&Considerations:
510(k) Current Status&Considerations: Conducting a Well-Controlled Clinical Study When Clinical Data is Required Introduction In an effort to promote innovation while protecting the population at large,
More informationArticle XIX DENTAL HYGIENIST COLLABORATIVE CARE PROGRAM
Article XIX DENTAL HYGIENIST COLLABORATIVE CARE PROGRAM Pursuant to ACA 17-82-701-17-82-707 the Arkansas State Board of Dental Examiners herby promulgates these rules to implement the dental hygienist
More informationProviderNews FEBRUARY
ProviderNews FEBRUARY 2017 Reminder: decimal billing required on time-based therapy codes for BadgerCare Plus members In accordance with Forward Health guidelines, Security Health Plan requires decimal
More informationDental Benefits. Glossary. Delta Dental of Virginia DeltaDentalVA.com 1
Dental Benefits Glossary Delta Dental of Virginia DeltaDentalVA.com 1 Table of Contents Dental Benefits Terms... 4 16 A Annual Maximum... 5 B Balance Billing... 5 Benefit Year... 5 Benefit Levels... 6
More informationIn its written comments on our draft report, CMS concurred with our recommendation.
Page 2 Kerry Weems We recommend that Congress and CMS consider the results our review, including the data provided, in any deliberations regarding Medicare Part D reimbursement. In its written comments
More informationCHAPTER 3 SECTION 1.6E COMBINED LIVER-KIDNEY TRANSPLANTATION. TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 Surgery And Related Services
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 Surgery And Related Services CHAPTER 3 SECTION 1.6E Issue Date: October 26, 1994 Authority: 32 CFR 199.4(e)(5) I. PROCEDURE CODE RANGE 47150 II. POLICY
More informationChanges to the Eighth Edition
Pharmacy Practice and the Law, Eighth Edition Includes Navigate 2 Advantage Access By Richard R. Abood, BS Pharm, JD-Professor Emeritus Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences,
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 02/01/12 REPLACED: 02/01/94 CHAPTER 5: PROFESSIONAL SERVICES SECTION 5.1: COVERED SERVICES PAGE(S) 6
Diabetes Education Management Training Diabetes self management training (DSMT) is a collaborative process through which recipients with diabetes gain knowledge and skills needed to modify behavior and
More informationUnderstanding the Administrative Hearing Process & 2017 Managed Care Regulations Changes
Understanding the Administrative Hearing Process & 2017 Managed Care Regulations Changes Home and Community Based Waiver Conference November 14, 2017 1 OUTLINE I. Purpose of Training II. Purpose of a Hearing
More informationNDA MF REMS ASSESSMENT ACKNOWLEDGMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration Silver Spring MD 20993 REMS ASSESSMENT ACKNOWLEDGMENT Insys Development Co. c/o Insys Therapeutics, Inc. 1333 South Spectrum Blvd.,
More informationWhat s New. Don t Forget! There are 2 different influenza vaccines available. Flu Vaccine. Michigan Newsletter Fall 2009
What s New Michigan Newsletter Fall 2009 Flu Vaccine Don t Forget! There are 2 different influenza vaccines available this year (one for seasonal flu and one for Novel H1N1 or swine flu). Both vaccines
More informationTools and Resources for Dental Offices. Prepared for the Pennsylvania Dental Association
2018 Tools and Resources for Dental Offices Prepared for the Pennsylvania Dental Association Introduction Dental insurance doesn't have to be difficult, which is why United Concordia Dental is committed
More informationManaged Health Services (MHS) Candace V. Ervin Market Manager, Indiana Provider Relations October 18, 2017
Managed Health Services (MHS) Candace V. Ervin Market Manager, Indiana Provider Relations Candace.Ervin@Envolvehealth.com October 18, 2017 1 Today s Agenda MHS ID Card Samples Provider Visits D1110 (Prophylaxis
More informationCBR201609: Diabetic Testing Supplies
Stay Tuned for Webinar Audio dial-in: 323 920 0091; PIN: 256-7691# For technical assistance, send email to support@anymeeting.com : Diabetic Testing Supplies 3:00 P.M. ET July 27, 2016 : Diabetic Testing
More informationWYOMING CHILDHOOD IMMUNIZATION RULES CHAPTER 7 COVERED SERVICES
WYOMING CHILDHOOD IMMUNIZATION RULES CHAPTER 7 COVERED SERVICES (NOTE: for the 120 days the emergency rules are in effect, the following rules shall apply. Emergency rules are no longer in effect 120 days
More informationA Bill Regular Session, 2015 SENATE BILL 717
Stricken language would be deleted from and underlined language would be added to present law. 0 State of Arkansas 0th General Assembly As Engrossed: S// H// A Bill Regular Session, SENATE BILL By: Senator
More informationProviderNews2015. a growing issue FLORIDA. Body mass index and obesity: Tips and tools for tackling
FLORIDA ProviderNews2015 Quarter 2 Body mass index and obesity: Tips and tools for tackling a growing issue For adults, overweight and obesity ranges are determined by using weight and height to calculate
More informationPHARMACY BENEFITS MANAGER SELECTION FAQ FOR PRODUCERS
PHARMACY BENEFITS MANAGER SELECTION FAQ FOR PRODUCERS For Producer Audience Only - Please Do Not Distribute Regence has selected Prime Therapeutics as the Pharmacy benefits manager for its health plans.
More informationFirstCare Health Plans (FirstCare) is on track to be ICD-10 ready by the October 1, 2015 deadline.
Overview In July 2014, the U.S. Department of Health & Human Services (HHS) issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care
More informationProposed Amendment of 10A NCAC 26E.0603 Requirements for Transmission of Data
Proposed Amendment of 10A NCAC 26E.0603 Requirements for Transmission of Data Agency: Contact: DHHS/ Mental Health, Developmental Disabilities, and Substance Abuse Services Amanda Reeder, Rule-Making Coordinator
More informationDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES (By authority conferred on the director of the department of licensing and regulatory affairs by
More informationDrug Diversion Controls. MedStar Mobile Healthcare Best Practices Chad Carr Compliance Officer, Paralegal
Drug Diversion Controls MedStar Mobile Healthcare Best Practices Chad Carr Compliance Officer, Paralegal Our Journey in Tracking Narcotics Has to Start Somewhere. Process Started on Paper omanual Process
More informationTHE LATEST ON THE 340B FRONT
September 1, 2015 Connie Ouellette, Principal Carole Barker, Senior Consultant THE LATEST ON THE 340B FRONT berrydunn.com AGENDA Mega Guidance released! Audit update from HRSA Maintaining compliance Areas
More informationChapter. CPT only copyright 2008 American Medical Association. All rights reserved. 15Diabetic Equipment and Supplies
Chapter 15Diabetic Equipment and Supplies 15 15.1 Enrollment...................................................... 15-2 15.2 Benefits, Limitations, and Authorization Requirements......................
More informationTherapeutic Practices Review Inventory practitioners, procedures, services, drugs, supplements, devices, labs.
SUMMARY CHECKLIST FOR LEGAL AUDIT OF INTEGRATIVE AND CAM PRACTICES Therapeutic Practices Review Inventory practitioners, procedures, services, drugs, supplements, devices, labs. Sources of regulation:
More informationGRIEVENCE PROCEDURES INFORMAL REVIEWS AND HEARINGS
GRIEVENCE PROCEDURES INFORMAL REVIEWS AND HEARINGS OVERVIEW Both applicants and participants have the right to disagree with and appeal, certain decisions of the PHA that may adversely affect them. PHA
More information1. Comply with the NCI CIRB s requirements and directives;
Michigan State University Human Research Protection Program Subject: Use of the National Cancer Institute Central Institutional Review Board Section: 1-5 This policy and procedure supersedes those previously
More informationSTATE OPERATIONS MANUAL
STATE OPERATIONS MANUAL Appendix W Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) And Swing-Beds in CAHs Revisions 84, 06-07-21013 C-0151 Physician Ownership
More informationSelf-Evaluation and Attestation
Legal Provider Name: Agreement No(s): Please submit this completed document with accompanying documentation by: Respond to all statements by placing a checkmark in the applicable box in the Provider Response
More informationFall 2016 Provider Newsletter
Fall 2016 Provider Newsletter In This Issue Molina Healthcare s 2016 HEDIS and CAHPS Results...1 Molina Healthcare s Special Investigation Unit Partnering With You to Prevent Fraud, Waste, and Abuse...3
More informationDarwin Marine Supply Base HSEQ Quality Management Plan
Darwin Marine Supply Base HSEQ Quality Management Plan REVISION SUMMARY Revision Date Comment Authorised 0 29.9.13 Initial input JC 1 12.1.15 General Review JC 2 3 4 5 6 7 8 9 Revision Log Revision No
More informationMore Changes! VFC Program Recommendations and Requirements
More Changes! 2014-2015 VFC Program Maribel Chavez-Torres, MPH Immunization Program Director City of Chicago Mayor Rahm Emanuel Chicago Department of Public Health Commissioner Bechara Choucair, M.D. VFC
More informationliterature that drug combinations containing butalbital should not be used in treatment of chronic pain and are not appropriate for long term routine
ACTION: Original BIA p(111397) pa(192459) d: (446870) DATE: 09/16/2013 2:14 PM print date: 04/02/2019 9:58 PM 1. Limit reimbursement for sedative hypnotic agents to the following medications: zolpidem
More informationFlorida Medicaid. Dental Services Coverage Policy. Agency for Health Care Administration
Florida Medicaid Agency for Health Care Administration Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions... 1 2.0 Eligible Recipient... 2 2.1 General
More informationEvaluation of a Medicaid Psychotropic Drug Management Program in Utah
Evaluation of a Medicaid Psychotropic Drug Management Program in Utah Dominick Esposito James M. Verdier 2008 SAMHSA/CMS Invitational Conference on Medicaid and Mental Health Service/Substance Abuse Treatment
More informationPARTICIPATING GENERAL DENTIST AGREEMENT
PARTICIPATING GENERAL DENTIST AGREEMENT THIS AGREEMENT, by and between (hereinafter referred to as "Dentist") who is duly qualified and licensed to practice dentistry in the State of and, a(n) corporation
More informationPhysician s Compliance Guide
Physician s Compliance Guide Updates to this guide will be posted on the Optum website and can be found at: http://www.optumcoding.com/product/updates/2013pcg/pcg13 Please use the following password to
More informationCOOPERATIVE AGREEMENTS FOR STATE-BASED COMPREHENSIVE BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAMS
APRIL 2011 93.919 COOPERATIVE AGREEMENTS FOR STATE-BASED COMPREHENSIVE BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAMS State Project/Program: NC BREAST AND CERVICAL CANCER CONTROL PROGRAM U. S. Department
More informationWA PMP Access by Public Payers. PDMP North Regional Meeting St. Louis, MO April 23-24
WA PMP Access by Public Payers PDMP North Regional Meeting St. Louis, MO April 23-24 Public Insurer Access PDMP Statute: Allows PDMP data to be provided to Medicaid and Workers Compensation Primary Goal:
More informationDELTA DENTAL PREMIER
DELTA DENTAL PREMIER PARTICIPATING DENTIST AGREEMENT THIS AGREEMENT made and entered into this day of, 20 by and between Colorado Dental Service, Inc. d/b/a Delta Dental of Colorado, as first party, hereinafter
More informationCARD/MAIL/PRE-APPROVAL/PREFERRED RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date:
RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date: CARD/MAIL/PRE-APPROVAL/PREFERRED The Prescription Drug Coverage under this Rider [replaces] [supplements] the Prescription
More informationKara A. Davis, RN, BSN Assistant Administrator/Director of Nursing at Logan County Department of Public Health
A Third Party Billing Success Story How a Small, Rural Public Health Department is Generating Significant Revenue Through Immunization and HIV Billing Kara A. Davis, RN, BSN Assistant Administrator/Director
More information1Oxford Contact Overview. Contact Information at a Glance... 11
1Oxford Contact Overview Contact Information at a Glance.......... 11 Oxford Contact Overview Section 1 10 www.oxfordhealth.com Oxford Contact Overview Section 1 Contact Information at a Glance Electronic
More information2015 Reimbursement Information for Mammography, CAD and Digital Breast Tomosynthesis 1
GE Healthcare 2015 Reimbursement Information for Mammography, CAD and Digital Breast Tomosynthesis 1 April, 2015 www.gehealthcare.com/reimbursement This advisory addresses Medicare coding, coverage and
More informationRESOLUTION AGREEMENT
RESOLUTION AGREEMENT Paul Public Charter School OCR Case No. 11 12 1444 Paul PCS (the School) agrees to fully implement this (Agreement) to resolve OCR Complaint No. 11 12 1444. GENERAL PROVISIONS 1. This
More informationWelcome and Key Contacts
Welcome and Key Contacts Table of Contents Welcome..page 2 Provider OnLine..page 4 Internet Site..page 5 How to Use This Manual..page 5 Key Contacts..page 6 Welcome and Key Contacts 3 Welcome Welcome to
More informationDental Therapy Toolkit SUMMARY OF DENTAL THERAPY REGULATORY AND PAYMENT PROCESSES
Dental Therapy Toolkit SUMMARY OF DENTAL THERAPY REGULATORY AND PAYMENT PROCESSES March, 2016 OFFICE OF RURAL HEALTH AND PRIMARY CARE EMERGING PROFESSIONS PROGRAM Acknowledgements This report was developed
More informationTexas Vendor Drug Program Specialty Drug List Process. February 2019
Texas Vendor Drug Program Specialty Drug List Process February 2019 Table of Contents Table of Contents...1 1 About the Specialty Drug List...2 1.1 Information for Pharmacies... 2 1.2 Information for Managed
More informationInspire Medical Systems. Physician Billing Guide
Inspire Medical Systems Physician Billing Guide 2019 Inspire Medical Systems Physician Billing Guide This Physician Billing Guide was developed to help providers correctly bill for Inspire Upper Airway
More informationCARE1ST PROVIDER FORUM
CARE1ST PROVIDER FORUM April 2017 1 Agenda 1. RAFFLE!! 2. WellCare Impact 3. Phoenix Health Plan Membership Transition 4. Health Plan Resources 5. EPSDT 6. Developmental Screening 7. Opioids 8. Medical
More informationReport for EYEGENETIX. Prepared on. May 24, By: David Davis, CPC, CPC-H, CCC (Ret.)
Report for EYEGENETIX Prepared on May 24, 2016 By: David Davis, CPC, CPC-H, CCC (Ret.) EyeGenetix EyeGenetix sells ophthalmic diagnostic equipment to primary care providers. This equipment performs the
More information11/11/2015. MVAs Suicide Firearms Homicide. Where Can I Find A Copy of the PDMP Law? Why Was the Law Established? Why Was the Law Established?
Where Can I Find A Copy of the PDMP Law? Alabama Uniform Controlled Substances Act Code of Alabama 1975 20-2- (Article 10) -210 through 220 and Rules 420-7-2-.11 through.13 1 Why Was the Law Established?
More information