1. Continuation of Benefits
a. American Eldercare, Inc. shall continue the enrollee’s benefits if:
(1) The enrollee or the enrollee’s authorized representative files an appeal with the American Eldercare, Inc. regarding American Eldercare, Inc.’s decision:
(a) Within ten (10) business days after the notice of the adverse action is mailed; or
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(b) Within ten (10) business days after the intended effective date of the action, whichever is later.
(2) The appeal involves the termination, suspension or reduction of a previously authorized course of treatment;
(3) The services were ordered by an authorized provider;
(4) The original period covered by the original authorization has not expired; and
(5) The enrollee requests extension of benefits.
b. If, at the enrollee’s request, American Eldercare, Inc. continues or reinstates the benefits while the appeal is pending, benefits must continue until one (1) of the following occurs:
(1) The enrollee withdraws the appeal;
(2) Ten (10) business days pass after American Eldercare, Inc. sends the enrollee the notice of resolution of the appeal against the enrollee, unless the enrollee within those ten (10) days has requested a Medicaid Fair Hearing with continuation of benefits;
(3) The Medicaid Fair Hearing office issues a hearing decision adverse to the enrollee; or
(4) The time period or service limits of a previously authorized service have been met.
c. If the final resolution of the appeal is adverse to the enrollee and American Eldercare, Inc.’s action is upheld, American Eldercare, Inc. may recover the cost of services furnished to the enrollee while the appeal was pending to the extent they were furnished solely because of the continuation of benefits requirement.
d. If the Medicaid Fair Hearing officer reverses American Eldercare, Inc.’s action and services were not furnished while the appeal was pending, the American Eldercare, Inc. shall authorize or provide the disputed services promptly.
e. If the Medicaid Fair Hearing officer reverses American Eldercare, Inc.’s action and the enrollee received the disputed services while the appeal was pending, American Eldercare, Inc. shall pay for those services in accordance with this Contract.
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7
FORMS
Authorization Forms:
Change of Services Request Hold/Resume Service Request Request for New Services Termination of Services Request Claim Forms:
CMS 1500 UB-04
Provider Complaint Form Provider Change of Notice Form
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APPENDIX
AEC Locations CARES Offices Denial Codes Remittance Advice59 | P a g e w w w . a m e r i c a n e l d e r c a r e . c o m Administrative Office 14565 Sims Road Delray Beach, FL 33484 561-499-9656 - Local 888-970-6663 - Toll Free 561-665-4444 – Fax
Provider Relations Department
561-860-8660 - Local 561-865-2006 – Fax
Palm Beach Office Serving Counties of:
Indian River, Palm Beach, Martin, Okeechobee & St. Lucie
14565 Sims Road Delray Beach, FL 33484 561-582-0331 - Local 877-227-3647 - Toll Free 561-582-0531 – Fax Clearwater Office Serving Counties of:
Pasco & Pinellas
4400 140th Avenue North, Suite 150 Clearwater, FL 33762
727-524-6600 - Local 866-383-6663 - Toll Free 727-524-6602 - Fax
Tampa Office Serving Counties of:
Hillsborough, Manatee, & Polk
204 S. Hoover Blvd, Suite 200 Tampa, FL 33609 813-286-8822 - Local 877-280-8822 - Toll Free 813-288-7357 – Fax Ocala Office
Serving Counties of:
Alachua, Citrus, Dixie, Hernando, Lake, Levy, Marion, Gilchrist, Lafayette & Sumter 3306 SW 26th Ave, Unit 301 Ocala, FL 34471 352- 547-4510 - Local 855-460-8498 - Toll Free 352-547-4511 - Fax Ft. Lauderdale Office Serving County of:
Broward 3320 NW 53rd Street, Suite 203 Fort Lauderdale, FL 33309 954-735-1150 - Local 888-735-1150 - Toll Free 954-735-1167 - Fax
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Jacksonville Office Serving Counties of:
Baker, Duval, Columbia, Clay, Nassau, Putnam, Bradford, Hamilton, Suwannee, Union & St. Johns
644 Cesery Boulevard, Suite 106 Jacksonville, FL 32211
904-724-5600 - Local 866-726-5600 – Toll 904-724-5080 - Fax
Ormond Beach Office Serving Counties of:
Flagler & Volusia
533 North Nova Rd., Suite 205 & 207 Ormond Beach, FL 32174
386-944-4360 - Local 866-746-3874 - Toll Free 386-944-4361 – Fax
Orlando Office Serving Counties of:
Orange, Osceola, & Seminole
1080 Woodcock Road, Suite 200 Orlando, FL 32803
407-898-9889 - Local 866-914-7300 - Toll Free 407-898-9890 – Fax
Melbourne Office Serving Counties of:
Brevard
1600 Sarno Road, Suite 108 Melbourne, FL 32935
321-421-1521 - Local 866-371-2104 - Toll Free 321-421-1520 – Fax
Pensacola Office Serving Counties of:
Bay, Gulf, Escambia, Franklin, Holmes, Okaloosa, Santa Rosa, Jackson, Walton,
Calhoun& Washington
7282 Plantation Blvd. Suite 301 Pensacola, FL 32504 850-462-1150 - Local 877-301-0070 - Toll Free 866-401-3121 – Fax Doral Office Serving County of:
Miami-Dade & Monroe
8260 NW 27th Street, Suite 410 Doral, FL 33122
305-418-9550 - Local 877-655-9660 - Toll Free 305-418-9520 - Fax
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Visit our website www.americaneldercare.com
If you need assistance after office hours, our provider and member help-line is available twenty- four (24) hours a day seven (7) days a week.
Provider Toll Free Help Line: (888) 998-7735
Member Toll-Free Help Line: (888) 998-7732 Ft. Myers Office
Serving Counties of:
Collier, Charlotte, DeSoto, Hardee, Highlands, Lee, Hendry & Sarasota
12381 S Cleveland Ave, Suite 505 Ft. Myers, FL 33907
239-337-9292 - Local 866-464-9292 - Toll Free 239-337-9290 – Fax
Tallahassee Office Serving Counties of:
Gadsden, Jefferson, Liberty, Leon, Madison, Taylor & Wakulla
2888 Remington Green Lane #C Tallahassee, FL 32308
850-462-1380 - Local 850-462-1388 – Fax
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Department of Elder Affairs
Comprehensive Assessment and Review for Long-Term Care Services
CARES OFFICES
COUNTY SERVED PHONE NUMBER PSA Office