Providers can contact the appropriate Ohana departments by viewing the Quick Reference Guide on the Ohana website at Once registered on the Ohana portal, providers must retain their username and password information for future reference.
Provider and Member Administrative Guidelines
Provider Administrative Overview
The following is a summary of the responsibilities of all Providers providing services to 'Ohana members. The following is a summary of the responsibilities specific to PCPs providing services to 'Ohana members'.
Cultural Competency Program and Plan
A Provider may request a paper copy by calling Ohana's Customer Service Department or contacting its Provider Relations representative. Providers can access the Cultural Competency Survey on Ohana's secure website at www.ohanahealthplan.com/provider/medicare/resources.
Member Administrative Guidelines
Quality Improvement
For Class 1 recalls, members and authorized prescribers will be notified within 10 calendar days of the date 'Ohana discovers the recall'. The purpose of the Chronic Care Improvement Program (CCIP) is to facilitate improvement in the quality of care and quality of life of 'Ohana's medically compromised Members by.
Utilization Management, Care Management and Disease Management
Utilization Management
Provider Network, Ohana will allow a member to continue ongoing treatment with a non-participating provider during the transition period. If a provider is canceled for reason, Ohana will promptly refer the member to another participating provider for further services and treatment. If a participating Ohana Provider is selected, the PCP will issue a referral to the member for a visit.
The member may file an appeal if "Ohana denies the second surgical/medical opinion Provider's request for services. Before discharging a member or reducing the level of care within a hospital setting, 'Ohana will obtain consent from the provider responsible for the member's If the member fails to make a timely request to the QIO, she or he may request an expedited 'Ohana' reconsideration.
Care Management Program
If the QIO determines that the member has not received a valid notice, 'Ohana's inpatient services coverage will continue until at least two calendar days after the valid notice is received. Continued coverage is not required if the QIO determines that coverage could pose a threat to the Member's health or safety. Care managers work with primary care physicians and specialists to coordinate the member's care and expedite access to care and needed services.
Ohana's Care Management teams also serve as PCP support and help actively connect the member with providers, health services, housing, social services and other support services as needed. The care management process begins with member identification and follows the member until discharge from the program. Care managers work closely with the provider on when to discharge a member from the care management program.
Disease Management Program
Claims
For more information about Ohana's covered services, please visit Ohana's website at www.ohanahealthplan.com/provider. Ohana, refer to “Ohana's Companion Guides” on “Ohana's website at www.ohanahealthplan.com/provider/medicare/claims. For help creating an EDI process, contact Ohana's EDI team by consulting the Quick Reference Guide.
Based on the review of the claim (including a review of medical records if requested by the provider), 'Ohana will make any necessary adjustments to the claim. To submit other insurance information electronically, refer to the 'Ohana Companion Guides on the 'Ohana website at Ohana has information that suggests the member has another policy, 'Ohana may deny the claim.
The primary insurance has ceased, the Provider is responsible for submitting the original claim with proof that the coverage has ceased. In the event that a claim was denied for other coverage, the provider must resubmit the claim with proof that coverage was terminated. Benefits are coordinated with another insurance company as primary and the payment amount equals or exceeds 'Ohana's liability, no additional payment will be made.
When 'Ohana receives a provider's meetings, the meetings are loaded into 'Ohana's meeting system and processed. For more information on free DDE options, refer to the 'Ohana Provider Resource Guide on. Voided Encounter - An encounter that the 'Ohana deletes from the encounter file and is not submitted to the state.
Supporting documentation when needed (eg, proof of timely attendance, medical records) To start the process, please refer to the Quick Reference Guide on Ohana's website at www.ohanahealthplan.com/provider /medical/resources. For institutional claims, the Provider must include the original Ohana claim number and billing frequency code according to industry standards. For professional claims, the Provider must include the original Ohana claim number and billing frequency code per industry standards.
Credentialing
In the event that the credentialing is delegated to an external agency, the agency will have to meet the criteria of 'Ohana' to ensure that the credentialing capabilities of the. Upon receipt of a written request, 'Ohana will provide the practitioner with written information regarding the status of the credentialing/certification application, usually within 15 business days. An existing provider who opts out of Medicare is not eligible to remain as a participating provider for 'Ohana.'
In accordance with Ohana's regulation, accreditation and policy and procedure, reaccreditation is required at least once every three years. The practitioner has 30 days from the date of Ohana's notification to submit a written request. Upon timely receipt of the request by Ohana, Ohana's medical director or his or her designee will notify the physician of the date, time, and telephone number for the hearing.
Reconsiderations (Appeals) and Grievances
Appeals
If the Member's request is made verbally, 'Ohana will send an acknowledgment letter to the Member to confirm the facts and basis of the complaint. After the Member submits the information, 'Ohana will mail the decision to the Member within the time frame specified above, based on the type of appeal. If 'Ohana denies the request to expedite a review, 'Ohana will provide the Member with verbal notification within 24 hours.
Notify the member of the decision to confirm the first refusal and that the matter has been forwarded to the IRE. If IRE overturns the original denial, IRE will notify the member or representative in writing of the decision. If IRE overturns the original rejection, IRE will notify the member or representative in writing of the decision.
Grievances
Compliance
Ohana's Corporate Ethics and Compliance Program, as may be amended from time to time, includes information regarding 'Ohana's policies and procedures related to fraud, waste and abuse, and provides guidance and oversight of the performance by Ohana, 'Ohana -employees, contractors (including delegated entities) and business partners in an ethical and legal manner. All Suppliers, including Supplier Employees and Supplier subcontractors and their employees, are required to comply with 'Ohana Compliance Program requirements. Laws and regulations related to fraud, waste and abuse (eg, False Claims Act, Anti-Kickback Act, HIPAA, etc.);.
Providers, including Provider's employees and/or Provider's subcontractors, must report to 'Ohana any suspected fraud, waste or abuse, misconduct or criminal activity by 'Ohana or any Provider, including Provider's employees and/or Provider's subcontractors, or from 'Ohana Members. CMS holds plan sponsors, such as Ohana, responsible for any comparative/descriptive materials developed and distributed on their behalf by their contracted providers. Providers may not engage in any marketing activity on behalf of 'Ohan without the prior express written consent of an authorized representative of 'Ohan, and only in strict accordance with such consent.
Code of Conduct and Business Ethics
Delegated Entities
WellCare oversees the delivery of services provided by the delegated entity and/or subdelegation, and is accountable to federal and state agencies for the performance of all delegated functions. It is WellCare's ultimate responsibility to monitor and evaluate the performance of the delegated functions to ensure compliance with legal requirements, contractual obligations, accreditation standards and WellCare's policies and procedures. WellCare's Delegation Oversight Committee (DOC) was established to oversee all outsourced providers where specific services have been delegated to an entity.
Conducting pre-delegation audits and reviewing the results to evaluate the prospective entity's ability to perform the delegated function. Conduct ongoing monitoring activities to evaluate an entity's performance and compliance with regulatory and accreditation requirements. Conducting annual audits to verify the entity's performance and processes supports continued compliance with regulatory requirements and accreditation standards.
Dual-Eligible Members
To bill the state, the Provider will submit the EOP provided by 'Ohana to the state. If 'Ohana has accepted the state's financial responsibility pursuant to an agreement between 'Ohana and the state', 'Ohana will be considered the 'appropriate state source'. If 'Ohana has. Providers must bill 'Ohana as they do today and submit the EOP provided by 'Ohana to the state for payment.
If 'Ohana is responsible for this amount through an agreement with the State,' Ohana will pay this amount on behalf of the State. If the BAE is submitted and approved, 'Ohana will resume the claim and send the appropriate payment to the provider. Providers must accept 'Ohana's payment in full and may not balance the member.
DSNP Care Management Program
Behavioral Health
Please see the Quick Reference Guide for information on how to contact the Behavioral Health Services Administrator. PCPs may provide any clinically appropriate behavioral health service within the scope of their practice. Behavioral health providers are required to use the Diagnostic and Statistical Manual of Mental Disorders when evaluating the member for behavioral health services and documenting the diagnosis and.
If a Member's medical or behavioral condition changes, 'Ohana expects that both PCPs and behavioral health providers will communicate those changes to each other. In the event a Member misses an appointment, the Behavioral Health Provider must contact the Member within 24 hours to reschedule. Behavioral health providers are expected to help Members access emergency, urgent, and routine behavioral services as quickly as the Member's condition warrants.
Pharmacy
The first-line drugs in Ohana's formulary have been evaluated using the clinical literature and approved by Ohana's P&T Committee. Medicare Part D drugs that require step therapy are designated by the letters "ST" on the 'Ohana's formulary. Part D drugs that have quantity limits are identified by the letters "QL" and the quantity allowed on the Ohana's formulary.
Part D drugs that are available by mail order are marked with the letters “MS” in the Requirements/Limitations column of the Ohana formulary. Member Registration, Prescription Order Form and Mail Order Pharmacy Prescription Form are located on the Ohana website at Drugs that have step-up and first-line treatment are inadequate Obtaining a request to determine coverage.
Definitions and Abbreviations
Definitions
Ohana Resources
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