Includes compliance with federal requirements, plan and member Identification (ID) card information.
General Coverage Information
Includes a summary of CMS requirements pertaining to the Harvard Pilgrim Medicare Advantage benefit plan.
Provider Roles and Reponsibilities
Includes provider agreement, provider anti-discrimination, non-acceptance and termination, termination of a provider contract with cause, medical records, network participation, provider participation and responsibilities.
Medical Records Requests and Submission of Encounter Data
Includes information on confidentiality and general consent, encounter data submission and reporting, encounter data for risk adjustment purposes, and risk adjustment data validation (RADV) audits.
Fraud, Waste, and Abuse
Includes detecting and preventing fraud, waste and abuse (examples provided); training requirements; statues, laws and regulations; marketing prohibitions; the repayment rule and contact information .
Includes provider responsibilities related to delegation activities.
Clinical Credentialing and Recredentialing
Includes provider credentialing prerequisites; credentialing and recredentialing information; notification of approval, denial/termination; changing provider enrollment information and ongoing monitoring.
Facility Credentialing and Recredentialing
Includes facility credentialing and recredentialing information; facility site visit exceptions; and accreditation agencies.
Includes electronic and paper submissions; claim submission guidelines; and special considerations when submitting Harvard Pilgrim Medicare Advantage claims.
Includes copayments/coinsurance and maximum out-of-pocket information; billing members; balance billing; provider responsibility for referrals for non-covered services; provider not qualified to furnish the services billed; and patient not entitles to Medicare Benefits.
Coordination of Benefits
Includes COB information and claim submission process.
Claims Review and Audit
Overview on Harvard Pilgrim’s provider claims audit process.
Includes provider reimbursement process; medical review and reimbursement methodology; National Coverage Determinations (NCDs); Local Coverage Determinations (LCDs); provider documentation for medical review; and payment by provider type for Harvard Pilgrim Medicare Advantage covered services.
Includes eligibility and enrollment; enrollment and disenrollment; provider’s advice and advocacy; the HIPAA privacy information; discrimination prohibited rules; and the member protections regulations.
Access to Care
Authorization and referrals; Advance directive information; care delivery programs; continuity of care–terminated provider; accessibility, timeliness requirements and after-hours services; PCP initiated member transfer; provider participating—telemedicine; provider information changes; medical record keeping practices; and confidential member information and release of medical records.