3. CREDENTIALING...34 Introduction...34

100  Download (0)

Full text



Introduction ...1 Mission Statement ...1 Freedom Service ...1 Accreditation ...2 Service Areas ...2 Florida Medicaid ...2 Medicare ...3


Introduction ...4

Primary Care Physician (PCP) Responsibilities ...4

Specialist Responsibilities ...5

Responsibilities of All Plan Providers ...5

Provider Licensure, Credentials and Demographic Information Changes ...7

Physician Availability & Accessibility ...7

Vacations ...8

Appointment Scheduling ...8

After-Hours Services ...8

Closing Physician Panel ...9

PCP Initiated Member Transfer ...9

Provider Participation with the Florida Medicaid Program...10

Provider Information Changes ...11

Participation & Credentialing...11

Provider Termination...12

Continuity of Care – Terminated Provider ...12

Utilization Management & Quality Management Programs (UM/QA) ...12

Preferred Drug List ...13

Confidential Member Information & Release of Medical Records ...13

Adult Health Screening Services ...14

Screening Schedule ...14

Required Service Components ...14

Child Health Check-Ups (CHCU) - Freedom 1st ...16

Vaccines for Children (VFC) Program ...17

Family Planning Services ...18

Emergency Shelter Medical Screenings...23

Quality Enhancement Programs ...23

Cultural Competency ...25

Consumer Assistance & Complaints ...25

Member Rights & Responsibilities...25

Advance Medical Directives ...26

Fraud and Abuse Reporting ...26

Marketing Prohibitions ...34


Introduction ...34

Credentialed Providers ...35

Initial Credentialing Process ...36

Re-Credentialing ...37

Professional Liability Insurance ...38

Updated Documents ...38

Appeal Rights ...38


Member Services ...39

Staff Selection and Training ...39

Service Standards ...39

Member Identification Card ...40

Member Transfers ...40

Methods of Eligibility Verification...41



Introduction ...42 Department Philosophy...42 UM Staff Availability ...42 Contact Information ...43 General Information ...43

Status of a Pre-Service Request...43

Referrals ...44

Referrals - Freedom 1st (Medicaid)...44

Pre-Certifications ...45

Criteria ...46

Emergency and Urgent Care Services ...47

Pharmacy and Provider Access During a Federal Disaster or Other Public Health Emergency Declaration ...48

Concurrent Review & Discharge Planning ...49

Second Opinions ...49

Covered Services ...50

Direct Access Programs ...61

Dermatology Services ...61

Podiatry Services ...61

Chiropractic Services ...61

Ophthalmology/ Optometric Services ...61

Vision Services ...62

Behavioral Health Services ...62

Well Woman – Routine & Preventive Services ...62

Clinical Practice Guidelines ...63

Case Management Program...63

Disease Management Programs ...64

Special Needs Plans ...64

Social Services Department ...66

Preventive Health Guidelines ...66

Financial Incentives ...66



Introduction ...67

Preferred Drug List ...67

Generic Substitution ...67

Drugs Not on the Preferred Drug List...67

Prior Authorization (PA)/ Step Therapy (ST) ..68

Quantity Limits...68

Co-payments ...68

Injectables ...68

Pharmacy Use ...69

Drug Utilization Review Program ...69




Goals/Objectives ...70

Provider Notification of Changes ...72

Medical Health Information ...72

Medical Record Standards ...72

Medical Record Review ...75

Medical Record Privacy & Confidentiality Standards ...75

8. CLAIMS ...80

General Payment Guidelines ...80

Member Responsibility ...81

Prohibition on Billing Members ... 81

Timely Submission of Claims ...81

Maximum Out-of-Pocket Expenses (MOOP) ..82

Physician and Provider Reimbursement ...82

Completion of “Paper” Claims ...82

Electronic Claims Submission ...83

Electronic Transactions and Code Sets ...84

Encounter Data...84

Coordination of Benefits (COB) ...84

Correct Coding...85

Claims Appeals ...85

Reimbursement for Covering Physicians ...86

Fee Schedule Updates ...86

Online Claims Information ...86


Introduction ...87

Definitions ...87

Grievance & Appeals System ...87

Grievance & Appeals - Freedom Medicare ....88

Member Grievance & Appeals ...88

Participating Provider Claims Appeals ...88

Non-participating Providers Appeal...89

Expedited Claims Appeals ...90

Medicare Grievance Process ...90

Grievance & Appeals - Freedom 1st Medicaid ...90

Medicaid Appeals ...90

Medicaid Grievances ...91

Provider Complaint Process ...91


<Insert> new guide here





Freedom Health, Inc. is an independently owned Florida Health Plan, with corporate headquarters in Tampa, Florida. The company was founded with the primary goal of designing and offering outstanding healthcare products to Floridians.

Mission Statement

We are dedicated to responsibly meeting and exceeding our Members’ expectations by living up to our core values.

Core Values:

x We are an integrity-based company.

x Every associate is committed to providing world-class service to all of our customers.

x We are respectful of our Members, our Providers and our Associates.

x We are prudent and thoughtful Managers of our financial resources.

x We care about our Members and are passionate about our work.

x We are innovative developers of Medical Care Management strategies that improve the quality of our Members’ lives.

What makes Freedom Health Different?

x Freedom Health is committed pay “clean” claims to promptly and accurately, meeting all regulatory guidelines.

x Freedom Health’s focus is on providing the most efficient methods to obtain referrals and authorizations.

x Freedom Health is committed to operating state-of-the-art information technology for claims processing, member services, enrollment management, Physician profiling and data analysis.

x Freedom Health has exceptionally trained Physician and Provider representatives available to answer all provider inquiries.

Freedom Service

Freedom Health, Inc. is adamant about service. We will accomplish our goal of superior service to Members and Physicians/Providers through:

x Outstanding telephone customer service,

x Cutting edge Web access,

x Dedicated Provider Relations “field” staff,

x Highly trained marketing staff,


x Recruiting only the most highly qualified staff, and

x Dedication to training.


Freedom Health is accredited by the National Committee for Quality Assurance (NCQA) with a designation as commendable. NCQA Accreditation is a rigorous and comprehensive evaluation through which the quality of Freedom Health’s systems, processes and results are assessed; including the care that is delivered to our Members.

In 2007, Freedom Health received an initial three year accreditation from NCQA. In 2009 a comprehensive audit for renewal was completed for NCQA and Freedom Health was awarded an additional three year accreditation for 2009 – 2012.

Service Areas

In 2011, we service the following counties: Medicaid

Broward, Hernando, Hillsborough, Manatee, Marion, Miami-Dade, Palm Beach, Pasco & Polk. Medicare

Brevard, Broward, Charlotte, Citrus, Clay, Collier, Dade, Duval, Escambia, Hernando, Hillsborough, Indian River, Jefferson, Lake, Lee, Leon, Manatee, Marion, Martin, Orange,

Osceola, Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole, St. Lucie, Sumter and Volusia.

Florida Medicaid

We are pleased to serve Medicaid eligible persons in the state of Florida. For service coverage by county, please see our Service Areas section.

Medicaid is the state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children. Medicaid is different in every state.

Florida implemented the Medicaid program on January 1, 1970, to provide medical services to indigent people. Over the years, the Florida Legislature has authorized Medicaid reimbursement for additional services. A major expansion occurred in 1989, when the United States Congress mandated that states provide all Medicaid services allowable under the Social Security Act to children under the age of 21.


MediKids is a Florida KidCare Program. Administered by the Agency for Health Care Administration, the program offers low-cost health insurance coverage for children ages 1 through 4.

MediKids enrollees receive most Medicaid benefits.


x MediKids is not an entitlement program.

x Families pay a $15 or $20 monthly premium per household, depending on income. x MediKids offers a full pay premium for families with incomes greater than the program


Your Plan Medikids membership will be included in your monthly Medicaid Membership listing from the Plan.


Providing Medicare health care services to persons eligible in Florida is our expertise. We take pride in offering competitive benefits and excellent care.

What is Medicare? Medicare is a health insurance program for people:

x age 65 or older,

x under age 65 with certain disabilities, and

x of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has:

Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A does not cover, such as some of the services of physical and

occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.




This section of the Provider Manual addresses the respective responsibilities of participating Physicians. Our expanding network of primary care providers, as well as the growing list of specialty providers, makes it more convenient to find Freedom Health in your neighborhood. Freedom Health does not prohibit or restrict Plan Providers from advising or advocating on behalf of a Plan Member about:

(1) The Plan Member’s health status, medical care or treatment options (including alternative treatments that may be self-administered), including providing sufficient information to

the Plan Member to provide an opportunity to decide among all relevant treatment options; (2) The risks, benefits and consequences of treatment or non-treatment; and

(3) The Plan Member’s right to refuse treatment and express preferences about future treatment decisions. An Ancillary Provider must provide information regarding treatment options in a culturally competent manner, including the option of no treatment. A Provider must ensure that individuals with disabilities are presented with effective communication on making decisions regarding treatment options.

Practitioners may freely communicate with patients about their treatment, regardless of benefit coverage limitations. As applicable, the Plan shall not prohibit the participating Provider from providing inpatient services to a Member in a contracted hospital if such services are determined by the Participating Provider to be medically necessary covered services under the Plan, Medicaid and/or Medicare Contract.

A Physician’s responsibility is to provide or arrange for Medically Necessary Covered Services for Members without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment. A Physician is further responsible to render Medically Necessary Covered Services to Plan Members in the same manner, availability and in accordance with the same standards of the profession as offered to the Physician’s other patients.

Primary Care Physician (PCP) Responsibilities

The following is a summary of responsibilities specific to Primary Care Physicians who render services to Plan Members:

x Coordinate, monitor and supervise the delivery of health care services to each Member who has selected the PCP for Primary Care services.

x Assure the availability of Physician services to Members in accordance with Section 2, “Appointment Scheduling”.


x Submit a report of an encounter for each visit where the Provider services the Member or the Member receives a Health Plan Employer Data and Information Set (HEDIS) service.

Encounters should be submitted on a CMS 1500 form.

x Ensure Members utilize network Providers. If unable to locate a participating Provider for services required, contact Utilization Management for assistance.

x Ensure Members are seen for an initial office visit and assessment within the first 90 days.

x Ensure sufficient supply and provide immunizations in accordance with the childhood

immunization schedule as approved by the Advisory Committee on Immunization Practices of the U.S. Public Health Service and the American Academy of Pediatrics or when it is shown to be medically necessary for the child’s health.

x Provide immunization information to Department of Children and Families (DCF) upon receipt of the Member’s written permission and DCF’s request, for Members requesting temporary cash assistance from the DCF in order to document that the Member has met the immunization requirements for recipients receiving temporary case assistance.

x A Physician/Provider will consider Member input into proposed treatment plans.

Specialist Responsibilities

Specialists are responsible for communicating with the PCP in supporting the Medical Care of a Member. Specialists are also responsible for treating Plan Members referred to them by the PCP; and communicating with the PCP for authorizations. These requests must be coordinated through the Member’s PCP.

Responsibilities of All Plan Providers

The following is an overview of responsibilities for which all Plan Providers are accountable. Please refer to your contract, or contact your Provider Relations Representative for clarification of any of the following:

x All Providers must comply with the appointment scheduling requirements as stated in the Appointment Scheduling Section.

x Provide or coordinate health care services that meet generally recognized professional standards and the Plan guidelines in the areas of operations, clinical practice guidelines, medical quality management, customer satisfaction and fiscal responsibility.

x Use Physician extenders appropriately. Physician Assistants (PA) and Advanced

Registered Nurse Practitioners (ARNP) may provide direct Member care within the scope or practice established by the rules and regulations of the State of Florida and Plan guidelines.

x The sponsoring Physician will assume full responsibility to the extent of the law when

supervising PA’s and ARNP’s whose scope of practice should not extend beyond statutory limitations.


x ARNP’s and PA’s should clearly identify their titles to Members, as well as to other health care professionals.

x A request by a Member to be seen by a Physician, rather than a Physician extender, must be honored at all times.

x Refer Plan Members with problems outside of his/her normal scope of service for consultation and/or care to appropriate Specialists contracted with Plan (PCP’s only).

x Refer Members to participating Physicians or Providers, except when they are not available, or in an emergency. Providers should contact the Utilization Management department in the event it is medically necessary to refer a Member to a non-participating Provider for continuity of care purposes.

x Admit Members only to participating Hospitals, Skilled Nursing Facilities (SNF’s) and other inpatient care facilities, except in an emergency.

x Respond promptly to Plan requests for medical records in order to comply with regulatory requirements, and to provide any additional information about a case in which a Member has filed a grievance or appeal.

x Not bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against any Plan Member, subscriber or enrollee other than for supplemental charges, co-payments or fees for non-covered services furnished on a “fee-for-service” basis. Non-covered services are benefits not included by the Plan in a Member’s healthcare policy, are excluded by the Plan, are provided by an ineligible Provider, or are otherwise not eligible to be Covered Services, whether or not they are Medically Necessary.

x Treat all Member records and information confidentially, and not release such information without the written consent of the Member, except as indicated herein, or as needed for compliance with State and Federal law.

x Apply for a Clinical Laboratory Improvement Amendments (CLIA) certificate, if applicable. x Maintain quality medical records and adhere to all Plan policies governing the content of

medical records as outlined in the Plan’s quality improvement guidelines. All entries in the Member record must identify the date and the Provider.

x Maintain an environmentally safe office with equipment in proper working order in

compliance with city, state and federal regulations concerning safety and public hygiene.

x Communicate clinical information with treating Providers timely. Communication will be monitored during medical/chart review. Upon request, provide timely transfer of clinical information to the Plan, the Member or the requesting party, at no charge, unless otherwise agreed to.

x Preserve Member dignity, and observe the rights of Members to know and understand the diagnosis, prognosis and expected outcome of recommended medical, surgical


x Not to discriminate in any manner between Plan Members and non-Plan Members.

x Fully disclose to Members their treatment options and allow them to be involved in treatment planning.

x A Physician/Provider will consider Member input into proposed treatment plans.

Provider Licensure, Credentials and Demographic Information Changes

x Inform the Plan, in writing, within 24 hours of any revocation or suspension of his/her DEA number, and/or suspension, limitation or revocation of his/her license, certification, or other legal credential authorizing him/her to practice in the State of Florida.

x Inform the Plan immediately of changes in licensure status, tax identification numbers, telephone numbers, addresses, status at participating hospitals, loss of liability insurance and any other change which would affect his/her status with the Plan.

Physician Availability & Accessibility

In accordance with the Freedom Health Physician Service Agreement, Physicians agree to make necessary and appropriate arrangements to ensure the availability of services to Members on a 24-hour per day, 7-day per week basis, including arrangements for coverage of Members after hours or when the Physician is otherwise unavailable.

In the event participating Providers are temporarily unavailable to provide care or referral services to Plan Members, they should make arrangements with another Plan-contracted and credentialed Physician to provide these services on their behalf.

If a covering Physician is not contracted and credentialed with the Plan, he/she must first obtain approval to treat Plan Members. The Physician should be credentialed by the Plan, he/she must sign an agreement accepting the Participating Provider’s negotiated rate and agree not to balance bill Plan Members. For additional information, please contact your local Provider Relations


Additionally, Physicians are to establish an appropriate appointment system to accommodate the needs of Plan Members, and shall provide timely access to appointments to comply with the following schedule:


Urgent Care within one (1) day of an illness;


Sick care within one (1) week of an illness; and


Well Care within one (1) month of an appointment request.

The Physician will ensure that Members with an appointment receive a professional evaluation within one (1) hour of the scheduled appointment time. If a delay is unavoidable, the patient shall be informed and provided with an alternative.



Primary Care Physicians should notify the Plan, in writing, of any extended vacation/ time-off of (1) one week or more, and disclose the provisions made for Provider coverage in the PCP’s absence. The Provider covering for the PCP must be a Participating Provider with our Plan.

Appointment Scheduling

The following criteria comply with access standards: 1. Primary Care Providers should:

x Provide medical coverage 24-hours a day, seven days a week;

x Scheduled appointments should be seen within 30 minutes;

x Schedule emergent referral appointments immediately;

x Schedule routine sick care within one (1) week; and

x Schedule well care within one (1) month. 2. Specialty Care Providers should:

x Schedule well care within one (1) month;

x Schedule routine sick care within one (1) week;

x Schedule urgent referral within 24 hours; and

x Schedule emergent referral appointments immediately.

Freedom collects and performs an annual analysis of access and availability data, and measures compliance to required thresholds. The analysis can include access to:


well care;


sick care;


urgent care; and/or


after hours care.

After-Hours Services

The Primary Care Physician or covering Physician should be available after regular office hours to offer advice and to assess any conditions, which may require immediate care. This includes referrals to the nearest Urgent Care Center or Hospital Emergency Room in the event of a serious illness.

To assure accessibility and availability, the Primary Care Physician should provide one of the following:


x 24-Hour answering service;

x Answering system with an option to page the Physician; or

x An advice nurse with access to the PCP or on-call Physician.

Closing Physician Panel

When closing Membership panel to new Plan Members, Providers must:

x Medicare: Submit a request in writing, 60 days prior to closing the Membership panel.

Medicaid: Submit a request in writing, 90 days prior to closing the Membership panel.

x Maintain the panel open to all Plan Members who were provided services prior to closing the panel.

x Submit a written notice of the re-opening of the panel, to include a specific effective date. Freedom Health will assist Physicians in providing communication to Members with disabilities or language services. Please contact Freedom Health Member Services to arrange services for the deaf, blind, or those who need a language interpreter.

PCP Initiated Member Transfer

A Participating Primary Care Provider (PCP) may not seek or request to terminate their relationship with a Member, or transfer a Member to another Provider of care based upon the Member’s

medical condition, amount or variety of care required, or the cost of covered services required by the Plan’s Member.

Reasonable efforts should always be made to establish a satisfactory Provider/Member

relationship. The PCP should provide adequate documentation in the Member’s medical record to support his/her efforts to develop and maintain a satisfactory Provider/Member relationship. If a satisfactory relationship cannot be established or maintained, the PCP must continue to provide medical care for the Plan Member until such time that the member can be transitioned to another PCP.

The PCP may request that a member be assigned to another practice if his/her behavior is disruptive to the extent that his/her continued assignment to the PCP substantially impairs the PCP’s ability to arrange for or provide services to either that particular member or other patients being treated by the PCP. The PCP may request transfer of the member only after it has met the requirements of this section and only with the Plan’s approval. The PCP may not request transfer of a member because he/she exercises the option to make treatment decisions with which the PCP disagrees, including the option of no treatment and/or diagnostic testing. The PCP may not request transfer of a member because he/she chooses not to comply with any treatment regimen

developed by the PCP or any health care professionals associated with the PCP.

Before requesting transfer of a member, the PCP must make a serious effort to resolve the problems presented by the member. Such efforts must include providing reasonable


accommodations for individuals with mental or cognitive conditions, including mental illnesses and developmental disabilities. The PCP must also inform the member of his/her right to use the Plan’s grievance procedures.

The PCP must submit documentation of the specific case to Plan for review. This includes documentation:

x Of the disruptive behavior;

x Of the PCP’s serious efforts to provide reasonable accommodations for individuals with disabilities, if applicable in accordance with the Americans with Disabilities Act;

x Establishing that the member’s behavior is not related to the use, or lack of use, of medical services;

x Describing any extenuating circumstances cited under 42CFR 422.74(d)(2)(iii) and (iv);

x That the PCP provided the member with appropriate written notice of the consequences of continued disruptive behavior;

x That the PCP then provided written notice of its intent to request transfer of the member. The PCP must submit to the Plan:

x The above documentation;

x The thorough explanation of the reason for the request detailing how the individual’s behavior

has impacted the MA organization’s ability to arrange for or provide services to the individual or other patients in the PCP’s practice;

x Member information, including age, diagnosis, mental status, functional status, a description of his/her social support systems and other relevant information;

x Statements from providers describing their experiences with the member; and

x Any information provided by the member.

A PCP Request for Transfer Form, a copy of which may be found in the Forms Section of this manual. Copies are also available from our Provider Relations Department.

The request for transfer must be complete, as described above. The Plan will review this

documentation and render a determination regarding the request for transfer. The Plan will make the determination within thirty (30) days of receipt of the request for transfer and will notify PCP within three (3) days of the determination.

Except in extreme circumstances, the transfer to a new PCP will not occur until the first of the month following Plan’s determination of approval of transfer.

Once the Plan has approved the transfer, the PCP must mail a certified letter to the member dismissing the member from the PCP’s care and directing the member to contact the Plan’s Member Service Department to coordinate selection of a new PCP.

The PCP will also be responsible for notifying their Plan Provider Representative so that the Plan can ensure the member selects a new PCP in a timely manner.

Provider Participation with the Florida Medicaid Program

Providers not already enrolled with the Florida Medicaid program, and who wish to perform services for Freedom Health Members with Medicaid coverage, may submit a Managed Care Treating Provider Registration form to the Plan. Freedom Health will then submit the form on a


Provider’s behalf to the Agency for Health Care Administration (AHCA) and a provider ID will be assigned solely for the submission of encounter data.

The form submission is a formal request to obtain a Florida Medicaid provider ID that is only valid to treat Freedom Health Medicaid Members. This form is available through our Provider Relations staff.

The Medicaid Provider ID will then be used to submit encounter data to Freedom Health for the services rendered to the Plan’s Members. Providers must follow the Plan’s encounter data submission requirements to ensure acceptance of said information by Florida MMIS and/or the state’s encounter data warehouse.

A Provider who is granted a Medicaid ID to treat Plan Members may also be an option for assignments in the choice counseling process.

It is important to note that the form may not be used to apply to the Medicaid program as a fee-for-service Provider. If a Provider plans to submit claims directly to Florida Medicaid for fee-for-fee-for-service reimbursement, they must submit the full Florida Medicaid Provider Enrollment Application,

available at http://mymedicaid-florida.com.

Provider participating with telemedicine

If the health plan has approved a provider to provide telemedicine services to Freedom health members, the provider is required to have protocols in place to prevent fraud waste and abuse. The provider must implement telemedicine fraud waste and abuse protocols that address the following:

(1) Authentication and authorization of users; (2) Authentication of the origin of the information;

(3) The prevention of unauthorized access to the system or information;

(4) System security, including the integrity of information that is collected, program integrity and system integrity; and

(5) Maintenance of documentation about system and information usage.

Provider Information Changes

Prior notice to your Provider Relations Representative is required for any of the following changes:

x Tax identification number

x Group name or affiliation

x Physical or billing address

x Telephone or facsimile number


Providers are accepted for participation if they meet the Plan’s credentialing requirements and business needs, at its sole discretion. Freedom Health, Inc. does not discriminate against race, creed or national origin of the Provider.

Participating Providers are required to notify the Plan immediately when a new Provider joins their practice. Notify the local Provider Relations Representative and the representative will send an application for completion. Please see the Credentialing Overview Section to learn more about our credentialing requirements.

Provider Termination

In addition to the Provider termination information included in your contractual agreement with the Plan, the Provider must adhere to the following terms:

x Any contracted Provider must provide at least 60 days prior written notice before a “without

cause” termination;

x Terminations occur on the last day of the month. For example, if a termination letter is dated January 15, the termination will be effective March 31; and

x Providers who receive a termination notice from the Plan may submit an appeal. Please refer to the Credentialing Section of the manual for specific guidelines.

Please Note: The Plan must provide written notification to all appropriate agencies and/or Members upon a Provider suspension or termination, as required by regulations and statutes.

Continuity of Care

Terminated Provider

Freedom Health will provide continued services to Members undergoing a course of treatment by a provider that no longer participates with the Plan, if the following conditions exist at the time of contract termination:

a. Such care is medically necessary. Continued care is allowed through the completion of

treatment, until the Member selects another treating provider, or until the next Open Enrollment period – not to exceed six (6) months after the termination of the provider’s contract.

b. Continuation of care through the postpartum period for Members who have initiated a course of prenatal care, regardless of the trimester in which care was initiated with a terminated treating provider.

For continued care under this subsection, the Plan and terminated provider continue to abide by the same terms and conditions as existed in the terminated contract. However, a terminated provider may refuse to continue to provide care to a Member who is abusive or noncompliant. This subsection does not apply to providers terminated from the Plan for cause.

Utilization Management & Quality Management Programs (UM/QA)

The Plan has UM/QM programs that include consultation with requesting providers when appropriate. Under the terms of the contract for participation with the Plan’s network, Providers agree, in addition to complying with state and federal mandated procedures, to cooperate and participate in the Plan’s UM/QM programs, including quality of care evaluation, peer review


process, evaluation of medical records, Provider or Member grievance procedures, external audit systems and administrative review.

Further, to comply with all final determinations rendered pursuant to the proceedings of the UM/QM programs, all participating Providers or entities delegated for Utilization Management are to use the same standards as defined in this section.

Compliance is monitored on an ongoing basis and formal audits are conducted annually.

Preferred Drug List

Please refer to the Pharmacy Section of this manual for a description of the Plan’s Preferred Drug List and prescribing criteria. Please contact your Provider Relations Representative for a copy of the Preferred Drug List.

Confidential Member Information & Release of Medical Records

All consultations or discussions involving the Member or his/her case should be conducted

discreetly and professionally in accordance with the HIPAA Privacy and Security Rules established on April 14, 2003. All Physician practice personnel must be trained on privacy and security rules. The Practice should ensure that there is a Privacy Officer on staff, that a policy and procedure is in place for confidentiality of Member’s protected health information and that the Practice is following procedure or obtaining appropriate authorization from Members to release protected health


All Members have a right to confidentiality. Any health care professional or person who directly or indirectly handles the Member or his/her medical record must honor this right. Every practice is required to post their Notice of Privacy Practice in the office or provide a copy to Members.

Employees who have access to Member records and other confidential information are required to sign a “Confidentiality Statement.”

Confidential Information includes:

a) Any communication between a Member and a Physician; and

b) Any communication with other clinical persons involved in the Member’s health, medical and mental care.

Included in this category are:

1) All clinical data, i.e., diagnosis, treatment and any identifying information such as name, address, Social Security Number, etc.;

2) Member transfer to a facility for treatment of drug abuse, alcoholism, mental or psychiatric problem; and


When a Member enrolls in the Plan, his/her signature on the “Enrollment Form” automatically gives the healthcare Provider permission to release his/her medical record to the Plan, other Physicians in the Plan network who are directly involved with the Member’s treatment plan and agencies conducting regulatory or accreditation reviews.

Before any individual not working for the Plan can gain access to the Member’s medical record, written authorization must be obtained from the Member, Member’s guardian or his/her legally authorized representative (except when there is a statute governing access to the record, a

subpoena or a court order involved). Disclosures without authorization or consent may include, but are not limited to Armed Services Personnel, Attorneys, Law Enforcement Officers, Relatives, Third Party Payers, and Public Health Officials.

Adult Health Screening Services

An adult health screening is performed by a Physician to assess the health status of a patient age 21 and older. It is used to detect and prevent disease, disability and other health conditions or monitor their progression. This is an all-inclusive service. The Plan does not allow separate billing for required or recommended components.

Freedom Health reimburses adult health screening services for recipients ages 21 and older, with the following procedure codes and no modifier:

x 99385 for new patient screenings ages 21-39;

x 99386 for new patient screenings ages 40-64;

x 99387 for new patient screenings ages 65 years and older;

x 99395 for established patient screenings ages 21-39; x 99396 for established patient screenings ages 40-64; or

x 99397 for established patient screenings ages 65 years and older. (Actual financial reimbursement is according with the terms of the provider’s contract.)

Screening Schedule

Freedom Health will reimburse for one adult health screening every 365 days (1 year). Adult health screenings are recommended for Members:

x Ages 21 through 39 - one screening every five years. x Ages 40 and older - one screening every two years.

Required Service Components

A Physician who provides adult health screenings must be able to provide or refer and coordinate the provision of all required screening components. These components must be documented in the Member’s medical record.


1. Health History

At a minimum, the following items must be documented in the Member’s medical record:

x Present history;

x Past history;

x Family history;

x A list of all known risk factors, allergies and medications; and

x Nutritional assessments. 2. Physical Examination

At a minimum, the following items must be documented in the Member’s medical record:

x Measurements of height, weight, blood pressure and pulse; and

x Physical inspection to include: assessment of general appearance, skin, eyes, ears, nose, throat, teeth, thyroid, heart, lungs, abdomen, breasts, extremities; and a pelvic, testicular, rectal and prostate exam, per gender, as appropriate.

3. Visual Acuity Testing

At a minimum, the testing must document a recipient’s ability to see at 20 feet. 4. Hearing Screen

At a minimum, the screen must document a recipient’s ability to hear by air conduction. 5. Required Laboratory Testing

At a minimum, the following are required and are included in the reimbursement of an adult health screening:

x Urinalysis dipstick for blood, sugar and acetone; and x Hemoglobin or hematocrit.

Manual or automated dipstick urine, hemoglobin and hematocrit tests performed during an adult health screening are not reimbursable as separate services from the adult health screening.

Recommended service components: 1. Mammography Screening Referral

The American Cancer Society recommends referral for routine screening mammography for all females ages 35 and older. Mammography screening guidelines are as follows:

x Ages 35 to 39, one screening baseline mammogram; and x Ages 40 and older, one screening mammogram every year.

A screening mammogram is limited to one per year. A diagnostic mammogram used to evaluate or monitor an abnormal finding may be performed more than once a year. Mammograms performed by a mobile x-ray Provider are not reimbursable.

2. Laboratory Procedures

The following laboratory procedures are recommended, when indicated:

x Stool for occult blood;


x Collection of cervical pap smear for sexually active females or all females 18 years old and older;

x Collection of prostatic surface antigen (PSA), if indicated for males 50 years old and older; and

x Collection of specimens for sexually transmitted diseases.

For Medicaid Coverage and Limitations, please refer to the Medicaid-specific handbooks on the State of Florida Agency for Health Care Administration’s (ACHA’s) website:


Child Health Check-Ups (CHCU) - Freedom 1st

Primary Care Providers are required to provide the services described in this section to Freedom

1st Medicaid Members. For additional information about providing and billing for these services,

please refer to the American Academy of Pediatrics, Recommendations for Preventive Pediatric Health Care, the Medicaid Child Health Check-Up Coverage and the Limitations Handbook. The handbook is available through the State of Florida Agency for Health Care Administration (AHCA). If a Provider is not approved by Medicaid, Freedom Health will provide him/her a copy of the Coverage & Limitations document which details the provision and billing for these services. The purpose of the Child Health Check-Up Program is to provide the services listed below to children ages 0 through 20:


Comprehensive, preventive, well child care on a regularly scheduled basis;


Identification and correction of medical conditions before the conditions become serious and disabling; and


An entry into the health care system and access to a medical home.

Policies and procedures are described in AHCA’s Child Health Check-Up Coverage and Limitations Handbook.

Policy requirements include:

The health screening examination shall consist of:


comprehensive health and developmental history, including assessment of past medical history, developmental history and behavioral health status;


comprehensive unclothed physical examination;


developmental assessment;



appropriate immunizations according to the appropriate Recommended Childhood Immunization Schedule for the United States;


laboratory testing (including blood lead test where required);


health education (including anticipatory guidance);


dental screening (including a direct referral to a dentist for Members beginning at three (3) years of age or earlier, as indicated);


vision and hearing screening including objective testing when required;


diagnosis and treatment; and


referral and follow-up, as appropriate.

The Physician will submit all health screening reports and clinical information in a timely manner, per the Primary Care Physician’s Service Agreement.


The Physician must refer Members to appropriate service Providers for further assessment and treatment of conditions found in the examination, within an outer limit of six months after the request for a CHCUP.


Members must be offered scheduling and transportation assistance to ensure they attend medical appointments.


A CHCUP includes the maintenance of a coordinated system to follow the Member through the entire range of screening and treatment, as well as supplying CHCUP training to Providers. Freedom Health does not reimburse Providers for venipuncture, collection, handling or

transportation of specimens for Freedom 1st Plan Members. Those services are considered part of

the Preventive Service Evaluation and management codes set forth in the State of Florida Agency for Health Care Administration’s Medicaid Coverage and Limitations.

Vaccines for Children (VFC) Program

Primary Care Physicians (PCP’s) shall participate in the Vaccines for Children Program (VFC), the program administered by the Department of Health (DOH), Bureau of Immunizations, which provides vaccines at no charge to Physicians, and eliminates a need to refer children to County Health Departments (CHD) for immunizations. You may contact DOH at:

Florida Department of Health Bureau of Immunization 4052 Bald Cypress Way BIN #A11

Tallahassee, FL 32399-1719 Telephone: 1-850-245-4342 Fax: 1-850-922- 4195


x Provision of immunizations in accordance with the appropriate Recommended Childhood Immunization Schedule for the United States or when medically necessary for the child’s health;

x Maintenance of adequate vaccine-supplies, through the Vaccines for Children program, in compliance with specific program guidelines;

x Maintaining up-to-date Member immunization records;

x Billing Freedom Health for the administrative fee associated with utilization of VFC vaccine supplies; and

x Administration of immunizations to avoid sending Freedom Health Members to local health departments and ensure continuity of care, timeliness and accurate record keeping.

For immunizations covered by Medicaid but not provided through VFC, Freedom Health will be responsible for reimbursement to the Provider, this includes:

x Payment of no more than the Medicaid program vaccine administration fee of $10.00 per administration (unless another rate is negotiated with the Provider).

The Vaccines for Children Program does not provide Vaccines for the Medikids program. The Primary Care Physician must bill the Plan for immunizations and will be paid at their contracted Plan rate for the vaccines.

Family Planning Services

Family planning services can be provided to Members of childbearing age who desire family planning services and supplies. The services are for the purpose of spacing children or preventing pregnancies.

Physicians will provide the following services, at minimum:

x Plan and referral;

x Education and counseling;

x Initial examination;

x Diagnostic procedures and routine laboratory studies;

x Contraceptive drugs and supplies; and

x Follow-up care in accordance with the Medicaid Physicians Services Coverage and Limitations Handbook.

Patients shall be allowed full freedom of choice of family planning methods covered under the Medicaid program, including implants when there are no medical contra-indications. These services shall be provided on a voluntary and confidential basis.

Services shall be provided to eligible Members under the age of 18, provided the Member is married, a parent, pregnant, has written consent by a parent or legal guardian or in the opinion of a Physician, the Member may suffer health hazards if the service is not provided. The provider must document the reason for providing family planning services to the minor in the Member’s medical record.


Providers shall make available and encourage all pregnant women and mothers with infants to receive scheduled postpartum visits for the purpose of voluntary family planning, including discussion of all methods of contraception, as appropriate.

Providers will also offer counseling and services for family planning to all women and their partners. Documentation shall be maintained in the medical record to reflect these services.

Pregnancy Related Requirements

Identification of Pregnant Enrollees

The Plan has established an outreach program and other strategies for identifying every pregnant enrollee. This includes identification through case management, claims analysis, and the use of a health risk assessment. The Plan requires participating providers to notify the Plan of any Medicaid enrollee who is pregnant.

Florida’s Healthy Start Prenatal Risk Screening

Providers shall offer Florida’s Healthy Start prenatal risk screening to Freedom Health Members who are pregnant, as part of the first prenatal visit. The visit shall be documented on a DOH prenatal risk DH Form 3134, which can be obtained from the local county health department. A copy of the completed screening form shall be retained in the Member’s medical record and another provided to the Member. The completed DH Form 3134 shall be submitted to the respective county health department within ten business days of completion.

Florida’s Healthy Start Infant (Postnatal) Screening Instrument

Freedom Health Providers who provide birthing services will record risk-factor information by means of Florida’s Healthy Start Infant (Postnatal) Risk Screening Instrument (DH Form 3135), to be completed as part of the Certificate of Live Birth. Providers shall submit the Infant (Postnatal) Risk Screening Instrument with the Certificate of Live Birth to the County Health Department of the county where the infant was born. DH Form 3135 can be obtained from the local county health department.

A copy of the completed screening instrument shall be maintained in the Member’s medical record and the remaining copy will be given to the Member.

Based on Freedom Health Member risk scores, pregnant women or infants who are not eligible for Healthy Start care coordination, may be referred for these services regardless of their score if:

x The referral is to be made at the same time the risk screen is administered, the Provider may indicate on the risk screening form that the woman or infant is invited to participate based on factors other than score; or

x The determination is made subsequent to risk screening; the Provider may directly refer the woman or infant to the Healthy Start care coordination Provider, based on assessment of actual or potential factors associated with high risk, such as HIV, Hepatitis B, substance abuse or domestic violence.

Freedom Health Providers Plan shall refer all pregnant, breastfeeding and postpartum women, infants and children up to age five, to the local Women, Infants and Children (WIC) office. For the initial referral for WIC certification, the Plan must complete the Florida WIC program Medical


Referral Form with the current height or length and weight (taken within 60 days of the WIC appointment); hemoglobin or hematocrit (see below); and any identified medical/nutritional problems.

For subsequent WIC certifications, the Plan encourages its Providers to coordinate with the local WIC office to provide the referral data from the most recent CHCUP. Each time a WIC Referral Form is completed, the Plan shall ensure the Provider gives a copy of the WIC Referral Form to the Member and retains a copy in the Member’s medical record.

Women, Infants and Children (WIC) Category WIC Blood Work Screening Schedule

x Pregnant Woman - Once during the current pregnancy;

x Breastfeeding Woman - Up to one (1) year postpartum, once after delivery;

x Postpartum Woman (not breastfeeding) - Up to six (6) months postpartum;

x Once after delivery/termination of pregnancy;

x Infant - Once between 6-12 months of age (preferably between 9-12 months);

x Child – Once between 1-2 years (preferably between 15 – 18 months); and

x Child – 2-5 years, Once every year unless an abnormal value is found, (<11.1gm/dl

hemoglobin, <33% hematocrit) then a follow-up blood test is required at six (6) month intervals. Freedom Health Providers are required to offer all women of childbearing age HIV counseling and HIV testing, including pregnant women at the initial prenatal care visit and again at 28-32 weeks. For pregnant women declining HIV testing, a signed objection is required.

Pregnant Freedom Health Members, who are HIV infected, shall be counseled and offered the latest antiretroviral regimen recommended by the U.S. Department of Health and Human Services, Public Health Service Task Force entitled “Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States”. To receive a copy of the guidelines, contact the Florida Department of Health, Bureau of HIV/AIDS at 1-850-245-4300, or you may reach the DHHS website at http://aidsinfo.nih.gov/guidelines/.

Freedom Health Providers shall routinely screen all Medicaid eligible women receiving prenatal care for the Hepatitis B surface antigen (HBsAg) at the time of the first examination, relating to the current pregnancy. Pregnant women who tested negative at the first visit and are considered high-risk for hepatitis B infection, shall have a second HBsAG test performed at 28 to 32 weeks of pregnancy. This test shall be performed at the same time that other routine prenatal screening is ordered.

All HBsAg-positive women shall be reported to the local county health department. Women who are HBsAg-positive shall be referred to the Healthy Start program regardless of their Healthy Start screening score.

Newborn Freedom Health Members born to HBsAg-positive Members shall receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine, preferably within 12 hours of birth and shall complete the hepatitis B vaccine series according to the recommended vaccine schedule. These


newborns shall be tested for HBsAg and Hepatitis B surface antibodies (anti-HBs) six (6) months after the completion of the vaccine series as a method to monitor the success or failure of the therapy.

A positive HBsAg result in any child ages 24 months or younger shall be reported to the local county health department within 24 hours. Infants born to women who are HBsAg-positive shall be referred to Healthy Start regardless of their screening score.

Freedom Health prenatal and postpartum Members, who are HBsAg-positive, shall have their test results and those of their newborns reported to the Perinatal Hepatitis B Prevention Coordinator at the local County Health Department. Information collected for each individual shall include: name, date of birth, race, ethnicity, address, ex: (infants and contacts), laboratory test performed and date the sample was collected, due date or EDC, whether or not prenatal care was provided (prenatal woman) and immunization dates (infants and contacts). Freedom Health encourages Provider use of the Practitioner Disease Report Form (DH Form 2136) to report any known Perinatal Hepatitis B Cases the form can be obtained from the county-specific Department of Health.

The Child Health Check-Up Schedule

xBirth or neonatal examination

x2-4 days for newborns discharged in less than 48 hours after delivery

xBy 1 month x2 months x4 months x6 months x9 months x12 months x15 months x18 months

xOnce per year for 2 through 20 year olds*

The child may enter the periodicity schedule at any time. For example, if a child has an initial screening at age 4, then the next periodic screening is performed at age 5.

* Florida Medicaid recommends check-ups at 7 and 9 years of age for children at risk.

Required Dental Referral for Recipients Three Years Old and Older

The provider must refer children who are three (3) years old and older for an assessment by a dentist and document this referral in the child’s medical record. The provider may refer a younger child if it is medically necessary.

Services by OB/GYN’s acting as Primary Care Providers

Freedom Health pregnant Members can select participating OB/GYN’s as their Primary Care Physicians if the OB/GYN is willing to participate as such. Freedom Health’s authorization process shall be the same for OB/GYN Primary Care Physicians as traditional Primary Care Physicians. Freedom Health Providers shall provide the most appropriate and highest level of quality care for pregnant Members, including:


1. Prenatal Care: Requirements include a pregnancy test and a nursing assessment with referrals to a Physician, Physician’s Assistant or Nurse Practitioner for comprehensive evaluation; case management through the gestational period according to the needs of the patient; referrals and follow-up. High medical risk diagnoses are listed in Appendix B of the Medicaid Physician Services Coverage and Limitations Handbook and require direct care by the Physician.

Freedom Health Members shall be scheduled for return visits at least every four (4) weeks until the 32nd week, every two (2) weeks until the 36th week and every week thereafter until delivery, unless the Member’s condition requires more frequent visits.

For Members who fail to keep appointments, Freedom Health shall attempt to contact the Members and arrange for their necessary and continued prenatal care. Members shall receive assistance in making delivery arrangements, when necessary.

All pregnant women must be screened for tobacco use with provision of smoking cessation counseling and appropriate treatment as needed.

2. Nutrition Assessment and/or Counseling: Freedom Health Providers shall provide nutrition assessment and counseling to all pregnant Members. Nutrition assessment/counseling should include the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and the proper use of breast milk substitutes. Public health nutritionists, nurses or Physicians can provide individualized diet counseling and a nutrition care plan following nutrition assessments. The nutrition care plan must be documented in the Member’s medical record by the person providing counseling.

3. Obstetrical Delivery: Freedom Health Providers shall adhere to generally accepted and approved protocols for both low risk and high risk deliveries, to reflect the highest standards of the medical profession, including a Healthy Start prenatal screen.

A preterm delivery risk assessment must be determined and documented in the Member’s medical record by the 28th week. If the delivery is determined to be high risk, obstetrical care during labor and delivery must include preparation by all attendants of extraordinary symptomatic evaluation, progress through the final stages of labor and immediate

postpartum care.

The high medical risk diagnoses are listed in Appendix B of the Medicaid Physician Services Coverage and Limitations Handbook and require direct care by the Physician. 4. Newborn Care: Freedom Health Providers shall provide for the highest level of care for

newborns; beginning immediately after birth, which includes but is not limited to:

x Instilling of a prophylaxis into each eye of the newborn in accordance with s.383.04 F.S.;

x Securing of a cord blood sample for laboratory testing for type Rh determination and direct Coombs test when the mother is Rh negative;


x Inspecting for abnormalities and/or complications;

x Administering of one half milligram of vitamin K;

x APGAR scoring;

x Any other necessary and immediate need for referral and consultation from a specialty Physician, such as the Healthy Start (postnatal) infant screen; and

x Newborn Hearing Screenings as follows:

Freedom Health newborns and infants shall have hearing screenings, conducted by a licensed Audiologist or an individual who has completed documented training

specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed Physician or licensed Audiologist.

5. Postpartum Care: Freedom Health Providers shall provide a postpartum examination for the mother within six (6) weeks after delivery. This visit shall include voluntary family planning, and a discussion of contraceptive methods. Freedom Health newborns and infants shall have available Child Health Check-Up screenings to allow for continuity of care.

Emergency Shelter Medical Screenings

The Plan provides post authorization to County Health Departments (CHDs) for emergency shelter medical screenings provided for the Department of Children & Families (DCF) clients.

Quality Enhancement Programs

In addition to covered services, Freedom Health Providers shall provide Quality Enhancement components to Medicaid Members. These services may be provided through community-based organizations and agencies.

When available, Freedom Health Primary Care Physicians shall make available to Members information on Quality Enhancement programs and community resources encouraged by Freedom Health.

Freedom Health Primary Care Physicians agree to provide counseling, education and/or coordination of services to assist in the provision of Medicaid Quality Enhancements; including, but not limited to:

x Prenatal/postpartum care;

x Children’s programs; x Pregnancy prevention;

x Domestic violence screening and referral; x Smoking cessation; and

x Substance abuse screening and referral.

Prenatal/Postpartum Pregnancy Programs


Members to encourage compliance with prenatal and postpartum programs. When appropriate, Providers shall offer Florida’s Healthy Start prenatal risk screening to Freedom Health Members who are pregnant, as part of the first prenatal visit.

Children’s Programs

Freedom Health Primary Care Physicians shall promote increased utilization of prevention and early intervention services for at-risk Members. Freedom Health Primary Care Physicians shall promote proper nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention and early intervention services.

Pregnancy Prevention

When appropriate, Freedom Health Providers shall encourage Members to enroll in community pregnancy prevention programs, such as the Abstinence Education Program.

Domestic Violence

Freedom Health Primary Care Physicians shall screen Members for signs of domestic violence, and offer referral services to applicable domestic violence prevention agencies in the community. Smoking Cessation

Freedom Health Providers shall participate in regularly scheduled smoking cessation programs, including community smoking cessation programs. Members shall also have access to smoking cessation counseling. Freedom Health Primary Care Providers may request a copy of the Quick Reference Guide, a distilled version of the Public Health Service-sponsored Clinical Practice Guideline and Treating Tobacco Use and Dependence, to assist in identifying tobacco users and supporting and delivering effective smoking cessation interventions.

Copies of this guide may be obtained by contacting the DHHS, Agency for Health Care Research and Quality (AHR) Publications Clearinghouse, at 1-800-358-9295 or write to P.O. Box 8547, Silver Spring, MD 20907.

Substance Abuse

Freedom Health Primary Care Physicians shall screen Members for signs of substance abuse as part of prevention evaluation at the following times and in the following circumstances:


initial contact with a new Member;


routine physical examination;


initial prenatal contact;


when the Member shows serious over-utilization of medical, surgical, trauma or emergency services; and


when documentation of emergency room visit suggests the need.

Providers should advise targeted Members to attend community or Plan sponsored substance abuse programs. Providers will have available annual substance abuse screening training.

Freedom Health Providers are encouraged to use the Florida Supplement to the American Society of Addictions Medicine Patient Placement Criteria for coordination and treatment of substance-related disorders with substance abuse Providers.


Cultural Competency

Freedom Health has a strong commitment to diversity in its workforce, customer base and communities it serves. When health care services are delivered without regard for cultural differences, patients are at risk for sub-optimal care. Patients may be unable or unwilling to communicate their health care needs in a culturally insensitive environment, reducing the effectiveness of the health care process.

Understanding the fundamental elements of culturally and linguistically appropriate services is necessary when striving for cultural competency in health care delivery. Implementing a strong cultural competency program in health care delivery allows Freedom Health to:

x Respond to demographic changes;

x Eliminate disparities in the health status of people of diverse backgrounds;

x Improve the quality of health care services and health outcomes;

x Gain a competitive edge in the health care market and decrease liability/malpractice claims; and

x Increase both Member and staff satisfaction.

Cultural Competency is defined as a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals and enable that system, agency or those professionals, to work effectively in cross-cultural situations.

Cultural competency occurs in both clinical and non-clinical areas. In the clinical area, it is based on the Patient-Provider relationship. In the non-clinical arena, it involves organizational policies and interactions that impact health care services.

Evaluation of the Cultural Competency Program will be performed on an annual basis as part of the Quality Management Program Evaluation.

Providers may obtain a full copy of the Cultural Competency plan, by contacting their local Provider Relations Representative.

Consumer Assistance & Complaints

Please refer to the Forms Section of this Manual for the Plan’s related forms.

Member Rights & Responsibilities

Freedom Health strongly endorses the rights of Members as supported by State and Federal laws. Freedom Health also expects Members to be responsible for certain aspects of the care and treatment they are offered and receive.

All Member rights and responsibilities are to be acknowledged and honored by Freedom Health staff and all contracted Providers. Contracted Providers are provided with a declaration of Freedom


Health Member rights and responsibilities in their Provider Manual. In addition, Providers are given a handout of these rights and responsibilities and are urged to post them in their respective offices. Members are afforded a listing of their rights and responsibilities as a Plan Member in their

Freedom Health Member Handbook. See the Forms section for rights and responsibilities that Freedom Health endorses and expects Providers and Members to acknowledge and reinforce.

Advance Medical Directives

Members have the right to control decisions relating to their medical care; including the decision to have withheld or taken away the medical or surgical means or procedures to prolong their life. The law provides that each Plan Member (age 18 years or older of sound mind) should receive

information concerning this provision and have the opportunity to sign an Advance Directive Acknowledgement Form to make their decisions known in advance. This allows members to designate another person to make a decision should they become mentally or physically unable to

do so. Please refer to the Forms Section of this manual. Digitally signed by Vickie Divens, RN DN: cn=Vickie Divens, RN, o=Agency


for Healthcare Adminstration,

ou=Medicaid Program Integrity,

Fraud and Abuse Reporting


.com, c=US

Divens, RN

Date: 2012.11.20 10:20:18 -05'00' Under the Centers for Medicare and Medicaid Services (CMS) and Agency for Health Care

Administration (AHCA) guidelines, the health plan is required to have an effective fraud, waste and abuse (FWA) program in place. Freedom Health has implemented a FWA program to prevent, detect and report health care fraud and abuse according to applicable federal and state statutory, regulatory and contractual requirements. Freedom Health will use a number of processes and procedures to identify and prevent fraud and abuse. Providers engaged in fraud and abuse may subject to disciplinary and corrective actions, including but not limited to, warnings, monitoring, administrative sanctions, suspension or termination as an authorized provider, loss of licensure, civil and/or criminal prosecution, fines and other penalties.

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which available online at: https://apps.ahca.myflorida.com/InspectorGeneral/fraud_ complintform.aspx and If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General's Fraud Rewards Program (toll-free 1-866-866-7226 or 850-414-3990). The reward may be up to 25 percent of the amount recovered, or a maximum of $500,000 per case) Florida statutes Chapter 409.9203). You can talk to the Attorney General's Office about keeping your identity confidential and protected.

In December 2007, CMS published a final rule that requires these organizations to apply certain training and communication requirements to all entities they partner with to provide benefits or services in the Part C or Part D programs.

To meet CMS requirements for Medicare Advantage Organizations and Part D Sponsors, this section covers general fraud, waste and abuse training guidelines for the Plan’s first tier, downstream, and related entities.