Provider Administrative Manual (PAM)
Table of Contents
Section 1: Introduction
- About Trinity Health Plan Of New England
- Important News and Updates to this Manual
- Provider Communications
- How to Contact the Plan
- Additional Resources
Section 2: Eligibility and Enrollment
Section 3: Provider Policies and Protocols
- Compliance with Policy/Protocol
- Provide Timely Notice of Demographic Changes
- Prohibited Billing Practices
- After Hours Care
- Delay in Service
- Medical Record Requirements
- Risk Adjustment Information
- Informing Members of Advance Directives
- Referrals and Prior Authorization Requests
- Member Rights and Responsibilities
Section 4: Quality Management
- Regulatory Requirements
- Healthcare Effectiveness Data and Information Set (HEDIS®)
- What are Medicare Star Ratings?
- Program Goals
- Program Activities
- Risk Management/Quality Concern Reporting
- Outcomes, Evaluations and Member-Based Studies
- Access and Availability
- Member and Provider Satisfaction
Section 5: Utilization Management
- Overview
- Medical Necessity
- Submission Process
- Prior Authorization
- Referrals
- Hospital Notifications
- Concurrent Review
- Readmission Process
- Urgent Care and Emergency Services
- Notifications to Members
- Availability of Utilization Management Staff
- Skilled Nursing Facilities (SNF)
Section 6: Case Management
- Overview
- Transitions of Care Program
- Disease Management Program
- Behavioral Health Program
- Chronic Care Improvement Program – Congestive Heart Failure
- CHF Telemonitoring Program (CHF)
- Nurse Advice Line
- Complex Case Management Program
Section 7: Medicare-Covered Drugs
- Medicare Part B Drugs
- Medicare Part D Drugs
- The Formulary
- Tiered Drug Benefit
- Medicare Part D Benefit Stages and Total Out-of-Pocket Costs
- Vaccines Covered Under Medicare Part D
- Provision of and Billing for SHINGRIX©
- Part D Utilization Management Requirements
- Diabetic Glucose Monitors, Test Strips, and Supplies
- Self-Administered Drugs in an Outpatient Setting
- Non-Covered Part D Utilization Management Requirements
- Inflation Reduction Act
Section 8: Claims Processing Procedures and Guidelines
- Copayment and Coinsurance
- Annual Wellness Exam
- Annual Women’s Exam
- Diabetic Retinopathy Screening
- Essential Trinity Health Plan Of New England Data Elements Required
- General Form Submissions
- Electronic Claim Submissions
- Paper Form Submissions
- Remittance Advice
- Electronic Payment and Remittance Enrollment
- Corrected Claims Submission
- Request for Claims Review Form
- Claims Timely Filing Limitations
- Provider Portal
- Transfer of Claims from Medicare Part B Carrier/MAC to Trinity Health Plan Of New England
- Coordination of Benefits
- Secondary Payor
- Medicaid as a Secondary Payor
- Subrogation
- Workers’ Compensation
Section 9: Compliance
- Overview
- Monitoring and Auditing First Tier, Downstream and Related Entities (FDR)
- Compliance Reporting
Section 10: Special Investigations Unit
- Fraud, Waste and Abuse (FWA)
- What is Fraud, Waste and Abuse?
- Examples of Provider, Pharmacy, or Vendor FWA
- Disclosure of Ownership, Exclusion and Criminal Conviction
- How to Report FWA
Section 11: Network Participation Responsibilities
- Overview
- How to Become a Participating Provider with Trinity Health Plan Of New England
- Trinity Health Plan Of New England’s Code of Conduct
- Credentialing Process
- Provide Official Notice
- Transition of Member Care Following Termination of Your Participation
- Performance Assessment
- Provisions of Access to Your Facility
- Physician Incentive Plan Regulation Compliance
- Remediation Policy
- Medicare Advantage Participation Provisions
Section 12: Member Grievance and Appeal Process
- Overview
- General Information on Medicare Appeals Procedures
- Who May File an Appeal
- Support for the Appeal
- Assistance with Appeals
- Medicare Standard Organization Determination and Appeals Procedures
- Medicare Expedited/72-Hour Determination and Appeal Procedure
- Types of Decisions Subject to Expedited/72-Hour Review
- How to Request an Expedited/72-Hour Review
- How an Expedited/72-Hour Determination/Review Request will be Processed
- Trinity Health Plan Of New England Grievance Procedures
- Quality Improvement Organization Immediate Review of Hospital Discharges
- Quality Improvement Organization Quality of Care Complaint Process