PROVIDER HANDBOOK

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Welcome to American Eldercare, Inc.

Thank you for joining our provider network. We look forward to working with

you to provide quality, accessible services to our members.

American Eldercare, Inc. is committed to distributing comprehensive and timely

information to providers through this Provider Handbook. This handbook will

assist you with information on:

♦ Care Management services

♦ Claims submission

♦ Covered Services

♦ Authorization process

You will be notified of updates to this handbook via bulletins and notices posted

on our website at www.americaneldercare.com. If you need further explanation on

any topics discussed in this handbook, please contact your local Provider Relations

Specialist. A complete listing of our offices is located in Section 8, Appendix.

Sincerely,

Provider Relations Department

http://www.americaneldercare.com/

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TABLE OF CONTENTS

Section 1 Introduction………………………………...…………………………… Page 6

Long Term Care Managed Care Program …………………………………….. Page 7

Practice Guidelines..................................................................................................... Page 8

Mission Statement ………………………………………………………………….. Page 8

Office Hours …………………………………………………..............………….... Page 9

AEC Website ………………………………………………………………………. Page 9

Confidentiality Statement…………………………………………………………… Page 9

Section 2 Covered Services .. ………………………………………………………. Page 10

Medical Necessary/Necessity ……………………………………………….. Page 11

Emergency Service Responsibilities ………………………………………… Page 11

Adult Day Care ………………………………………………………………. Page 12

Assistive Care ……………………………………………………………….. Page 12

Assisted Living ……………………………………………………………… Page 12

Behavioral Management …………………………………………………… Page 14

Home Adaptations Accessibility …………………………………………. Page 14

Home Delivered Meals……………………………………………………. Page 15

Home Health Care ………………………………………………..………. Page 15

Hospice ………………………………………………………….………... Page 17

Medical Supplies (Consumable Medical)…………..………………………. Page 18

Medical Supplies (Durable Medical Equipment)………………………….. Page 18

Nursing Facility Services ……………………………………………………. Page 19

Nutritional Assessment/Risk Reduction……………………………………… Page 20

Personal Emergency Response Systems……………………………………. Page 20

Pharmacy Benefits …………………………………………………………… Page 21

Transportation……………………………….………………………………. Page 21

Quality Enhancements ……………………………………………………… Page 21

Section 3 Eligibility ……………………………………………………………….. Page 22

Conditions of Enrollment…………………………………………….…………. Page 22

Medicaid Pending ………………………………………………………………. Page 23

Membership Identification Card ……………………………………………….. Page 23

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Referrals to American Eldercare ………………………………………………... Page 24

Member Disenrollment……………………………………………………….. Page 24

Hospice …………………….……………………………………………………. Page 26

Section 4 Care Management ………………………………………………………. Page 27

Authorizations………………………………………………………………….. Page 27

Chronic/Complex Conditions …………………………………………………. Page 28

Abuse, Neglect, Exploitation……………………………………………………. Page 29

Critical Incident Reporting ……………………………………………………… Page 30

Member Rights and Responsibilities ………………………………………….. Page 30

Section 5 Provider Responsibilities………………………………………………… Page 33

Credentialing Committee ……………………………………………………….. Page 33

Initial Credentialing …………………………………………………………….. Page 33

Re-credentialing …………………………………………………………………. Page 34

Provider Monitoring ……………………………………………………………. Page 35

Right to Review and Correct Information ……………………………………… Page 35

Right to Appeal Adverse Credentialing Determination ………………………… Page 35

National Provider Identification ………………………………………………… Page 36

Provider Orientations and Education …………………………………………… Page 36

Notice Obligation ……………………………………………………………….. Page 36

Provider Handbook …………………………………………………………… Page 37

Provider Directory ……………………………………………………………… Page 37

Participating Agreement Standards…………………………………….......... Page 37

Accessibility & Availability …………………………………………………. Page 38

Provider Satisfaction …………………………………………………………. Page 38

Provider Medical/Case Record Review ……………………………………….. Page 38

Termination of Provider Contract ……………………………………………… Page 39

Out-of-Network/Non-Contracted Services ……………………………………… Page 39

Community Outreach/Marketing ………………………………………………. 0

Provider Responsibilities ………………………………………………………. Page 41

Provider Complaints …………………………………………………………. Page 41

Cultural Competency ……………………………………………………….. Page 43

Section 6 Claims/Billing ………….……………………………………………….. Page 44

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Claims Submission …………………………………………………………… Page 44

Electronic Claims …………………………………………………………. Page 44

Paper Claims ……………………………………………………………. Page 45

Encounter Data ……………………………………………………………. Page 46

Assisted Living Facilities Providers ………………………………………….. Page 47

Skilled Nursing Facility Providers …………………………………………… Page 48

Home Health Providers……………………………………………………….. Page 49

Claims Acknowledgement………………………………………………………….. Page 49

Payments……………………………………………………………………… 0

Balance Billing ……………………………………………………………… Page 51

Claim Inquiry ……………………………………………………………….. Page 51

Claim Denial……………………………………………………………….. Page 51

Claims Reconsideration of Payment ………………………………………. Page 52

Formal Grievance/Appeals ………………………………………………………… Page 52

Formal Appeal ………………………………………………………………. Page 52

Expedited Appeals …………………………………………………………… Page 54

Beneficiary Assistance Program …………………………………….. Page 54

Unresolved Grievance/Appeals- Medicaid Fair Hearing …………………….. Page 55

Section 7 Forms ……………………………………………………………………… Page 57

Authorization Forms …………………………………………………………. FORMS

Claims Form ………………………………………………………………….. FORMS

Provider Complaint Form …………………………………….……………… FORMS

Provider Change of Notice Form ………………………………………….. FORMS

Section 8 Appendix …………………………………………………………………. Page 58

AEC Locations …………………………………………………………….. Appendix

CARES Offices ……………………………………………………………… Appendix

Denial Codes …………………………………………………………………. Appendix

Remittance Advice ………………………………………………………….. Appendix

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w w w . a m e r i c a n e l d e r c a r e . c o m

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INTRODUCTION ______________________________________________

American Eldercare Inc. (AEC) is a Provider Service Network (PSN) and home health

agency that provides services to our members in the most appropriate care setting. Our

Long-Term Care Managed Care Plan works directly with the State of Florida to provide our

members with quality community and/or facility care with a focus to coordinate the

member’s primary care through his/her primary insurance. American Eldercare, Inc. was

the only company to be chosen as a state-wide contractor of this program, allowing our

membership to freely move to any county they choose in the state.

Our first goal is to keep our members in their home and provide quality home health care

and community-based services to delay or avoid long-term placement in a nursing facility.

If our members needs a more supervised environment or wants more socialization we will

assist to subsidize and monitor them to receive services in an Assisted Living Facility or an

Adult Family Home. We understand that some of our members will require nursing home

care, and we ensure that they transition to this level of care when it is no longer safe to

remain in a community setting. We offer care to meet the individual needs of each of our

members.

The State of Florida’s goals for this program are:

• Coordinated long-term care across different health care settings.

• A choice of the best long-term care plan for their needs.

• Long-term care plans with the ability to offer more services.

• Access to cost-effective community-based long-term care services.

American Eldercare, Inc. has established guidelines to assist you in understanding the goals

of our program. This handbook will provide you with vital information in order to

develop and maintain an effective partnership in meeting our members’ needs. As

American Eldercare, Inc. (AEC) is a Provider Service Network (PSN) that is contracted with

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the State of Florida to participate in the Long Term Care Managed Care Program. Our primary

goal is to identify members that may safely remain in their home environment and provide them

with quality community-based services in order to delay or avoid long-term placement in a

nursing home. We accomplish this by completing a comprehensive assessment and creating a

care plan that meets the individual needs of our members. If members are no longer able to

safely remain in their home we coordinate services for them to reside in an assisted living

facility, adult family home or a nursing home that meets their level of care. We are successful in

having our members remain in the least restrictive environment that safely meets their needs by

having a care manager specifically assigned to each individual member to coordinate both their

acute and long-term care needs.

LONG-TERM CARE MANAGED CARE PROGRAM

American Eldercare, Inc. is proud to participate as a contractor for the State of Florida to

operate a Medicaid funded program known as the Long-Term Care Managed Care

Program. Medicaid is a program for eligible individuals and/or families with low incomes

and resources. It is a means-tested program that is jointly funded by the state and federal

governments, and is managed by the states. People served by Medicaid must be U.S.

citizens or legal permanent residents, including low-income adults, their children, and

people with certain disabilities. Poverty alone does not necessarily qualify someone for

Medicaid. Medicaid is the largest source of funding for medical and health-related services

for people with limited income in the United States.

The Long-Term Care Managed Care Program is designed to care for all eligible individuals

over the age of 18 who meet a level of care to require nursing home care as well as a

financial criterion; both qualifications are determined by the state. The program provides

eligible individuals to access care in a nursing home or a less restrictive environment in the

community. The goal is to reduce the number of individuals residing in nursing homes that

can be cared for in a less restrictive environment in order to create cost savings for the state.

http://en.wikipedia.org/wiki/Means_test

http://en.wikipedia.org/wiki/Citizenship_in_the_United_States

http://en.wikipedia.org/wiki/Citizenship_in_the_United_States

http://en.wikipedia.org/wiki/Disability

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PRACTICE GUIDELINES

American Eldercare, Inc. has adopted practice guidelines that are embedded within our

policy and procedures and our daily business practices.

Practice Guideline Requirements:

a) Are based on valid and reliable clinical evidence or a consensus of healthcare

professionals in the field of disabilities and geriatric industry.

b) Considers the needs of the members.

c) Are adopted in consultation with contracted health care professionals when

deemed necessary.

d) Are reviewed and updated periodically as appropriate.

e) AEC will disseminate the guidelines to all affected providers and

upon request to members and potential members.

f) Decisions for utilization management, member education, coverage of services,

and other areas to which these guidelines apply will be consistent throughout the

Policy and Procedure Manual and daily business practices.

MISSION STATEMENT

Our mission is to provide comprehensive, effective, cost-efficient health care and related

services, through a community-based program tailored to the individual.

Core Values:

A - Advocacy

E - Ethics

C - Compassion

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OFFICE HOURS

Our dedicated staff is available to answer any questions between the hours of 8:00 am -

8:00 pm, Monday – Friday. If you have questions regarding services or benefits, you can

call the Provider Help Line at (888) 998-7735. Our provider help-line is available twenty-

four (24) hours a day seven (7) days a week including weekends and holidays. For a

complete listing of our offices, please refer to Section 8, Appendix of this handbook.

AMERICAN ELDERCARE WEBSITE (www.americaneldercare.com)

The American Eldercare, Inc. website is designed to give providers quick access to current

provider and member information twenty four (24) hours a day, seven days a week. You

will also find information about other programs and useful information and resources about

American Eldercare, Inc. Please contact your local Provider Relations Specialist with any

questions or concerns regarding the website.

CONFIDENTIALITY STATEMENT

American Eldercare, Inc. maintains a policy to ensure that medical records, claims

information and grievances pertaining to members and providers will remain confidential.

The authorized release of any information is used only for the resolution of medical

problems or to enhance a member’s health. American Eldercare, Inc. will ensure

compliance with the Privacy and Security provisions of the Health Insurance Portability and

Accountability Act (HIPAA).


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____________________________________________

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COVERED SERVICES ______________________________________________

American Eldercare, Inc. provides coverage for members who are enrolled in our Long-

Term Care Managed Care Program. Coverage is limited to those services authorized in

writing by the member’s Care Manager and in accordance with the Agency for Health Care

Administration Medicaid Services Coverage & Limitations Handbooks. A summary of

these services is below:

Adult Companion Care Medication Administration

Adult Day Health Care Medication Management

Assistive Care Services Nutritional Assessment/Risk Reduction

Services

Assisted Living Nursing Facility Services

Attendant Care Personal Care

Behavioral Management Personal Emergency Response System

(PERS)

Caregiver Training Respite Care

Care Coordinator/Case Management Occupational Therapy

Home Accessibility Adaptation Services Physical Therapy

Home Delivered Meals Respiratory Therapy

Hospice Speech Therapy

Intermittent and Skilled Nursing Transportation*

Medical Equipment and Supplies

*Non-emergent transportation services will

be offered in accordance with the member’s

plan of care and coordinated with other

service delivery system.

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MEDICAL NECESSARY/NECESSITY

Medical Necessary or Medical Necessity is determined as per 59G-1.010(166) as described

below:

“Medically necessary” or “medical necessity” means that the medical or allied care,

goods, or services furnished or ordered must:

(a) Meet the following conditions:

1. Be necessary to protect life, to prevent significant illness or significant disability, or

to alleviate severe pain;

2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of

the illness or injury under treatment, and not in excess of the patient’s needs;

3. Be consistent with generally accepted professional medical standards as determined

by the Medicaid program, and not experimental or investigational;

4. Be reflective of the level of service that can be safely furnished, and for which no

equally effective and more conservative or less costly treatment is available

statewide; and

5. Be furnished in a manner not primarily intended for the convenience of the

recipient, the recipient's caretaker, or the provider.

(b) “Medically necessary” or “medical necessity” for inpatient hospital services

requires that those services furnished in a hospital on an inpatient basis could not,

consistent with the provisions of appropriate medical care, be effectively

furnished more economically on an outpatient basis or in an inpatient facility of a

different type.

(c) The fact that a provider has prescribed, recommended, or approved medical or

allied care, goods, or services do not, in itself, make such care, goods or services

medically necessary or a medical necessity or a covered service.

EMERGENCY SERVICE RESPONSIBILITIES

If a member requires emergency acute care services, contact their primary insurance for

pre-certification or send them to the emergency room as deemed appropriate. Please

contact their assigned Care Manager or AEC Customer Service department once the

emergency is addressed so the Care Manager may follow up to coordinate care.

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If a member requires emergency care that is a covered long-term care service, please

contact the Care Manager or AEC Customer Service Department to receive precertification.

If it is after business hours, please follow the prompts to reach our after-hours staff.

ADULT DAY CARE (ADC)

This service provides member with supervision, socialization and therapeutic activities in

an outpatient setting. This also provides caregiver with respite. Meals are included as part

of this service when the member is at the center during meal times.

Adult Day Care health services include but not are limited to the following:

1. Licensed nurse full-time

2. Supervised, recreational activities at least 80% of the day

3. Physical exercises

4. Cognitive exercises

5. Lunch and snacks

6. Coordination of transportation

7. Medication administration and management

8. Vital signs monitoring

9. Basic health monitoring, to include glucose level checks

10. Referral to physical therapy screening (conducted on-site)

11. Hands-on assistance with personal care, such as toileting, eating, ambulating and

grooming

ASSISTIVE CARE

24-hour services for Members in assisted living facilities, adult family care homes and

residential treatment facilities.

ASSISTED LIVING (ALF)

This service provides member with an alternative living arrangement where there is access

to 24-hour staff. Meals, personal care and housekeeping services are provided by staff.

Facility may be used for respite care. The facility provides a “home-like” environment to

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members. The Community will provide member with the following services or as indicated

in each individual provider contract:

1. 24- hour access to staff

2. Bathing assistance

3. Medication management

4. Three meals per day, plus snacks

5. Incontinence management

6. Incontinence supplies

7. Nutritional supplements

8. Housekeeping

9. Personal laundry & linen service

10. Utilities

11. Transportation or coordination of transportation

12. Alarmed doors or locked unit

13. Personal hygiene items

14. Escort to dining room

15. Emergency/Disaster Plan

16. Dementia care

Respite Care – Provides caregivers with relief, for short periods of time. (May be

provided by an Assisted Living Community) Respite care does not substitute for the

care usually provided by a registered nurse, a licensed practical nurse or a therapist.

Transportation – All AEC contracts with ALFs require the ALF to coordinate

transportation for our members. AEC enrollees are eligible for transportation trips to

long-term care covered services as authorized by AEC. Please contact the enrollee’s

Care Manger for authorization approval. Our members will use their Medicaid gold

card or their current acute Medicaid health plan ID card respectively for all trips to

non-LTC covered services (including emergent transportation) as they do now.

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AEC Welcome Home Program

Discharge planning from Hospital & Rehabilitation – AEC has a “Welcome Home

Program” in place in order to assist our members to return to your facility as soon as

their needs can be met in your community. Our Care Management staff will assist in

the coordination of their discharge including access to Medicare Home Health

services if needed. The success of this program requires your facility to participate

by evaluating your residents in a timely manner to coordinate a safe return.

Facilities that are not willing to participate in the Welcome Home Program may not

be eligible for a bed-hold payment.

Hospice

Providers are required to inform AEC staff of any changes or concerns they may

identify while providing services to a member in order to ensure their needs are

being met. This includes notification of a member being admitted to a hospital

and/or enrolling in a Medicare Hospice program. Notification must be provided

within twenty four (24) hours of the admission. Medicaid Hospice services require

pre-authorization from AEC.

BEHAVIORAL MANAGEMENT

This service provides behavioral health care services to address mental health or substance

abuse needs of long-term care members. The services are used to maximize reduction of

the member’s disability and restoration to the best functional level.

HOME ADAPTATIONS ACCESSIBILITY

These services provide member with home modifications, which promote safety. This

Includes installation of grab bars, ramps and widening of doors. Services do not include

home modifications, which are considered home improvements. All services must be

provided in accordance with applicable state and local building codes.

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Members or caregivers will be contacted within two (2) business days of receipt of

authorization from the AEC Care Manager to schedule an appointment. Installation will

take place within two (2) weeks.

HOME DELIVERED MEALS

This service provides members who are unable to shop or cook with nutritionally sound

meals that are delivered to the home hot, cold, frozen, dried, or canned with a satisfactory

storage life. Each meal is designed to provide 1/3 of the Recommended Dietary Allowance

(RDA). A signature must be obtained from the member or caregiver upon delivery of

meals. Members must go through their Care Manager to make any changes to their meal

delivery. Services will begin within five (5) business days of receiving a written

authorization from the AEC Care Manager.

HOME HEALTH CARE (HHC)

As a contracted provider for AEC the following procedures will be adhered to when

providing services.

a) AEC reserves the right to determine the plan of care for its members, and

will send a request of specific services and frequency in order to meet the

member’s needs. Services may be provided in a member’s home or an

assisted living facility on an hourly or per visit fee as authorized by AEC.

The HHC provider has a maximum of two (2) days to inform AEC staff if

the requested services can be provided and the anticipated start date.

b) HHC staff is required to have the Agency’s designated form signed by the

member verifying that the services were provided at the time of each visit,

including date/time of service and direct care staff that provided the service.

A copy of this form must be submitted to AEC when the claim is submitted.

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c) If an AEC member is entitled to Medicare Home Health benefits, these

benefits will be utilized prior to services being authorized under your

contract with AEC.

Home Health services are authorized by the Care Manager on a weekly basis (Sun – Sat).

Pre-authorization is required by the Care Manager to provide services that exceed the

number of hours authorized in a day or in a week. The only variation that is allowable

without a pre-authorization is to switch the days of services within the same week, with

prior authorization of the member (patient). If the schedule change is permanent, the

provider should inform the Care Manager of the change.

Adult Companion

Companions can perform tasks such as meal preparation, laundry and shopping, while

providing socialization for the member. This includes light housekeeping tasks incidental to

the care and supervision of the member. Services do not include hands-on nursing care or

bathing assistance.

Family Training

This service provides training to family members in order to promote safety while caring

for the member. This includes education on diabetic management, transferring a person,

and how to use safety equipment properly.

Homemaker Services

This service provides member assistance with general household activities to include meal

preparation, laundry and light housekeeping.

Occupational Therapy

This service provides member with treatment to restore, improve or maintain impaired

function in regards to daily living tasks. (E.g. using a fork, shower chair, or cooking from a

wheel chair)

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Personal Care

This service provides member with assistance with bathing, dressing, eating, personal

hygiene and other activities of daily living. A personal care worker can do incidental

housekeeping, such as making beds and cleaning up areas where they have performed

services.

Physical Therapy

This service provides member with treatment to restore, improve or maintain impaired

function in regards to ambulation and mobility such as walking, transferring, or using a

walker or wheel chair.

Respite Care

This service provides caregivers with relief, for short periods of time. Respite care may be

provided by a Home Health Agency, Assisted Living Community or a Skilled Nursing

Facility. Respite care does not substitute for the care usually provided by a registered

nurse, a licensed practical nurse or a therapist.

Speech Therapy

This service provides member with evaluation and treatment with regards to oral motor

functions. (E.g. difficulties swallowing or speaking) This service also includes treatment to

restore, improve or maintain impaired functions in order to promote a member’s

independence and capacity to live safely in the home setting. This includes physical,

occupational and speech therapies.

HOSPICE

This service provides forms of palliative medical care and services designed to meet the

physical, social, psychological, emotional and spiritual needs of terminally ill members and

their families. Care Managers will coordinate this care with members enrolled in Medicare

Hospice services. If a member requires any hospice service traditionally covered by

Medicaid, pre-authorization is required from the Care Manager.

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MEDICAL SUPPLIES (CONSUMABLE)

These services provide member and caregiver with supplies that assist in meeting the

member’s needs. Items include incontinent supplies and diabetic supplies not covered by

Medicare. These services do not include personal toiletries, over the counter medications or

household items.

Consumable medical supplies include adult disposable diapers, tubes of ointment, cotton

balls and alcohol for use of injections, medicated bandages, gauze and tape, colostomy and

catheter supplies, and other consumable supplies. Not included are supplies covered under

Home Health service, personal toiletries, and household items such as detergents, bleach,

paper towels, or prescription drugs.

Services require written authorization from the AEC Care Manager. Supplies will be

delivered to the member’s home and the member or caregiver will sign an itemized receipt.

Members must go through their Care Manger to make any changes to their order.

Nutritional supplements require both a Physicians prescription and pre-authorization from

the AEC Care Manager. Members authorized to live in a contracted facility will receive

this service directly from the facility.

MEDICAL SUPPLIES (DURABLE MEDICAL EQUIPMENT)

Durable Medical Equipment is medical equipment that can withstand repeated use; is

primarily and customarily used to serve a medical purpose; is generally not useful in the

absence of illness or injury; and is appropriate for use in the recipient's home. Medicare

and Medicaid Acute Care Programs cover most DME equipment that AEC members need.

Any items needed by AEC members that are not covered by Medicare require pre-

authorization from the AEC Care Manager.

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NURSING FACILITY SERVICES (SNF)

This service provides twenty-four (24) hour assistance and nursing services for the member,

when they can no longer remain in the community. Member must be evaluated by

American Eldercare, Inc. staff to determine if they can be maintained in a less restrictive

environment.

Skilled nursing facility services will be coordinated with the members acute care coverage.

If a member is dual eligible for Medicare/Medicaid, AEC is responsible for coinsurance as

per the Medicaid crossover guidelines. Claims must be submitted with Medicare EOB.

The SNF staff is expected to inform AEC staff of any changes or concerns they may

identify while providing services to a member in order to ensure that their needs are being

met.

Respite Care – Provides caregivers with relief, for short periods of time. (May be

provided by a Skilled Nursing Facility Respite care does not substitute for the care

usually provided by a registered nurse, a licensed practical nurse or a therapist.

Transportation – All AEC contracts with SNFs require the SNF to coordinate

transportation for our members. AEC enrollees are eligible for transportation to

long-term care covered services, as authorized by AEC. Please contact the

enrollee’s Care Manager for authorization approval. Our members will use their

Medicaid gold card or their current acute Medicaid health plan ID card,

respectively, for all transportation trips to non-LTC covered services (including

emergent transportation) as they do now.

Hospice – Providers will inform AEC staff of any changes or concerns they may

identify while providing services to a member in order to ensure their needs are

being met. This includes notification of a member being admitted to a hospital

and/or going to a Medicare or Medicaid Hospice program. Medicaid Hospice

services require pre-authorization from AEC. Notification must be provided within

twenty-four (24) hours of a significant change in the member’s health care needs.

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Custodial Care

All members requiring this service must be assessed and determination must be

made by American Eldercare, Inc. that the member can no longer live in a less

restrictive setting. Members who receive approval for placement in a contracted

Nursing Facility for custodial care are required to pay the facility a patient

responsibility based on their income, which is determined by the Department of

Children and Families. Prior authorization is required by AEC.

AEC Welcome Home Program

Discharge planning from Hospital & Rehabilitation – AEC has a “Welcome Home

Program” in order to assist our members to return to the least restrictive

environment that safely meets their needs. Our Care Management staff will assist in

the coordination of our members discharge plan (including access to Medicare

Home Health and/or Assisted Living Placement services if needed). The success of

this program requires your facility to partner with the American Eldercare, Inc. staff

in order to implement a safe discharge plan.

NUTRITIONAL ASSESSMENT/RISK REDUCTION

This service provides member with an assessment, hands-on care and guidance for the

caregiver and members with respect to nutrition. (Provided by a dietitian usually from a

Home Health Agency) AEC reserves the right to determine the plan of care for its

members and will send a request of specific services and frequency in order to meet the

member’s needs. Services may be provided in a member’s home or an assisted living

facility on an hourly or per visit fee as authorized by AEC. The provider has a maximum of

two (2) days to inform AEC staff if the requested services can be provided and the

anticipated start date.

PERSONAL EMERGENCY RESPONSE SYSTEM (PERS)

The installation and service of an electronic device that enables members at high risk of

institutionalization to secure help in an emergency. The PERS is connected to the

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member's phone and programmed to signal a response center once a "help" button is

activated. The member may also wear a portable "help" button to allow for mobility.

PERS services are generally limited to those members who live alone or are alone for

significant part of the day and who would otherwise require extensive supervision.

Provider will train AEC members on the use and monthly testing of the unit upon

installation and will notify AEC via telephone or fax if a member utilizes the system.

Provider is expected to install a medical alert system within five (5) business days after

receiving written authorization from an AEC Care Manager.

PHARMACY BENEFITS

American Eldercare, Inc. provides a $15 over the counter (OTC) benefit for our members.

OTC formulary is available upon request. Members must have a physician’s order to

receive OTC under this benefit.

TRANSPORTATION

All AEC contracts with SNFs, requires the SNT to coordinate transportation for our

members. AEC enrollees are eligible for transportation trips to long-term care covered

services, as authorized by AEC. Please contact the enrollee’s Care Manager for

authorization approval. Our members will use their Medicaid gold care or their current

acute Medicaid health plan card, respectively, for all transportation trips to non-LTC

covered services (including emergent transportation) as they do now.

Transportation for non-medical appointments can be provided for services AEC pre-

authorized only. Please contact the member’s assigned Care Manager for more details.

QUALITY ENHANCEMENTS

Quality enhancement is education and/or community-based services will be coordinated by

the Care Manager to address any concerns related to: safety and fall prevention, disease

management, education on end of life issues, advance directives, and domestic violence.

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______________________________________________

3

ELIGIBILITY _____________________________________________

Enrollment in American Eldercare, Inc’s. Long-Term Care Managed Care Program is

based on standards of eligibility established by the Department of Elder Affairs (DOEA),

Comprehensive Assessment and Review for Long Term Care Services (CARES) unit and

financial eligibility by the Florida Department of Children and Families (DCF).

CONDITIONS OF ENROLLMENT

Recipients eligible for enrollment must be:

18 years of age or older;

Reside in the State of Florida;

Determined by CARES to be at risk of nursing home placement, meet specific

clinical criteria, and can be safely served with home and community-based services;

DCF determines a person’s financial eligibility. Financial eligibility for the

program is the same as Medicaid Institutional Care Program (ICP).

For specific information on the eligibility criteria, you may contact your Provider Relations

Specialist or the Care Management Department near your local office. If you know

someone that may qualify for the program, you may have him or her contact your local

Care Management staff or call the CARES office directly to apply.

CARES Referrals

If a member believes they may qualify, the member or their representative must contact

their local CARES office to apply for the AEC Long-Term Care Managed Care Program

Plan. As a professional, if you decide to assist a potential enrollee in the application

process, first make sure to obtain written consent from the enrollee or their representative.

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MEDICAID PENDING

These are individuals who have applied for the Program and have been determined

medically eligible by CARES but not been determined financially eligible for Medicaid by

DCF. These individual are designated at “Medicaid Pending”.

American Eldercare, Inc. has elected to provide services to these individuals who reside in

the community, and assist them with completing and returning their application to DCF. If

DCF determines the individual is not financially eligible for Medicaid, American Eldercare,

Inc. will terminate services and seek reimbursement from the individual that signed the

Financial Agreement on the member’s behalf. The individual will receive an itemized bill

for services received from AEC during the ineligible span.

If a Medicaid pending enrollee resides in a nursing home, the facility is required to assist

with the Medicaid pending process.

MEMBERSHIP IDENTIFICATION (ID) CARD

Each member of American Eldercare, Inc. Plan receives an American Eldercare, Inc. Plan

member identification (ID) card. If the card is lost or stolen, the member should contact

their Care Manager. A copy of the member’s identification card is below.

MEMBERSHIP CARD

Member & Care Management Services

Toll Free#:

RX BIN # 009430

RX Group # AEC00001

Name:

AEC ID#

Medicaid ID#

Person Code: 01

American Eldercare is your long-term care service provider only. Utilize your

primary insurance for acute care services. All long-term services are required to

have pre-authorization contract your Care Manager at the number listed on the

front of this ID card. After hours:

American Eldercare Member Help Line: 888-998-7732

American Eldercare Provider Help Line: 888-998-7735

Claims: American Eldercare Plan: 14565 Sims Road, Delray Beach, FL 33484

ProCare PBM Pharmacy Network (800) 699-3542

Member: OTC Drugs that are covered by your plan may be filled by

participating pharmacies per your plan requirements. This card is for

identification purposes only, and you may be required to provide additional ID

at the time your prescription is filled. Presentation of this card does not

guarantee eligibility. Unauthorized or fraudulent use of this card is punishable

by law. ProCare PBM reserves the right to revoke this ID card at any time

Pharmacy: ProCare PBM is not responsible for payment of claims to a

nonparticipating Pharmacy

SAMPLE SAMPLE

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REFERRALS TO AMERICAN ELDERCARE

If a person believes he/she may qualify to participate in the program, the person or their

representative must contact the local CARES office to apply for American Eldercare, Inc.

Long-Term Care Managed Care Program Plan. As a provider, if you decide to assist the

person in the application process, you must obtain their consent. The person or the provider

is always welcome to contact AEC prior to or after contacting CARES to obtain

information about our program. To locate the CARES office in your area, please refer to

Section 8, Appendix, of this handbook.

MEMBER DISENROLLMENT

Disenrollment with Cause

If a member is a mandatory enrollee and want to change plans after the initial

ninety (90) day period ends or after open enrollment period ends, the member must have a

state-approved good cause reason to change plans.

State will review and determine approval of the member’s request. Please contact the

Enrollment Broker at (877) 711-3662 for more information. The following are potential

good cause reasons to change managed care plans:

1) The enrollee does not live in a region where the Managed Care Plan is

authorized to provide services, as indicated in FMMIS.

(2) The provider is no longer with the Managed Care Plan.

(3) The enrollee is excluded from enrollment.

(4) A substantiated marketing or community outreach violation has occurred.

(5) The enrollee is prevented from participating in the development of his/her

treatment plan/plan of care.

(6) The enrollee has an active relationship with a provider who is not on the

Managed Care Plan’s panel, but is on the panel of another managed care plan. “Active

relationship” is defined as having received services from the provider within the six (6)

months preceding the disenrollment request.

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(7) The enrollee is in the wrong Managed Care Plan as determined by the Agency.

(8) The Managed Care Plan no longer participates in the region.

(9) The state has imposed intermediate sanctions upon the Managed Care Plan, as specified

in 42 CFR 438.702(a)(3).

(10) The enrollee needs related services to be performed concurrently, but not all

related services are available within the Managed Care Plan network, or the enrollee’s PCP

has determined that receiving the services separately would subject the enrollee to

unnecessary risk.

(11) The Managed Care Plan does not, because of moral or religious objections, cover

the service the enrollee seeks.

(12) The enrollee missed open enrollment due to a temporary loss of eligibility,

defined as sixty (60) days or less for LTC enrollees and one hundred eighty (180) days

or less for MMA enrollees.

(13) Other reasons per 42 CFR 438.56(d)(2) and s. 409.969(2), F.S., including, but not

limited to: poor quality of care; lack of access to services covered under the Contract;

inordinate or inappropriate changes of PCPs; service access impairments due to significant

changes in the geographic location of services; an unreasonable delay or denial of service;

lack of access to providers experienced in dealing with the enrollee’s health care needs; or

fraudulent enrollment.

Some Medicaid recipients may change managed care plans whenever they choose, for any

reason. To find out if a member may change plans, call the Enrollment Broker at (877)-711-

3662.

Disenrollment without Cause

(1) During the ninety (90) days following the enrollee’s initial enrollment, or the date the

Agency or its agent sends the enrollee notice of the enrollment, whichever is later;

(2) At least every twelve (12) months;

(3) If the temporary loss of Medicaid eligibility has caused the enrollee to miss the open

enrollment period;

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(4) When the Agency or its agent grants the enrollee the right to terminate enrollment

without cause (done on a case-by-case basis); or

(5) During the thirty (30) days after the enrollee is referred for hospice services in order to

enroll in another managed care plan to access the enrollee’s choice of hospice provider.

Without cause, for members not subject to open enrollment, is at any time.

HOSPICE

Members can be simultaneously enrolled in American Eldercare, Inc. and Hospice.

Medicaid Hospice services require prior approval from AEC. Dual eligible may enroll in

Medicare hospice, and the Care Manager will assist to coordinate services. Members or

their representative is required to contact their American Eldercare, Inc. Care Manager,

prior to enrolling in a hospice program.

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______________________________________________

4

CARE MANAGEMENT ______________________________________________

The Care Management team provides assistance to members and families to gain access to

community services in order to delay or avoid nursing home placement. If a member needs

can no longer be met safely in a community, the Care Manager will assist in placement and

supervision in a community setting or a nursing home that can safely meet their needs.

The Care Manager is responsible for developing an individualized plan of care that meets

each member’s needs in a safe environment. Most Long-Term Care services and supplies

must be pre-authorized by our Care Management team before they can be provided to an

American Eldercare, Inc. member. Please contact the local Care Management team with

requests for prior authorizations.

Care Managers can assist members with:

Authorization for services (See “Procedures for Authorization of Services”)

Change in services

Coordination of acute care services

Discharge planning from inpatient services

Disenrollment

Eligibility

Obtaining replacement ID Card

Answer any questions

Concerns about their care

AUTHORIZATIONS

If a member requires specialized treatment or services, a Care Manager will issue an

authorization for services to a participating provider. Our Care Managers will assess our

member’s needs prior to ordering any services.

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Procedures for Authorization of Services

1. Upon determination that a member needs services from a facility or agency, the

Care Manager will contact your staff to inquire if the services can be provided. If so,

the Care Manager will fax a Request for New Services form. A sample of this

form can be found in Section 7, Forms of this handbook. This authorization is good

for one year of services unless otherwise indicated at the time of authorization. If

dates of services are not established, your staff is responsible to follow up with the

Care Manager with the date services will begin.

2. If a member needs to stop services for a short period of time (e.g. due to a

hospitalization), the Care Manager will fax a Hold/Resume Services Request form.

A sample of this form can be found in Section 7, Forms, of this handbook.

3. If a member no longer needs services from your agency, the Care Manager will fax

a Termination of Services Request form. A sample of this form can be found in

Section 6, Forms of this handbook.

4. If a member needs an increase or decrease in services, the Care Manager will fax a

Change of Services Request form. A sample of this form can be found in Section

7, Forms of this handbook.

If you have any questions or concerns about a member, please contact our Care

Management team in your local area.

Chronic/Complex Conditions

All AEC covered services including but not limited to treatment for chronic and complex

conditions requires pre-authorization from a Care Manager. AEC staff will coordinate

those services with a provider of the member’s choice. If the member requires a service

which is available through Medicaid or Medicare but is not covered by American Eldercare,

Inc., the member may receive the service through other coverage they are enrolled. A Care

Manager will assist with the coordination if it is determined there is a need for the service.

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Service Limitations:

Services must be pre-approved

Services must be provided by an active provider in AEC’s provider network

Services must be a covered benefit or approved expanded benefit (see below

“Covered Services”)

Services must be medically necessary:

o Be necessary to protect life, to prevent significant illness or significant

disability, or to alleviate severe pain;

o Be individualized, specific, and consistent with symptoms or confirmed

diagnosis of the illness or injury under treatment, and not in excess of the

patient’s needs;

o Be consistent with generally accepted professional medical standards as

determined by the Medicaid program, and not experimental or

investigational;

o Be reflective of the level of service that can be safely furnished, and for

which no equally effective and more conservative or less costly treatment is

available; statewide; and

o Be furnished in a manner not primarily intended for the convenience of the

recipient, the recipient's caretaker, or the provider.

ABUSE, NEGLECT, EXPLOITATION

American Eldercare, Inc. must notify government authorities if we suspect that one of our

members is a victim of abuse, neglect or exploitation. Our network providers are expected

to report any incidents or concerns regarding our members.

Please report any suspected cases of abuse, neglect, and/or exploitation to Adult Protective

Services toll free: (800) 96ABUSE (962-2873), should you have any questions please call

our local office for assistance.

American Eldercare, Inc. requires all direct service providers who provide hands-on care to

our members to attend and complete Abuse, Neglect & Exploitation Training. If your

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licensure does not require Abuse, Neglect and Exploitation Training and you would like

American Eldercare Inc.’s staff to assist you in developing a program for your staff, please

contact your local Provider Relations Specialist.

CRITICAL INCIDENT REPORTING

Critical incidents are required to be reported to American Eldercare, Inc. staff at the time

they are identified by a provider. A critical incident is defined as an adverse or critical

event that negatively impacts the health, safety, or welfare of a member. Critical incidents

may include events involving abuse, neglect, exploitation, major illness or injury,

involvement with law enforcement, elopement/missing, or major medication incidents.

Critical incidents involving abuse, neglect or exploitation must also be reported by the

provider to Adult Protective Services. Providers are expected to work with AEC staff in

resolving all identified critical incidents in a timely manner to ensure the safety and well-

being of our members.

MEMBER RIGHTS AND RESPONSIBILITIES:

Care Managers provide all members with this information at the time of enrollment and

annually.

You have the right:

To be fully informed in advance of all care and treatment to be provided by

the agency, and changes in care or treatment; the right to receive a copy of

his/her plan of care if he/she so requests.

To be fully informed of services available from the agency and how to access

care.

To be fully informed by a physician of health status unless medically

contraindicated.

To be afforded the opportunity to participate in the planning of the care plan

and to refuse treatment without retribution, while fully informed of the

possible medical consequences of his/her refusal.

To be assured of confidentiality of records and to approve or refuse the release

of information not authorized by law.

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To be treated with consideration, respect, full recognition of dignity and

individuality, including privacy in treatment and in care for personal needs; to

have property treated with respect.

To file a grievance without fear of discrimination or reprisal from the agency;

to be informed of the State Hotline number with hours of operation and

purpose for obtaining information on home health agencies.

To be assured qualified personnel who provide proper identification at time of

visit.

To be served without regard to race, color, creed, sex or age, national origin,

ancestry or handicap/disability.

To be advised, before care is initiated, of the cost of services and the extent to

which payment may be required by the patient.

To receive home and community-based services in a home-like environment and

participate in his or her community regardless of his or her living arrangement.

To direct your care with your own staff and/or providers.

You have a responsibility:

To provide accurate and complete medical and health history information as

he/she understands it.

To participate with the plan of treatment, when possible, and make available

an informal caregiver to assume primary care, as appropriate.

To have a primary care physician who will provide orders (as required) for

skilled home care treatments and services.

To inform agency staff about any changes in health status, medications or

treatments; to inform the agency of any change in financial status that may

affect reimbursement for home care.

To have a plan for management of emergencies and to access this plan if

necessary for safety.

To inform the agency of the presence of advance directives and provide

copies, as appropriate.

To accept services of agency staff, without regard to race, creed, color,

religion, national origin, handicap, sex or age.

To report fraud, abuse, and overpayment :

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(a) To report suspected fraud and/or abuse in Florida Medicaid, call the

Consumer Complaint Hotline toll-free at 1-888-419-3456: FL General Hotline:

1-866-966-7226: AEC Compliance Hotline: 1-877-217-9717 or complete a

Medicaid Fraud and Abuse Complaint Form, which is available online at:

https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx;

(b) 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 1-866-966-7226 or 850-414-3990). The reward may be up to twenty-

five percent (25%) of the amount recovered, or a maximum of $500,000 per

case (Section 409.9203, Florida Statutes). You can talk to the Attorney

General’s Office about keeping your identity confidential and protected.

https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx

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_________________________________________________

5

PROVIDER RESPONSIBILITIES ________________________________________________

The Provider Relations Department has designed this handbook to assist network providers with

an overview of our operational policies and procedures. As a participating provider, you and

your staff will have a dedicated Provider Relations Specialist who will be a key contact. They

are responsible for ensuring services are available to our members by obtaining contracts,

providing ongoing community and provider training and education about American Eldercare,

Inc.’s Long-Term Care Managed Care Program. They also assist our network providers in

understanding the terms of our contract and resolve any problems you may encounter.

You are encouraged to contact your Provider Relations Specialist whenever you have any

questions, comments or concerns. To locate your local Provider Relations Specialist, please

refer to the list of offices located in Section 8, Appendix of this handbook.

CREDENTIALING COMMITTEE

The Credentialing Committee has the responsibility to establish and adopt, as necessary, criteria

for provider participation and termination and direction of the credentialing procedures,

including provider participation, denial and termination. Committee meetings are held at least

monthly and as deemed necessary. Failure of an applicant to adequately respond to a

request for assistance may result in termination of the application process.

INITIAL CREDENTIALING

Providers seeking participation with American Eldercare, Inc. must complete an application with

required documentation and a signed contract. It is required that all providers maintain active

status with licensure and insurance coverage and will provide proper documentation annually as

documents expire. It is required that American Eldercare, Inc. be immediately notified of any

changes in your licensure, status of insurance coverage, disciplinary actions, and/or ownership.

AEC credentialing review includes but not limited to the following criteria:

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1) Copy of current provider’s medical license, or occupational or facility license as

applicable to provider type, or authority to do business including documentation of

provider qualification as outline by governing Agency;

2) No revocation, moratorium or suspension of license;

3) A satisfactory Level II background check pursuant to guidelines for all treating

providers not currently enrolled in Medicaid’s fee-for –service program;

4) Medicaid ID number for enrollment by state Medicaid program for compliance with

data submission. AEC will take the necessary steps necessary to ensure that your

business is recognized by the state Medicaid program including its enrollment broker

as a participating provider and that your submission of encounter data is accepted by

the Florida MMIS and/or the state’s encounter data warehouse.

5) Certificate of Insurance

a) Proof of General Liability, Professional Liability (as applicable)

b) Proof of Workers Compensation (as applicable);

c) American Eldercare Inc. should be listed as notify agent or Certificate Holder on

the certificate of insurance;

6) Licensure Inspection/AHCA survey as applicable;

7) W-9 indicating Taxpayer Identification Number.

Site Visits

Site visits evaluate appearance, accessibility, recordkeeping practices, and safety procedures.

These visits are performed at assisted living facilities and adult family care homes to evaluate a

home-like environment. Other site visits will be performed as deemed necessary.

RE-CREDENTIALING

Re-credentialing is the process of re-verifying the credentialing information of all providers

previously credentialed. The purpose of this process is to identify any changes in the provider’s

licensure, sanctions, certification, competence or health status, which may affect the ability to

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perform services the provider under contract. Each provider will be re-credentialed at a

minimum every three years. A notification will be sent to the provider for re-verification of

credentialing. All network providers must submit updated documents as it expire. Failure to

provide updated documentation may delay payment. A provider’s agreement may be terminated

if at any time it is determined the credentialing requirements are no longer being met or the

provider fails to complete the re-credentialing process.

.

PROVIDER MONITORING

American Eldercare, Inc. will routinely monitor providers to ensure any changes in licensure

status, sanctions or other adverse actions are reviewed by the Credentialing Committee.

Providers whose license was suspended or revoked are subject to termination.

RIGHT TO REVIEW AND CORRECT INFORMATION

All providers participating with American Eldercare, Inc. have the right to review information

obtained to evaluate their credentialing and/or re-credentialing application. This includes

information obtained from any outside primary source such as the National Practitioner Data

Bank, insurance carriers and other sources as appropriate. This does not allow a provider to

review references, recommendations or other information that is peer review protected.

RIGHT TO APPEAL ADVERSE CREDENTIALING DETERMINATIONS

Providers who are declined participation have the right to request a reconsideration of the

decision in writing within fourteen (14) days of formal notice of denial. All written requests

should include additional supporting documentation in favor of the applicant’s reconsideration

for participation in American Eldercare, Inc. Reconsiderations will be reviewed by the

Credentialing Committee at the next regularly scheduled meeting, but in no case later than sixty

(60) days from the receipt of the additional documentation. The applicant will be sent a written

response to the request within two (2) weeks of the final decision.

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NATIONAL PROVIDER IDENTIFIER (NPI)

The National Provider Identifier is a unique government-issued standard 10 digit identifier

mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This

identifier will replace all current health care providers’ numbers that are used in HIPAA standard

transactions. American Eldercare, Inc. will require participating provider as appropriate to

comply with this mandate. Please refer to the CMS website at

www.cms.hhs.gov/apps/npi/01_overview.asp for additional information and assistance with

applying for a NPI.

PROVIDER ORIENTATION AND EDUCATION

Your Provider Relations Specialist is available to provide an initial orientation within thirty (30)

calendar days of completing the credentialing process to review American Eldercare, Inc.’s

policies and procedures. These personalized meetings are scheduled at your convenience,

including any staff you would like to attend. Additional educational trainings can be scheduled

anytime by contacting your local Provider Relations Specialist.

NOTICE OBLIGATION

The network provider is responsible for giving the appropriate notices as outlined in this provider

handbook and under the terms of your contract with American Eldercare, Inc.

Changes in your Office

Notify your Provider Relations Specialist immediately of any changes in your office such as:

Physical address change

Tax identification/billing address change (W-9 required)

Demographic changes (e.g. telephone, fax, email, and administrative staff changes)

Name and Ownership change (60-day notice)

This will ensure your information is properly listed in the Provider Directory and all payments

made are properly reported to the Internal Revenue Service. A Provider Notice of Change form

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is located in Section 7, Forms of this handbook. Failure to comply with this section could lead to

a delay in payments.

Providing Covered Services

In the event there are changes in your office that will affect your company’s ability to provide

services to American Eldercare Inc.’s members, please notify the Provider Relations Department

immediately.

PROVIDER HANDBOOK

The Provider Handbook provides comprehensive information to assist you with information on

American Eldercare Inc’s. process and procedures. You will be notified of updates to this

handbook via bulletins and notices posted on our website. You can access the Provider

Handbook by visiting our website at www.americaneldercare.com and click on the Provider tab.

If you would like to receive a hard copy of this handbook mailed to your office at no charge,

please contact your Provider Relations Specialist. While visiting our website, you will find other

educational materials and resources to assist you with the program.

PROVIDER DIRECTORY

The Provider Directory is a monthly listing of all participating network providers with American

Eldercare, Inc. A copy of this document is available upon request from the Provider Relations

Department. You can also access the Provider Directory on our website at

www.americaneldercare.com

PARTICIPATING AGREEMENT STANDARDS

By signing an American Eldercare Inc. contract, providers are required to comply with all

applicable federal and state laws and licensing requirements. Providers are required to maintain

back up procedures for absent employees to ensure services are not interrupted and sufficient

staff. American Eldercare, Inc. may exercise its options to terminate a participating provider

from the provider network with the appropriate notice.



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ACCESSIBILITY AND AVAILABILITY

American Eldercare, Inc. has adopted service standards regarding the availability of participating

provider services. All providers are expected to maintain these standards as outlined in your

contract.

Accessibility Monitoring

Compliance with the availability and accessibility standards are monitored on a regular basis

through random sampling, review of member concerns, and member satisfaction surveys to

ensure members have reasonable access to providers and services.

PROVIDER SATISFACTION SURVEY American Eldercare, Inc. conducts an annual provider satisfaction survey which includes

questions to evaluate provider satisfaction with our services such as claims, communications,

utilization management, and provider services. Providers are randomly selected and are kept

anonymous. We encourage you to participate and respond to the survey as the results are

analyzed and used to form provider related quality improvement initiatives.

PROVIDER MEDICAL/CASE RECORD REVIEW

1. AEC staff will conduct reviews at all the following provider and facility provider sites

every other year:

a. Adult Family Care Homes

b. Assisted Living Facilities

c. Adult Foster Care Facility Sites

d. Home Health Agencies

2. For service providers with multiple office locations, staff will conduct reviews at each

practice site at least every three (3) years.

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3. Specific review tools applicable to each type of provider will be shared with the provider

and utilized to conduct the reviews after establishment of inter-rater reliability.

4. A minimum of five (5) records or 5% of the member census (whichever is greater) will

be reviewed per site. The cases will be selected randomly and be evaluated for

compliance in meeting nationally recognized accrediting body medical/case record

review standards.

5. Medical Record confidentiality will be maintained by use of patient ID numbers and

records will not be removed from the provider or facility provider location for security

reasons.

6. After each provider review is complete, the data will be submitted to the Corporate Q/I

department where it will be analyzed, aggregated and compared.

7. On a quarterly basis, the Q/I department will report the results of the record reviews to

the COO, Senior Management team and the Provider Relations department with

recommendations for further action if indicated.

TERMINATION OF PROVIDER CONTRACT

Each provider has the right to terminate his/her contract with American Eldercare, Inc. You

must submit your request in writing and provide a sixty (60) days notice. All termination

requests should be mailed to the following:

American Eldercare, Inc.

14565 Sims Road

Delray Beach, FL 33484

Attention: Provider Relations Department

OUT-OF-NETWORK / NON-CONTRACTED SERVICES

An out-of-network provider is any provider that is not directly contracted with American

Eldercare, Inc. American Eldercare, Inc. is not responsible for payment of any services provided

by an out-of-network provider without written prior authorization.

Non-contracted services are any services not defined on Schedule B of your contract. American

Eldercare, Inc. is not responsible for payment of non-contracted services. If you or your staff

identifies a service that a member may require that is not listed in your contract please contact

the members Care Manager to evaluate the members needs and determine if the service can be

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authorized by AEC. If the Care Manager determines the services should be authorized by AEC,

they will contact your local Provider Relations Specialist to discuss adding an addendum to your

contract.

American Eldercare, Inc. is not responsible for payments of any services ordered by a member

from a participating provider, without written pre-authorization from an American Eldercare,

Inc. Care Manager. Please contact the member‘s assigned Care Manager to request authorization

prior to providing services.

COMMUNITY OUTREACH/MARKETING

All providers must comply with the following standards regarding outreach marketing activities

in your office or at sponsored events:

1. Providers may display health plan specific materials in their own offices.

2. Providers cannot orally or in writing compare benefits or provider networks among

Plans, other than to confirm whether they participate in a Plan’s network.

3. Providers may announce a new affiliation with health plan and include it on a list

given to their patients with plans with which they contract.

4. Health care providers may co-sponsor events, such as health fairs and advertise in

indirect ways; such as television, radio, posters, fliers, and print advertisement.

5. Providers may not furnish lists of their Medicaid patients to another Plan with which

they contract, or any other entity, nor can providers furnish other health plans’

membership lists to the health plan, nor can providers take applications in their office.

6. Providers may distribute information about non health plan-specific health care

services and the provision of health, welfare and social services by the State of

Florida or local communities, as long as any inquiries from prospective members are

referred to member services or the Agency enrollment broker.

The use of American Eldercare, Inc. name will require written notice prior to use in television,

radio, posters, fliers, and print advertisement.

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PROVIDER RESPONSIBILITIES

The Provider should adhere to the following:

Provide all services in a culturally competent manner accommodate those with

disabilities and not discriminate against anyone based on his/her health status.

Treat all members with respect and dignity, provide them with appropriate privacy and

treat member disclosures and records confidentially, giving members the opportunity to

approve or refuse their release.

Maintain a safe environment and comply with City, State, and Federal regulations

concerning safety and public hygiene.

Ensure accessibility and availability of services to members.

Participate and cooperate in quality management, utilization review, and continuing

education with other similar programs to provide quality care in a responsible and cost

effective manner.

Participate in and cooperate with grievance procedures when notified of any member

complaints or grievances.

Comply with all applicable federal and state laws regarding the confidentiality of member

records.

Maintain communication with the appropriate agencies to provide quality member care.

Ensure enrollment by state Medicaid program for compliance with data submission.

American Eldercare, Inc. providers should refer to their contract for complete information

regarding providers’ responsibilities and obligations. Failure to comply with could result in

contract termination.

PROVIDER COMPLAINT SYSTEM

Providers have the right to register a provider complaint involving a dispute with American

Eldercare, Inc. policies, procedures or any aspect of the Plan’s administrative function. Every

effort will be made to resolve the issue informally. In the event the issue cannot be resolved

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informally, a complaint may be filed telephonically at (561) 860-8660 or toll free at (888) 970-

6663. You can also submit the compliant in writing by mailing to the Provider Relations

Department at:


14565 Sims Road


ATTN: Provider Relations – Provider Complaint

Provider Complaint Review

Upon receipt of a complaint, American Eldercare, Inc. will thoroughly investigate each

complaint using applicable statutory, regulatory, contractual and provider contract provisions,

collecting all pertinent facts from all parties and applying the Plan’s written policies and

procedures. A provider complaint may be filed using the following steps:

Verbal Complaint

A Provider Relations Specialist will receive the initial call and attempt to resolve any

issues or concerns at the time of the call. If the Provider requests to file a complaint, the

Provider Relations Specialist will log the details in the Provider Relations Module

immediately.

All complaints will be acknowledged in writing within three (3) business days from the

initial call. The provider will be notified verbally or in writing that the complaint has

been received and the expected date of resolution. The Provider will be notified in

writing regarding the results of the inquiry within fifteen (15) calendar days from receipt

of the initial complaint.

Written Complaint

The Provider will complete the Provider Complaint Form (see Section 7 – Forms) and fax

or mail the form. The complaint will be logged in the Provider Relations Module on the

same day of receipt.

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All complaints will be acknowledged in writing within three (3) business days from the

initial call. The provider will be notified verbally or in writing that the complaint has

been received and the expected date of resolution. The Provider will be notified in

writing regarding the results of the inquiry within fifteen (15) calendar days from receipt

of the initial complaint.

The Provider has forty-five (45) calendar days to file a written complaint for issues that are

claims related.

CULTURAL COMPETENCY

American Eldercare, Inc. expects our members will receive understandable and respectful care

that is provided in a manner compatible with their cultural health beliefs and practices and

preferred language. AEC encourages participatory and collaborative partnerships with

communities to be utilized in a variety of formal and informal mechanisms to facilitate

community and member involvement in designing and implementing culturally and linguistically

appropriate services. AEC staff will coordinate language assistance to our members who have a

limited English proficiency.

Providers may access the full AEC Cultural Competency Plan on our website or you can request

a hard copy of the Cultural Competency Plan at no charge by contacting the Provider Relations

Customer Service Line at (888) 998-7735.

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_________________________________________________

6

CLAIMS/BILLING _________________________________________________

American Eldercare, Inc. maintains and complies with HIPAA standards for the submission and

adjudication of claims. This section will provide you information regarding the submission and

payment process.

CLAIM SUBMISSION

A clean claim is a claim that can be processed without obtaining additional information from the

provider of the service or from a third party. It does not include a claim from a provider who is

under investigation for fraud or abuse, or a claim under review for medical necessity, pursuant to

42 CFR 447.45.

All claims should be submitted to American Eldercare Inc. within six (6) months from the date

of service. If AEC is the secondary payer, claims should be submitted within ninety (90)

calendar days after the final determination of the primary payer. The Managed Care Plan shall

not deny claims submitted by a non-participating provider solely based on the period between the

date of service and the date of clean claim submission, unless that period exceeds three-hundred

sixty-five (365) days. Claims that are incomplete, illegible or missing any identifiable

information may delay payment or could result in a denial of payment.

ELECTRONIC CLAIMS

American Eldercare, Inc. is capable of receiving electronic claims submission. The acceptable

formats include X12 5010 837 institutional, professional, and dental formats. American

Eldercare, Inc. also allows for direct data entry (DDE) through our company portal. To be set up

with electronic claim submission, please contact the eBilling department below:

Email Address: [email protected]

Phone Number: 561.665.4415

mailto:[email protected]

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PAPER CLAIMS

Please submit claims on one of the following claim form types:

Form CMS 1500

(Adult Day Care, Assisted Living Facility, Home Health, Home Delivered Meals, Consumable

Medical Supplies, Environmental Adaptation)

Form UB04 (Skilled Nursing Facility, Hospitals)

Please make sure that the description of services listed on your claim form matches the Service

Requests authorization document forwarded by the Care Manager.

To avoid a delay in processing your claims, please include the following information on claims:

Member’s name (Last, First)

Member’s date of birth

Member’s address

Provider information (Provider’s name, address and tax identification)

Provider signature

Description of service and code provided

Service / Procedure/ HCPCS code

Date(s) of service

Units of Service (amount of service hours provided or quantity of items provided)

Total number of units billed and total dollar amount billed

Amount of hours services provided or quantity of items provided

AEC Member ID or Medicaid ID, if available

Plan Identification

Mail all paper claims to the following address:


Attn: Claims Department

14565 Sims Road


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If you have any questions or require training regarding submitting claims, please contact your

local Provider Relations Specialist.

ENCOUNTER DATA

Transportation and capitated providers will need to submit encounter data claims and encounter

data is also required for any service American Elder Care directly pays (not claims processed

through the Medicaid fiscal agent). American Eldercare is authorized to take the necessary steps

to ensure that providers are recognized by the state Medicaid program, including its enrolment

broker contractor(s) as a participating provider of the Plan and your submission of encounter data

is accepted by the Florida MMIS and/or the state’s encounter data warehouse.

Protocols for submitting encounter data:

1) All Transportation providers and any provider that has services directly paid by American

Eldercare, Inc. are required to submit encounter data to AEC to reflect the authorized

services provided to our members.


Eldercare, Inc. who bill AEC via paper claims (HCFA1500, UB92), or electronically

need to ensure all the required fields are completed in their submission in order for AEC

to extract the encounter data information.


Eldercare, Inc. who submit claims that are not submitted in one of the above formats for

payment, are required to submit the appropriate 837i, 837p or 837d for their line of

business for encounter data purposes. (applies to PBM only)

4) Please review required fields for claims submissions in the AEC companion guide.

5) If you have any questions on what is required of your agency/company please contact

your Provider Relations Specialist or call the Provider Customer Service number at (888)

998-7735.

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ASSISTED LIVING FACILITY PROVIDERS

Assisted Living Facilities are encouraged to participate in our automatic payment process. Any

provider participating in this process will be paid for existing members by the 10th

of the current

month without submitting a claim. Any existing members that were enrolled by the previous

month and have an open care plan in the current month will be paid.

Please note that if a member leaves your facility for any reason that would require American

Eldercare, Inc. to recoup money, your facility will see a debit adjustment on the following

month’s payment and/or will receive an invoice for payment.

Also note that a claim is required prior to payment for the first month that a member enters the

facility or the first month of enrollment.

All providers that do not participate in the automatic payment process must submit claims after

the end of the current month. These claims will be paid within thirty (30) days of receipt.

Room and Board Rate

Members are responsible to pay their room and board rate (as indicated in the provider’s

contract) plus patient responsibility (as determined by the Department of Children and Families).

Prorated fees will be determined for members who do not reside in the community for a full

month. AEC will be responsible for payment using the following formula:

Contracted ALF Rate minus Room & Board Rate minus Patient Responsibility = AEC Payment

These amounts will be reflected on each member‘s individual Service Requests sent by the Care

Managers. The patient responsibility is subject to change based on the Notice of Case Action

(NOCA) received by DCF or estimated member responsibility until the appropriate NOCA is

completed.

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The provider is required to notify AEC within twenty-four (24) hours of a member

hospitalization or leave of absence from the community.

Bed-Hold Payments

AEC Plan will pay up to a fourteen (14) day bed-hold when our member is not in your

community except in the following occurrences:

1. Member loses Medicaid Eligibility

2. Member expires

3. Member is placed in a Skilled Nursing Facility for Long-Term Care

4. The community fails to notify AEC Plan within twenty-four (24) hours of a

hospitalization or leave of absence from the community.

5. Prorated fees will be determined for members who reside in a facility for less than a

full month.

Bed-holds OR stop payment begins the day the member leaves the facility. The facility

will not be paid for the day of discharge unless the member is eligible for a bed hold. If the

facility fails to notify AEC of a member leaving the community within (24) hours of discharge,

this will result in a forfeit of payment for the bed-hold. The facility may not charge the member

for AEC’s portion of their bill during this time.

SKILLED NURSING FACILITY PROVIDERS (SNF)

Custodial Care

All members requiring custodial care must be assessed and determination must be made by

American Eldercare, Inc. that the member can no longer live in a less restrictive setting.

Members who receive approval for placement in a contracted Skilled Nursing Facility for

custodial care are required to pay the facility a patient responsibility based on their income,

which is determined by the Department of Children and Families. Prior authorization is

required.

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Bed-Holds for Custodial Care Members

AEC follows the same guidelines as Medicaid. If your facility is requesting payment for a bed-

hold on an AEC member, please submit a copy of your census along with your claim for the

time-frame in question.

Custodial Care Payments

The facility will be reimbursed by AEC at the current Medicaid Per-Diem Rate established with

the State minus any patient responsibility determined by the Department and Children and

Families.

HOME HEALTH PROVIDERS

Home Health providers must attach, to all claims submitted, a form signed by the member

verifying what services were provided including date/time of service and direct care staff who

provided the service. If billing electronically, this information must be made available to

American Eldercare, Inc. “on demand.” It is recommended that services are not billed in a date

range format. Each service should be listed separately by date of service. Ranges should only be

used if billing consecutive days with the same units and amount for each day billed. If you bill

in a date range format, appropriate documentation such as time sheet or nurses notes must be

accompanied to ensure prompt and accurate payment for services rendered.

CLAIM ACKNOWLEDGEMENT

Paper Claims:

Within fifteen (15) business days after receipt of all paper claims submitted to AEC for non-

capitated services, AEC will provide the provider or designee with acknowledgement of receipt

of the claim. AEC will provide access to a web portal and allow the provider or designee to

check the status of all submitted claims. AEC will also provide provider with a provider services

telephone number to call and check the status of their submitted claims.

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Within fifteen (15) business days after receipt of all paper claims submitted to AEC for non-

capitated services, AEC will authorize and forward the claim to the Medicaid fiscal agent or

notify the provider or designee that the claim is contested or denied. The notification to the

provider of a contested or denied claim will include an itemized list of additional information or

documents needed to process the claim.

Electronic Claims:

Within twenty-four (24) hours after the beginning of the next business day after receipt of all

electronically submitted claims for non-capitated services, AEC will provide electronic

acknowledgment of receipt of the claim to the provider or the electronic source submitting the

claim.

Within ten (10) business days after receipt of all electronically submitted claims for non-

capitated services, AEC will authorize and forward the claim to the Medicaid fiscal agent or

notify the provider or designee that the claim is contested or denied. The notification to the

provider or designee of a contested or denied claim will include an itemized list of additional

information or documents needed to process the claim.

PAYMENTS

Payments for transportation services will be made by the Medicaid fiscal agent. Reimbursement

will be made for correct, authorized, clean claims according to the Florida Medicaid fee

schedules for reimbursement for covered services provided to enrollees. The Agency or its fiscal

agent will also reimburse non-participating providers on a FFS basis for Provider Service

Network (PSN) authorized services.

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All claims payments made by American Eldercare, Inc. to a provider will be accompanied by an

explanation of payment. The explanation of payment will contain an itemized accounting of the

individual claims included in the payment including the enrollee's name, the date of service, the

procedure code, service units, the amount of reimbursement and the identification of American

Eldercare, Inc. The date of the check will also be included on the explanation of payment. The

date of the check will be considered the date of payment.

BALANCE BILLING

Payments made by or processed through American Eldercare, Inc. are in accordance with the

terms of your agreement. Providers may not balance bill members of American Eldercare, Inc.

for any covered, authorized service.

CLAIM INQUIRY

Providers are encouraged to contact the Claims Customer Service Department to inquire about

the status of a claim, status of reconsideration, or explanation of a denial. A Customer Services

Representative can be reached from 8:00am-7:00pm Monday-Friday at (561) 499-9656

Extension 1987. If you are calling during peak or after-hours, please leave a message and a

representative will return your call within one (1) business day.

CLAIM DENIALS

All denials include an explanation of denial and/or explanation of adjustment when applicable.

Denial codes are subject to change and/ additional codes utilized, please contact the claims

Customer Service Department for any questions or concerns regarding a denial or partial denial

of payment. A copy of denial codes performed by American Eldercare, Inc. and descriptions of

denial codes can be found in Section 8 of this handbook. American Eldercare will not deny

Medicare crossover claims solely based on the period between the date of service and the date of

clean claim submission, unless that period exceeds three (3) years. A copy of denial codes

performed by the Medicaid Fiscal Agent may be found in the applicable Medicaid General

Provider Reimbursement Handbook. If you disagree with a denial received, you have the right to

reconsideration.

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CLAIMS RECONSIDERATION OF PAYMENT

A provider has the right to request reconsideration if they do not believe the determination on a

claim is correct. Parties not involved in the initial determination will review the reconsideration.

All reconsiderations, should be submitted in writing within sixty (60) days of the denial notice

and include any additional information needed.

Claims Reconsideration of payment should be mailed to the following address:


Attn: Claims Department (Reconsiderations)

14565 Sims Road


FORMAL GRIEVANCES/APPEALS

A provider may file a grievance or an appeal for denial of payment on behalf of an American

Eldercare, Inc. member. Grievances are filed as complaints about services provided or about the

appeal process itself. These may be filed by the member, member representative, or a provider

on behalf of a member. The formal grievance must be submitted orally or in writing either by

letter or by completed grievance/appeal form to the Grievance/Appeal Coordinator within 365

days from the date of the event that caused your concern or grievance.

Formal Appeals are filed in response to American Eldercare, Inc.’s decision to:

Deny payment;

Deny or limit the authorization of a requested service; Or…

Reduce, suspend, or terminate a previously authorized service.

Formal appeals must be made within thirty (30) days of written notice of American Eldercare

Inc.’s decision to reduce, deny services, or payments. Appeals may be made orally or in writing.

Oral appeals must be followed up with a signed, written appeal.

American Eldercare, Inc. considers the member or member’s representative as parties to an

appeal or a grievance. We encourage them to explore the informal complaint process first in an

53 | P a g e


attempt to work out the issue directly with the Care Manager and/or their supervisor. If the

concern or complaint was not resolved satisfactorily with the Care Manager, a grievance or

appeal may be filed with American Eldercare, Inc.

Grievance/Appeal Coordinator located address:

American Eldercare, Inc. Plan

Attn: Grievance/Appeal Coordinator

14565 Sims Road

Delray Beach, Florida 33484

Toll Free (866) 352-1192

If the member or representative wish to write a letter to the Grievance/Appeal Coordinator

addressing the concern, the letter should include the member’s name, address, member ID

number, date, and signature. The Care Manager is available to assist with this process if needed.

If the member or representative prefers to call the Grievance/Appeal Coordinator, office hours

are 9:00 a.m. – 5:00 p.m. Eastern Standard Time, Monday – Friday. Telephone messages are

forwarded twenty-four (24) hours a day. The Grievance/Appeal Coordinator will return the

phone call, provide the member or representative with a complete explanation of our procedures,

and mail a grievance/appeal form within three (3) working days. The immediate member or

representative will need to complete this grievance form and mail it back to the

Grievance/Appeal Coordinator at the address provided above.

Upon oral receipt of the grievance or completed grievance form, the Grievance/Appeal

Coordinator will have the concern investigated and a written decision will be mailed to the

member within ninety (90) days.

Upon oral receipt of the appeal (followed by a signed written copy), the Grievance/Appeal

Coordinator will have the concern investigated and a written decision will be mailed to the

member within forty-five (45) days. The person(s) who originally made the decision to reduce

or deny services will not be a decision maker in the determination process.

To request a complete description of American Eldercare, Inc. Plan’s Grievance /Appeals

Procedure, you may call our corporate office toll free at (866) 352-1192.

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Expedited Appeals

If the request is deemed urgent by American Eldercare, Inc., an expedited review will take place.

This process can only be utilized if an AEC member is being denied access to services. The

person(s) who originally made the decision to reduce or deny services will not be a decision

maker in the determination process.

Within seventy-two (72) hours (or sooner, if warranted) of the receipt of the request, a decision

will be determined and the member or representative will be notified by phone. The final

determination will be sent to the member in writing.

American Eldercare, Inc. will continue the member’s benefits if:

The appeal is filed timely, meaning on or before the later of the following:

Within ten (10) days of the date on the notice of action (or fifteen (15) days of the notice

is sent via U.S. mail).

The intended effective date of Plan’s proposed action.

The appeal involves the termination, suspension, or reduction of a previously authorized

course of treatment.

The services were ordered by an authorized provider.

The authorization period has not expired.

The member requests extension of benefits.

At the conclusion of the appeal process, in the event of a ruling in favor of American Eldercare,

Inc. the member may have to pay for those services rendered during the appeal process.

Beneficiary Assistance Program

In the event you have received a notice of resolution after your American Eldercare, Inc. internal

appeal, you may request review of that decision within one (1) year by the Beneficiary

Assistance Program. You may not request the review if you have already requested a Medicaid

Fair Hearing. The program is operated by AHCA and may be contacted at:

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Agency for Health Care Administration

Beneficiary Assistance Program Building 1, MS

#26

2727 Mahan Drive

Tallahassee, Florida 32308

(850) 412-4502

(888) 419-3456 (toll-free)

Unresolved Grievances/Appeals – Medicaid Fair Hearing

To appeal the decision made by American Eldercare, Inc. Plan’s Grievance/Appeal Committee in

response to their grievance/appeal, the member or their representative may request a Medicaid

Fair Hearing within ninety (90) days from the notice of resolution. An enrollee who chooses to

seek a Medicaid Fair Hearing without pursuing the Managed Care Plan’s process must do so

within ninety (90) days of receipt of the Managed Care Plan’s notice of action.

The member or member representative must contact:

Office of Public Assistance Appeals Hearing

1317 Winewood Boulevard

Building 5, Room 203

Tallahassee, FL 32399-0700

(850) 488-1429

In the event a member or provider wishes to contact the Agency for Health Care Administration,

you can call the State-Wide Consumer Center at (888) 419-3456.

IMPORTANT INFORMATION REGARDING GRIEVANCES/APPEALS

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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_________________________________________________

8

APPENDIX

AEC Locations

CARES Offices

Denial Codes

Remittance Advice

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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

Escambia, Okaloosa, Walton,

Santa Rosa

(850) 916-6700 1

Bay, Calhoun, Gulf, Jackson,

Washington, Holmes

(850) 747-5840 2A

Leon, Franklin, Gadsden,

Madison, Taylor, Wakulla,

Liberty, Jefferson

(850) 414-9803 2B

Alachua, Bradford, Columbia,

Dixie, Gilchrist, Hamilton,

Lafayette, Levy, Putnam,

Suwannee, Union

(352) 955-6560 3A

Citrus, Hernando, Lake, Marion,

Sumter

(352-620-3457 3B

Baker, Clay, Duval Nassau &

St. Johns

(904) 391-3920 4A

Flagler & Volusia (386) 238-4946 4B

Pinellas (Central and Southern) (727) 588-6882 5A

Pasco & Pinellas (North) (727) 376-7152 5B

Hillsborough & Manatee (813) 631-5300 6A

Polk, Hardee, Highlands (863) 680-5584 6B

Orange, Osceola & Seminole (407) 228-7700 7A

Brevard (321) 690-6445 7B

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Charlotte, Collier, DeSoto,

Glades, Hendry, Lee, &

Sarasota

(239) 278-7210

8

Palm Beach (561) 840-3150 9A

Indian River, Martin,

Okeechobee & St. Lucie

(772) 460-3692 9B

Broward (954) 597-2240 10

Miami-Dade (North & Central) (786) 336-1400 11A

Miami-Dade (South), Monroe (305) 671-7200 11B

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CLAIMS DENIAL CODES

Code DESCRIPTION A01 Service type not specified.

A02 Duplicate claim already in process.

A03 Duplicate claim: payment already issued.

A04 Resubmit complete claim and E.O.B.: Claim and/or E.O.B.

unreadable, altered, or do not match

A05 Rate billed is inconsistent with contracted rate.

A06 Patient allowance changed.

A07 Claim lacks the anesthesia configuration in minutes needed for

processing.

A08 Payment for this claim must be adjudicated by primary insurance

prior to submission.

A09 Payment issued to another provider due to change of ownership

notification.

A10 Incorrect Federal Tax Identification.

A11 Lack of correct W-9 on file for provider.

A12 Incomplete provider file.

B01 Service not covered.

B02 Co-pay not covered.

B03 Coverage not in effect at the time the service was provided.

B04 Claim denied as patient cannot be identified as our insured.

B05 Exceeds Medicare/Medicaid maximum allowable or Plan maximum

allowable.

B06 Service not covered due to determination by primary insurance.

B07 Not covered under Medicaid Waiver, covered under Medicaid Fee-

for-Service.

B08 Denied: Effective July 1, 2007 (Senate Bill 2800), exceeds Medicaid

Maximum allowable.

C01 Service not authorized.

C02 Service not authorized for this date(s).

C03 Exceeds authorized number of days or hours per week.

C04 Service authorized for once a month.

C05 Service authorized for once every two months.

C06 Service authorized for once every three months.

D01 Services billed prior to date of service.

D02 Service not rendered on this date(s).

D03 Time limit for filing has expired.

D04 Date of death precedes date of service.

E01 Mail order prescription refills and supplies are not reimbursed.

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E02 Reimbursement is made for copayments on medications that are

covered by your Medicare Part D provider.

E03 You are not enrolled with a Medicare Part D provider for which co-

pays are reimbursed.

E04 Receipts not submitted within 30 days of purchase.

E05 Receipts submitted do not match claim total.

E06 Resubmit claim including AEC Reimbursement Form, original

receipt(s) and pharmacy label.

Z01 Provider improperly refuses access to members.

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REMITTANCE ADVICE

Date: 1/3/2011

Check #: 130888

Remittance: 7047Q00009

Page: 1 of 2

Vendor ID: 9999999

Sample Provider

123 Fake St.

Somewhere, FL 12345


14565 Sims Road


(561) 499-9656, ext 1987

Invoice # Receive Date Type of Bill Member's Name (ID) DOS-From DOS-Thru

Service Code Modifier Amount Billed Amount Paid Amount Denied Reason Code

135191W 11/3/2010 1500 Jane Doe (9999) 3/18/2010

11721 GW $50.00 $0.00 $50.00 042

135191W 11/3/2010 1500 John Doe (9998) 3/18/2010

99335 25, GW $90.00 $73.18 $16.82 042

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Right of Reconsideration - If you believe the determination on this claim is incorrect, you have the right to request a reconsideration. The reconsideration will be reviewed by parties not involved in the initial determination. In order to

request a reconsideration, you must submit your request in writing within 60 days of this notice. Once you have completed the request, you should mail it to the Claims Department.

CONFIDENTIALITY NOTICE: This Remittance Advice is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under

applicable law. Any unauthorized review, use, disclosure, or distribution is prohibited. If you have received this document in error, please do not distribute it. Please notify the sender by the United States Postal Service at the address

shown above. Date: 1/3/2011

Check #: 130888

Remittance: 7047Q00009

Page: 2 of 2

Vendor ID: 9999999

Sample Provider

123 Fake St.

Somewhere, FL 12345


14565 Sims Road


(561) 499-9656, ext 1987

Reason Codes

042: Charges exceed Medicaid maximum allowable amount.

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Corporate office:


14565 Sims Road


Approved 5/17/13

08/01/13

PROVIDER HANDBOOK - Humana

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Transcript of PROVIDER HANDBOOK - Humana