Cenpatico Provider Manual Kansas KanCare Plan www.cenpatico.com

Transcription

Cenpatico Provider Manual
www.cenpatico.com
Kansas KanCare Plan
v. 4/2014
www.cenpatico.com
Call us toll free: 866-896-7293
Table of Contents
Welcome To Cenpatico ..................................................................................................................................... 3
About Cenpatico ....................................................................................................... ........................................3
MISSION ........................................................................................................................ ........................................3
VISION ........................................................................................................................... ........................................3
GOAL ............................................................................................................................ ........................................3
History and Structure of Cenpatico ........................................................................ ........................................4
Managed Care Philosophy ...................................................................................... ........................................4
Quick Reference Guide ...................................................................................................................................... 6
The Cenpatico Provider Network ...................................................................................................................... 7
Network Provider Selection Process .................................................................................... ........................................8
The Network Provider’s Office ............................................................................................ ........................................9
Network Provider Concerns ..................................................................................... ......................................10
Verifying Member Enro ment .................................................................................. ......................................10
Eligibility Screening For SUD Service ....................................................................... ......................................10
Network Provider Standards of Practice ............................................................... ......................................10
Credentialing ...................................................................................................................................................... 12
Re-Credentialing Requirements and Schedule.................................................... ......................................16
Council for Affordable Quality HealthCare (CAQH) ........................................... ......................................17
Right to Review and Correct Information .............................................................. ......................................17
Cenpatico Credentialing Policies and Procedures ............................................. ......................................17
Cenpatico Credentialing Committee & Approval of Applications.................. ......................................18
Status Change Notification ...................................................................................... ......................................18
Network Provider Demographic/Information Updates ...................................... ......................................18
Network Provider Request to Terminate................................................................. ......................................19
Cenpatico’s Right to Terminate .............................................................................. ......................................19
Cultural Competency ....................................................................................................................................... 20
Understanding the Need for Culturally Competent Services .................................................................... 21
Facts about Health Disparities ................................................................................. ......................................22
Access and Coordination of Care ................................................................................................................. 23
Quality Improvement......................................................................................................................................... 28
Monitoring Clinical Quality........................................................................................ ......................................28
Network Provider Participation in the QI Process ................................................. ......................................29
Confidentiality and Release of Member Information .......................................... ......................................29
Communication with the Primary Care Physician................................................ ......................................29
Consent for Disclosure ............................................................................................... ......................................30
Critical Incident Reporting ........................................................................................ ......................................31
Abuse and Neglect Reporting ................................................................................ ......................................31
Member Concerns about Network Providers ....................................................... ......................................31
Records and Documentation .................................................................................. ......................................32
Cenpatico Compliance Program ................................................................................................................... 33
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Waste, Abuse and Fraud (WAF) System................................................................. ......................................33
Federal and States Laws Governing the Release of Information...................... ......................................34
Treatment Record Guidelines .................................................................................. ......................................35
Preventative Behavioral Health Programs ............................................................ ......................................36
Complaints, Grievances and Appeals Member Grievances and Provider Complaints .............................. 37
Member Rights and Responsibilities ............................................................................................................... 40
Customer Service ............................................................................................................................................... 42
The Cenpatico Customer Service Department ................................................... ......................................42
Verifying Member Enrollment ................................................................................... ......................................42
Sunflower Health Plan Member ID Cards ...................................................................................................... 43
Interpretation/Translation Services .......................................................................... ......................................44
NurseWise ..................................................................................................................... ......................................44
Specialty Therapy and Rehabilitative Services (STRS) ................................................................................. 65
Utilization Management.................................................................................................................................... 66
The Utilization Management Program ................................................................... ......................................66
Member Eligibility................................................................................................................................................ 67
Outpatient Treatment Request (OTR)/ Requesting Additional Sessions .......... ......................................67
Disease Management ....................................................................................................................................... 74
Claims ................................................................................................................................................................... 74
Cenpatico Billing Policies .................................................................................................................................. 78
Resolving Claims Issues ...................................................................................................................................... 80
Claim Reconsideration .............................................................................................. ......................................80
UB-04 Claim Form Instructions .......................................................................................................................... 91
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Welcome to Cenpatico
Welcome to the Cenpatico Behavioral Health, LLC (Cenpatico) Provider network. We look
forward to a long and mutually rewarding partnership as we work together in the delivery of
behavioral health and substance use disorder services to Sunflower Health Plan Members in
Kansas.
The Cenpatico Provider Manual is designed to answer your questions about our behavioral
health program and to explain how we manage the delivery of behavioral health and substance
use disorder services to the Members we serve.
This Manual provides a description of Cenpatico and Sunflower Health Plan’s treatment
philosophy and the policies and procedures administered in support of this philosophy. It also
describes the requirements established by Cenpatico and its clients and the performance
standards for Network Providers in the delivery of services to Members. Cenpatico will provide
bulletins as needed to incorporate any needed changes to this Manual online at
www.cenpatico.com. Additionally, we offer a wealth of resources for our Kansas Providers on
our website including this Manual and Provider forms.
We look forward to working with you and providing you with support and assistance. We hope
you find your relationship with Cenpatico a satisfying and rewarding one.
About Cenpatico
MISSION
Creating innovative solutions that drive quality health care for vulnerable populations.
VISION
To establish a national presence as an industry leading health solutions organization for
children, Medicaid, and specialty therapies.
GOAL
To improve outcomes and deliver savings through innovation.
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History and Structure of Cenpatico
Cenpatico is a wholly-owned subsidiary of CenCorp Health Solutions, Inc. (CenCorp). CenCorp is
a wholly-owned subsidiary of Centene Corporation (Centene). Sunflower Health Plan
(http://www.sunflowerstatehealth.com), a Centene health plan, delegates the provision of
covered behavioral health and substance use disorder services to Cenpatico.
Cenpatico has provided comprehensive managed behavioral healthcare services for more than
eleven (11) years, and currently operates in Arizona, California, Florida, Georgia, Illinois, Indiana,
Kansas, Massachusetts, Mississippi, Missouri, New Hampshire, Ohio, South Carolina, Texas,
Washington and Wisconsin. As an integral part of our core philosophy we believe quality
behavioral healthcare is best delivered locally. Cenpatico is a clinically driven organization that
is committed to building collaborative partnerships with Providers.
Cenpatico defines "behavioral health” as inclusive of acute and chronic psychiatric and
substance use disorders as referenced in the most recent International Statistical Classification of
Diseases and Related Health Problems (ICD-9). Cenpatico provides quality, cost effective
behavioral healthcare services for Members of Sunflower Health Plan through a comprehensive
Provider Network of qualified behavioral health Providers.
An experienced Provider Network is essential to provide consistent, superior services to our
Members. To achieve our goals, Cenpatico builds strong, long-term relationships with our
Provider Network. This Provider Manual was designed to assist you with the administrative and
clinical activities required for participation in our system. Cenpatico prefers and encourages a
partner relationship with our Provider Network. Member care is a collaborative effort that draws
on the expertise and professionalism of all involved.
Managed Care Philosophy
Cenpatico is strongly committed to the philosophy of providing appropriate treatment at the
least restrictive level of care that meets the Member’s needs.
We believe careful case-by-case consideration and evaluation of each Member’s treatment
needs are required for optimal medical necessity determinations. We believe Members need to
be fully involved in their care and participate in decisions regarding treatment needs.
Outpatient treatment is generally considered the first choice treatment approach, with the
exception of when medical necessity is met for a higher level of care. Many factors support
this position:
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Outpatient treatment allows the Member to maximize existing social strengths and
supports, while receiving treatment in the setting least disruptive to normal
everyday life.
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Outpatient treatment maximizes the potential of influences that may contribute to
treatment motivation, including family, social, and occupational networks.
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Allowing a Member to continue in occupational, scholastic, and/or social activities
increases the potential for confidentiality of treatment and its privacy. Friends and
associates need not know of the Member’s treatment unless the Member chooses to tell
them.
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Outpatient treatment encourages the Member to work on current individual, family, and
job-related issues while treatment is ongoing. Problems can be examined as they occur
and immediate feedback can be provided. Successes can strengthen the member’s
confidence so that incremental changes can occur in treatment.
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The use of appropriate outpatient treatment helps the Member preserve available
benefits for potential future use. Benefits are maximized for the Member’s healthcare
needs.
At Cenpatico, we take privacy and confidentiality seriously. We have processes and policies
and procedures in place to comply with applicable Federal and State regulatory requirements.
We appreciate your partnership with Cenpatico in maintaining the highest quality and most
appropriate level of care for Sunflower Health Plan Members.
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Quick Reference Guide
Cenpatico Contact Information:
Cenpatico
866-896-7293
www.cenpatico.com
Health Plan Contact Information:
Sunflower Health Plan 877-644-4623
http://www.sunflowerstatehealth.com/
Eligibility Verification:
Phone: 866-896-7293
Web: www.cenpatico.com (you must have a Provider log-on to verify eligibility on this site)
ERA/EFT Enrollment:
Please call PaySpan Health at
877-331-7154 or visit www.payspanhealth.com
Cenpatico Customer Service:
Please call Customer Service at
866-896-7293 to assist with eligibility determinations and Provider referrals
Claims Guidelines:
Claims must be submitted within 180 days of the date of service.
Claim Submission:
Claims can be submitted on the Cenpatico website at www.Cenpatico.com
EDI Vendors:
Emdeon (866-369-8805)
Availity (800-282-4548)
Gateway EDI (800-969-3666)
Cenpatico’s Payor ID Number is 68068
For further information regarding electronic submission, contact the Cenpatico EDI Department
at 800-225-2573, ext. 25525 or email at ediba@centene.com
Paper Claims Address:
KanCare
Office of Fiscal Agent PO
Box 3571
Topeka, KS 66601-3571
Claims Customer Service:
866-896-7293
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Claim Appeals Address:
Cenpatico Appeals
PO Box 6000
Farmington, MO 63640-3809
Benefits/ Covered Services:
Please refer to your fee schedule and the Kansas Covered Services & Authorization Guidelines
document within the Provider Manual.
Prior Authorization:
Call Medical Management at 866-896-7293
Download and complete an Outpatient Treatment Request (OTR) online at www.cenpatico.com
After-Hours Admissions:
Please notify Cenpatico of after-hours or weekend admissions on the next business day.
Medical Necessity and Administrative Appeals:
Cenpatico
Attn: Appeals Coordinator
12515-8 Research Blvd.
Suite 400
Austin, TX 78759
or Fax to: 866-714-7991
Provider Relations:
Cenpatico
Telephone: 866-944-7588
Fax: 866-263-6521
Email: ProviderRelationsKS@cenpatico.com
The Cenpatico Provider Network
Cenpatico Service Area
Cenpatico reimburses claims for the covered behavioral health and substance use disorder
benefits for Sunflower Health Plan Members throughout the State of Kansas.
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Network Provider Selection Process
The Cenpatico Network includes, but is not limited to the following provider types:
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Community Mental Health Centers (CMHCs)
Licensed Psychiatrists
Licensed Psychologists
Licensed Psychiatric Advance Practice Nurses
Licensed Clinical Professional Counselors
Licensed Specialist Clinical Social Workers
Licensed Clinical Marriage and Family Therapists
Licensed Clinical Psychotherapists
Licensed Master’s Level Psychologists*
Licensed Mental Health Professionals*
Physician Assistants
Kansas Licensed Substance Abuse Counselors
Autism Waiver Providers
State Licensed Behavioral Health or Substance Use Disorder Programs
Federally Qualified Health Centers
Rural Health Clinics
Psychiatric Residential Treatment Facilities
Psychiatric Hospitals
General Hospitals offering psychiatric and/or substance use disorder services
*Supervision is required in accordance with the Kansas Behavioral Sciences Regulatory Board or
its equivalent
We work with Providers that consistently meet or exceed Cenpatico clinical quality standards
and are comfortable practicing within the managed care arena, including those Providers that
demonstrate and support Sunflower Health Plan’s integrated care approach to Member care.
Network Providers should support a brief, solution-focused approach to treatment and should
be engaged in a collaborative approach to the treatment of Sunflower Health Plan’s
Members.
Cenpatico consistently monitors network adequacy. Network Providers are selected based on the
following standards;
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Clinical expertise;
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Geographic location considering distance, travel time, means of
transportation, and access for Members with physical disabilities;
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Potential for high volume referrals;
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Specialties and accessibility standards, including meeting the Americans with
Disabilities Act (ADA) requirements, to best meet our Members’ needs;
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Ability to accept new Members;
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Ability to act as the Member’s medical home; and
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Experience in utilizing evidence-based practices in working with seriously mentally ill
(SMI) and developmentally delayed/disabled (DD) populations. This includes but is not
limited to Assertive Community Treatment (ACT), Trauma Informed Cognitive Behavioral
Therapy, IMR, etc.
Cenpatico contracts its Provider Network to support and meet the linguistic, cultural and other
unique needs of every individual Member, including the capacity to communicate with
Members in languages other than English and communicate with those Members who are deaf
or hearing impaired.
The Network Provider’s Office
Cenpatico reserves the right to conduct Network Provider site visit audits. Site visits may be
conducted as a result of Member dissatisfaction or as part of a chart audit. The site visit auditor
reviews the quality of the location where care is provided. The review assesses the accessibility
and adequacy of the treatment and waiting areas.
General Network Provider Office Standards
Cenpatico requires the following:
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Office must be professional and secular;
Offices and facilities must be easily accessible with accommodations for Members with
disabilities as required and covered by titles II and III of the Americans with Disabilities
Act (ADA) of 1990;
Provide designated accessible parking spaces;
Appropriate door sizes for clear openings with easy opening mechanism;
Provide adequate space in clinic rooms to turn a wheelchair;
Signs identifying office must be visible;
Display all marketing and health education materials provided by contracted
health plans in an equal fashion;
Office must be clean, and free of clutter with unobstructed passageways;
Office must have a separate waiting area with adequate seating;
Clean restrooms must be available;
Office environment must be physically safe;
Network Providers must have a professional and fully-confidential telephone line
and twenty-four (24) hour availability;
Member records and other confidential information must be locked up and out of
sight during the work day; and
Medication prescription pads and sample medications must be locked up and
inaccessible to Members.
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Network Provider Concerns
Network Providers who have concerns about Cenpatico should contact the Network/Provider
Relations department at 866-944-7588 or Quality Improvement department at 866-896-7293 to
register these complaints. All concerns are investigated, and resolution is provided to the
Network Provider on a timely basis.
Verifying Member Enro ment
Network Providers are responsible for verifying eligibility every time a Member schedules an
appointment, and when they arrive for services.
Network Providers should use either of the following options to verify Member enrollment:
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Access the Kansas Medical Assistance program (KMAP) website at
https://www.kmap-state-ks.us/Public/Provider.asp or call 800-933-6593
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Contact Cenpatico Customer Service at 866-896-7293
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Verify online at www.cenpatico.com
Until the actual date of enrollment with Sunflower Health Plan, Cenpatico is not financially
responsible for services the prospective Member receives. In addition, Cenpatico is not
financially responsible for services Members receive after their coverage has been terminated.
Eligibility Screening For SUD Service
The Provider shall use the AAPS funding source as the payor of last resort. To this end, Providers
shall conduct eligibility screenings for all Members that present to their location to determine
the appropriate funding stream for the Member. Eligibility screenings shall include verification
of possible funding through the Kansas Medical Assistance Program (KMAP) prior to admission
and a minimum of monthly while the Member is in treatment. When appropriate, this shall
include the facilitation of Medicaid enrollment activities, up to and including referral of a
Member to an SRS Office and/or a Medicaid enrollment entity.
As part of the eligibility determination Providers shall obtain proper documentation on each
Member for whom an eligibility screening is conducted and place it in the Member file.
Documentation must confirm that the Member’s income and residency meet the most
recent AAPS (Addiction and Prevention Services) eligibility guidelines. This section of the
contract is meant to address deviations from the standard course of provider practice.
Network Provider Standards of Practice
Network Providers are required to:
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Refer Members with known or suspected physical health problems or disorders to
the Member’s PCP for examination and treatment;
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Send initial and bi-annually (or more frequently if clinically indicated) summary reports
of a Member's behavioral health status to the PCP, with the Member's or the Member's
legal guardian's consent;
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Only provide physical health services if such services are within the scope of the
Network Provider’s clinical licensure;
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Network Providers must ensure Members that are discharging from inpatient care are
scheduled for outpatient follow-up and/or continuing treatment prior to the Member’s
discharge. Cenpatico strives to meet the National Committee for Quality Assurance
(NCQA) Health Care Effectiveness Data and Information Set (HEDIS) guidelines for
follow up and/or continuing treatment after an inpatient visit. To that end, Cenpatico
requires Network Providers offering inpatient psychiatric services to ensure that
outpatient treatment is scheduled within seven (7) days following the date of
discharge;
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Attempt to outreach to Members who have missed appointments within
twenty-four (24) hours to reschedule;
Comply with State of Kansas appointment access standards;
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Ensure all Members receive effective, understandable and respectful treatment
provided in a manner compatible with their cultural health beliefs and practices
and preferred language (which can be accomplished by engaging professional
interpreter services at the onset of treatment);
Comply with all State and Federal requirements governing emergency, screening
and post-stabilization services;
Provide Member’s clinical information to other providers treating the Member, as
necessary, to ensure proper coordination and treatment of Members who express
suicidal or homicidal ideation or intent, consistent with State law;
Exchange information with Member’s PCP and/ or other behavioral health providers upon
Member consent;
Comply with all Cenpatico non-discrimination and cultural competency requirements;
Accommodate the needs of Members with disabilities;
Ensure behavioral health treatment plans are developed with the Member and
Member’s family involvement;
Submit all documentation in a timely fashion;
Comply with Cenpatico’s Case Management and UM processes;
Cooperate with and participate in all Cenpatico’s Quality Improvement (QI) activities
as requested;
Use appropriate Medical Necessity and Evidence-Based Best Practices when
formulating treatment plans and requesting ongoing care;
Assist Members in identifying and utilizing community support groups and resources;
Maintain confidentiality of records and treatment and obtain appropriate written
consents from Members when communicating with others regarding Member treatment;
Notify Cenpatico of any critical incidents;
Notify Cenpatico of any changes in licensure, any malpractice allegations and any
actions by your licensing board (including, but not limited to, probation, reprimand,
suspension or revocation of license);
Notify Cenpatico of any changes in malpractice insurance coverage;
Notify Cenpatico of any change of address/location within thirty (30) days of the change;
Complete credentialing and re-credentialing materials as requested by Cenpatico;
and,
Maintain an office that meets all standards of professional practice.
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Credentialing
Credentialing Requirements
The Cenpatico Provider Network includes but is not limited to: Community Mental Health Centers
(CMHCs), Licensed Psychiatrists, Licensed Psychologists, Licensed Psychiatric Advance Practice
Nurses, Licensed Clinical Professional Counselors, Licensed Master Social Workers, Licensed
Clinical Social Workers, Licensed Clinical Workers, Licensed Clinical Marriage and Family
Therapists, Licensed Clinical Psychotherapists, Licensed Master’s Level Psychologists, Licensed
Mental Health Professionals, Physician Assistants, Kansas Licensed Substance Abuse Counselors,
Autism Waiver Providers, State Licensed Behavioral Health or Substance Use Disorder Programs,
Federally Qualified Health Centers, Rural Health Clinics, Psychiatric Residential Treatment
Facilities and Psychiatric Hospitals.
Cenpatico Network Providers must adhere to the following requirements:
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Adhere to Cenpatico’s Clinical Practice Guidelines and Medical Necessity Criteria.
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Consistently meet our credentialing standards and Cenpatico guidelines on Primary
Care Physician (PCP) notification.
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Failure to adhere to guidelines and standards at any time can lead to termination from
our network.
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Notify Cenpatico immediately upon receipt of revocation or suspension of the Network
Provider’s State License by the State of Kansas.
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All solo and group Network Providers must be licensed to practice independently in
compliance with Cenpatico’s credentialing standards and guidelines.
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Licensed Master’s Level Psychologists and Licensed Mental Health Professionals must
meet the supervision requirements established by the Kansas Behavioral Sciences
Review Board.
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License/Certification must be current, active and in good standing.
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MDs and DOs must have hospital privileges and/or a coverage plan.
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Hospital privileges must be current and active.
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All Network Providers’ graduate degrees must be from an accredited institution.
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All Network Providers are subject to the completion of primary source verification of the
Network Provider through our Credentialing Department located in Austin, Texas.
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The Network Provider agrees to complete and provide appropriate documentation
for this primary source verification in a timely manner.
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The Network Provider further agrees to provide all documentation in a timely
manner required for credentialing and/or re-credentialing.
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The Network Provider agrees to maintain adequate professional liability insurance as
set forth in the Provider Agreement with Cenpatico.
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All credentialing applications are subject to consideration and review by the
Cenpatico Credentialing Committee which meets monthly.
Providers
Providers must submit at a minimum the following information when applying for participation with
Cenpatico:
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Properly completed, signed and dated Kansas Provider Application;
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Signed attestation of the correctness and completeness of the application, history of
loss of license and/or clinical privileges, disciplinary actions, and/or felony convictions;
lack of current illegal substance registration and/or alcohol abuse; mental and physical
competence, and ability to perform the essential functions of the position, with or
without accommodation;
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Copy of W-9 form;
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Statement regarding history of loss or limitation or privileges or disciplinary activity;
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A statement from each Network Provider applicant regarding the following: any physical
or behavioral health problems that may affect the Provider’s ability to provide
healthcare; any history or chemical dependency/substance use disorder problems; any
history of loss of license and/or felony conviction;
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A copy of current and unrestricted license to practice in the State of Kansas;
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Malpractice face sheet: Network Providers must carry $1/$3M in coverage, or such other
amounts as required by State law;
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Proof of the highest level of education—a copy of certificate or letter certifying formal postgraduate training;
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For MDs and DOs, Cenpatico will require proof of the Network Provider’s medical school
graduation, completion of residency and other postgraduate training. Evidence of board
certification shall suffice in lieu of proof of medical school graduation, residency and other
postgraduate training, as applicable and a copy of the Educational Commission for
Foreign Medical Graduates (ECFMG) certificate, if applicable;
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MDs and DOs are also asked to supply Drug Enforcement Administration (DEA)
registration, and Board Certification(s);
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For MDs and DOs, good standing of privileges at the hospital designated as the
primary admitting facility;
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Providers licensed as LMFT, LPC, LMSW, LMLP and LAC must provider a Supervising
Physician Statement indicating that they are following the supervision standards as
set forth by The Kansas Behavioral Sciences Regulatory Board;
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Valid Drug Enforcement Administration (DEA) certificates (where applicable);
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A completed Kansas Disclosure of Ownership & Control Interest Statement;
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Current curriculum vitae, which includes at least five (5) years of work history with
explanation in writing for a six (6) month, or more, gap;
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Completed Cenpatico Provider Specialty Profile; and,
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Any sanction or exclusion imposed on the Provider by Medicare or Medicaid.
Facilities
Facilities must submit at a minimum the following information when applying for participation with
Cenpatico:
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A complete signed and dated Cenpatico facility application;
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List of current professional Behavioral Health/Substance Use Disorder staff privileged to
admit and/or treat patients in your facility, (include license type, address, telephone
numbers and social security numbers) that you would recommend that we contact for
membership on Cenpatico’s Individual Provider Panel;
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Copy of The Joint Commission/CARF/COA/AOA accreditation letter with dates of
accreditation in addition to a list of all practice locations covered under the applicable
accreditation body;
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Copy of the State or local license(s) and/or certificate(s) under which your facility
operates;
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Copy of Clinical Laboratory Improvement Amendments (CLIA), if applicable;
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Copy of current Drug Enforcement Administration (DEA) registration certificate, if
applicable;
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Copy of professional and general liability insurance policy with the limits of coverage per
occurrence and in aggregate, name of liability carrier, and insurance effective date and
expiration date (Month/Day/Year);
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Listing of satellite locations and services offered at each location (include copies of
accreditation, license, insurance, CLIA, and DEA certificate, if applicable);
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Kansas Disclosure of Ownership and Controlling Interest Statement; and,
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Facilities contracted under a Cenpatico Facility Agreement that list a rendering NPI in box
24-J of the claim form that is different than the Facility’s billing NPI (box 33-A), must submit
a facility roster of clinicians rendering covered services with their credentialing materials.
This information should be submitted in the Cenpatico Facility Roster Format, which can
be obtained from the Provider Relations Specialists. Any changes or updates to this list
must be submitted to providerrelationsks@cenpatico.com
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Non-Accredited Facilities must include the following in addition to the items above:
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Copy of State or local Fire/Health Certificate
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Copy of Quality Assurance Plan
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Description of Aftercare or Follow-up Program
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Organizational Charts including staff to patient ratio
It is the Provider’s responsibility to notify Cenpatico of any of the following within ten (10) days of
the occurrence:
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Lawsuits related to professional role;
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Licensing board actions ;
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Changes to NPI and TIN;
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Malpractice claims or arbitration;
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Disciplinary actions before a State agency and Medicaid/Medicare sanctions;
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Cancellation or material modification of professional liability insurance;
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Member complaints against Practitioner;
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Changes in physical address and fiscal/billing address; and
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Any situation that would impact a Provider’s ability to carry out the provisions of their
Behavioral Health Provider Agreement (“Agreement”) with Cenpatico, including the
inability to meet Member accessibility standards, changes or revocation with DEA
certifications, hospital staff changes or NPDB or Medicare sanctions.
Please notify Cenpatico immediately of any updates to your Tax Identification Number,
service site address, phone/fax number and ability to accept new referrals in a timely
manner so that our systems are current and accurately reflect your practice. In addition,
we ask that you please respond to any questionnaires or surveys submitted regarding
your referral demographics, as may be requested from time to time.
Credentialing of Health Delivery Organizations
(CMHCs and other Behavioral Health Providers/Facilities)
Prior to contracting with Health Delivery Organizations (HDO), Cenpatico verifies that the
following organizations have been approved by a recognized accrediting body or meet
Cenpatico standards for participation, and are in good standing with State and Federal
agencies:
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Hospital or Facility
Community Mental Health Center (CMHC)
Psychiatric Residential Treatment Facility (PRTF)
Kansas Facilities/Health Delivery Organizations are required to utilized the Cenpatico
facility application and provide information on accreditation, license, regulatory status
and certificate of insurance. In addition, the facility must complete the Kansas Disclosure
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of Ownership & Control Interest Statement.
Cenpatico recognizes the following accrediting bodies:*
 CARF - Commission on Accreditation of Rehabilitation Facilities
 COA - Council on Accreditation
 JCAHO - Joint Commission on Accreditation of Healthcare Organizations.



NCQA - National Committee for Quality Assurance
URAC - Utilization Review Accreditation Commission
Council on Accreditation of Services for Family & Children
*This list may not be inclusive of all accrediting organizations
For those organizations that are not accredited, an on-site evaluation will be scheduled to
review the scope of services available at the facility, physical plant safety, the Quality
Improvement program, and Credentialing and Re-credentialing Policies and Procedures.
Cenpatico may substitute a Center for Medicare and Medicaid Services (CMS) or State review
in lieu of the site visit. Cenpatico would require the report from the organization to verify that
the review has been performed and the report meets its standards. Also acceptable is a letter
from CMS or the applicable State agency which shows that the facility was reviewed and
indicates that it passed inspection.
Re-Credentialing Requirements and Schedule
Kansas Network Providers will be re-credentialed every 36 months from the initial credentialing
date in accordance with the current NCQA guidelines, unless otherwise dictated by State law.
Providers will receive notice that they are due to be re-credentialed well in advance of their
expiration date and, as such, are expected to submit their updated information in a timely
fashion. Failure to do so could result in suspension and/or termination from the Network.
Quality indicators including but not limited to, complaints, appointment availability, critical
incidents, and compliance with discharge appointment reporting will be taken into consideration
during the re-credentialing process.
Cenpatico will verify the following information submitted for Credentialing and/or
Re-Credentialing:

License through appropriate licensing agency;

Board certification, or residency training, or medical education;

National Practitioner Data Bank (NPDB) and HIPDB claims;

Five years of work history; and

Sanction or exclusion activity including Medicare/Medicaid services (OIG-Office of
Inspector General and EPLS – Excluded Parties Listing).
Once the application is completed, the Cenpatico Credentialing Committee will render a final
decision on acceptance following its next regularly scheduled meeting.
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Council for Affordable Quality HealthCare (CAQH)
Cenpatico subscribes to the CAQH to streamline the Credentialing/Re-credentialing process. If
you are interested in having Cenpatico retrieve your credentialing/re-credentialing application
from CAQH, or if you are not enrolled with CAQH, Cenpatico can assist you with contacting
CAQH for enrollment.
Once a CAQH Provider ID number is assigned, you can visit the CAQH website or call the help
desk, to complete the credentialing application. There is no cost for Providers to participate with
CAQH and submit their credentialing applications.
CAQH Website: www.caqh.org
Phone Number: 1-888-559-1717
Right to Review and Correct Information
All Network Providers participating with Cenpatico have the right to review information obtained
by Cenpatico to evaluate their credentialing and/or re-credentialing application. This includes
information obtained from any outside primary source such as malpractice insurance carriers and
the licensing/certification agencies. This does not allow a provider to review references, personal
recommendations or other information that is peer review protected.
Should a Provider believe any of the information used in the credentialing/re-credentialing
process is erroneous, or should any information gathered as part of the primary source
verification process differ from that submitted, Providers have the right to correct any erroneous
information submitted by another party. To request release of such information, a written request
must be submitted to the Credentialing Department. Upon receipt of this information, the
Provider will have fourteen (14) days to provide a written explanation detailing the error or the
difference in information to Cenpatico. The Cenpatico Credentialing Committee will then
include this information as part of the credentialing/re-credentialing process.
Cenpatico Credentialing Policies and Procedures
Cenpatico maintains written credentialing and re-credentialing policies and
procedures that include the following:

Formal delegation and approvals of the credentialing process;

A designated credentialing committee;

Identification of Network Providers who fall under its scope of authority;

A process which provides for the verification of the credentialing and recredentialing criteria;

Approval of new Network Providers and imposition of sanctions, termination,
suspension and restrictions on existing Network Providers;

Identification of quality deficiencies which result in Sunflower Health Plan or
Cenpatico’s restriction, suspension, termination or sanctioning of a Network
Provider; and

A process to implement an appeal procedure for Network Providers whom
Cenpatico has terminated.
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Cenpatico Credentialing Committee & Approval of Applications
The Cenpatico 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. The Cenpatico
Credentialing Committee meets monthly, at a minimum ten (10) times per year.
Cenpatico has delegated the approval of credentialing applications that meet all the
credentialing standards/criteria to the Medical Director who reviews files on a weekly and or
bi-weekly basis.
Status Change Notification
Network Providers must notify Cenpatico immediately of any change in licensure and/or
certifications that are required under federal, State, or local laws for the provision of
covered behavioral health services to Members, or if there is a change in Network
Provider’s hospital privileges. All changes in a Network Provider’s status will be
considered in the re-credentialing process.
Network Provider Demographic/Information Updates
Network Providers should advise Cenpatico with as much advance notice as possible for
demographic/ information updates. Network Provider information such as address, phone
and office hours are used in our Provider Directory, and having the most current
information accurately reflects our Kansas Provider Network. Please use the Cenpatico
Provider Information Update Form located on our website at www.cenpatico.com.
Completed Provider Information Update Forms should be sent to Cenpatico using one of the
following methods;
Fax: 866-263-6521
Email: providerrelationsks@cenpatico.com
Mail: Cenpatico|Att: Provider Data Management
12515-8 Research Blvd., Suite 400 |Austin, Texas 78759
Provider Rosters
Cenpatico requires a listing of rendering employed professional Behavioral Health/Substance Use
Disorder staff privileged to admit and/or treat patients. This list must include the Provider’s license
type, address, telephone numbers, NPI number, and social security numbers. Cenpatico must be
notified of any updates to this listing to ensure data accuracy. In addition, please note that the
information provided may be accessed by Cenpatico for network accessibility and Member
referral services.
Providers should submit the updates to this listing to providerrelationsks@cenpatico.com
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Network Provider Request to Terminate
Network Providers requesting to terminate from the network must adhere to the Termination
provisions set forth in their Provider Agreement with Cenpatico. This notice can be sent to the
following:
Fax: 866-263-6521
Mail: Cenpatico|Attn: Provider Data Management
12515-8 Research Blvd., Suite 400 |Austin, Texas 78759
The notification will be acknowledged by Cenpatico in writing and the Network Provider will be
advised on procedures for transitioning Members if indicated.
Cenpatico fully recognizes that a change in a Network Provider’s participation status is
difficult for Members. Cenpatico will work closely with the terminating Network Provider
to address the Member’s needs and ensure a smooth transition as necessary. A Network
Provider who terminates the contract with Cenpatico must notify all Cenpatico Members
who are currently in care at the time and who have been in care with that Network
Provider during the previous six (6) months. Treatment with these Members must be
completed or transferred to another Cenpatico Network Provider within three (3) months
of the notice of termination, unless otherwise mandated by State law. The Network
Provider needs to work with the Cenpatico Care Management Department to determine
which Members might be transferred, and, which Members meet Continuity of Care
Guidelines to remain in treatment.
Cenpatico’s Right to Terminate
Please refer to your Provider Agreement with Cenpatico for a full disclosure of causes for
termination. As stated in your Provider Agreement, Cenpatico shall have the right to
terminate the Provider Agreement by giving written notice to the Network Provider upon the
occurrence of any of the following events:

Termination of Cenpatico’s obligation to provide or arrange behavioral health/
substance use disorder treatment services for Members of Sunflower Health Plan, or
any other health plan or agency in the State of Kansas with which Cenpatico is the
behavioral health vendor;

Restriction, qualification, suspension or revocation of Network Providers’ license or
certification;

Network Provider's loss of liability insurance required under the Provider Agreement
with Cenpatico;

Network Provider’s exclusion from participation in the Medicare or Medicaid
program;

Network Provider’s insolvency or bankruptcy or Network Provider’s assignment
for the benefit of creditors;

Network Provider’s conviction, guilty plea, or plea of nolo contendere to any felony or
crime involving moral turpitude;

Network Provider’s ability to provide services has become impaired, as determined
by Cenpatico, at its sole discretion;
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
Network Provider’s submission of false or misleading billing information;

Network Provider’s failure or inability to meet and maintain full
credentialing status with Cenpatico;


Network Provider’s breach of any term or obligations of the Provider Agreement;

Network Provider’s breach of Cenpatico Policies and Procedures.
Any occurrence of serious misconduct which brings Cenpatico to the reasonable
interpretation that a Network Provider may be delivering clinically inappropriate
care; or
Network Provider Appeal of Suspension or Termination of Contract Privileges
If a Network Provider has been suspended or terminated by Cenpatico, contact the Cenpatico
Provider Data Management department at 866-896-7293 to request further information or
discuss how to appeal the decision.
For a formal appeal of the suspension or termination of contract privileges, the Network Provider
should send a written reconsideration request to Cenpatico to the attention of the Quality
Improvement Department:
Cenpatico
Attn: Quality Improvement Department
Suite 400
Austin, TX 78759
Please note that the written request should describe the reason(s) for requesting reconsideration
and include any supporting documents. This reconsideration request must be postmarked
within thirty (30) days from the receipt of the suspension or termination letter to comply with the
appeal process.
Cenpatico will use the Provider Dispute Policy to govern its actions. Details of the Provider
Dispute Policy will be provided to the Network Provider with the notification of suspension/
termination. To request a copy of Cenpatico’s Provider Dispute Policy, please contact the
Quality Improvement Department at 866-896-7293.
Each Network Provider will be provided with a copy of their fully-executed Provider Agreement
with Cenpatico. The Provider Agreement will indicate the Network Provider’s Effective Date in
the network and the Initial Term and Renewal Term provisions in Cenpatico’s Provider Network.
The Provider Agreement will also indicate the cancellation/ termination policies. There is no
“right to appeal” when either party chooses not to renew the Provider Agreement.
Cultural Competency
Cultural Competency within the Cenpatico Network is defined as described below:
“Davis (1997) defines cultural competence as the integration and transformation of knowledge,
information, and data about individuals and groups of people into specific clinical standards,
skills, service approaches, techniques, and marketing programs that match the individual's
culture and increase the quality and appropriateness of behavioral health care and outcomes.
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Cultural competence occurs in behavioral health service delivery when cultural issues are
acknowledged and addressed at all levels of an organization administration, service delivery,
and clinician.”
Cenpatico is committed to the development, strengthening, and sustaining of healthy Provider/
Member relationships. Members are entitled to dignified, appropriate and quality care. When
healthcare services are delivered without regard for cultural differences, Members are at risk for
sub-optimal care. Members may be unable or unwilling to communicate their healthcare needs
in an insensitive environment, reducing effectiveness of the entire healthcare process.
The Cenpatico vision for culturally competent care is:
 Care is given with the understanding of, and respect for, the Member’s health-related
beliefs and cultural values.
 Cenpatico staff respect health related beliefs, interpersonal communication styles and
attitude of the Members, families and communities they serve.
 Each functional unit within the organization applies a trained, tailored approach to
culturally sensitive care in all Member communications and interactions.
 All Cenpatico Network Providers support and implement culturally sensitive care models to
Sunflower Health Plan Members.
The Cenpatico goal for culturally sensitive care is:
 To support the creation of a culturally sensitive behavioral health system of care that
embraces and supports individual differences to achieve the best possible outcomes for
individuals receiving services.
Network Providers must ensure the following:
 Members understand that they have access to medical interpreters, signers, and TTY
services to facilitate communication without cost to them.
 Care is provided with consideration of the Members’ race/ ethnicity and language and its
impact/ influence on the Members’ health or illness.
 Office staff that routinely come in contact with Members have access to and participate
in cultural competency training and development.
 The office staff responsible for data collection makes reasonable attempts to collect race
and language specific Member information.
 Treatment plans are developed and clinical guidelines are followed with consideration of
the Member’s race, country of origin, native language, social class, religion, mental or
physical abilities, heritage, acculturation, age, gender, sexual orientation and other
characteristics that may result in a different perspective or decision-making process.
 Office sites have posted and printed materials in English, Spanish, or other prevailing
languages within the region.
Understanding the Need for Culturally Competent Services:
Research indicates that a person has better health outcomes when they experience culturally
appropriate interactions with Providers. The path to developing cultural competency begins with
self-awareness and ends with the realization and acceptance that the goal of cultural
competency is an ongoing process. Network Providers should note that the experience of a
Member begins at the front door.
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Failure to use culturally competent and linguistically competent practices could result in the
following:
 Member’s feelings of being insulted or treated rudely;
 Member’s reluctance and fear of making future contact with the Network Provider’s
office;
 Member’s confusion and misunderstanding;
 Non-compliance by the Member;
 Member’s feelings of being uncared for, looked down upon and devalued;
 Parents’ resistance to seek help for their children;
 Unfilled prescriptions;
 Missed appointments;
 Network Provider’s misdiagnosis due to lack of information sharing;
 Wasted time for the Member and Network Provider; and/or
 Increased grievances or complaints.
The road to developing a culturally competent practice begins with the recognition and
acceptance of the value of meeting the needs of your patients. Cenpatico is committed to
helping you reach this goal.
Take the following into consideration when you provide services to Members:
 What are your own cultural values and identity?
 How do/can cultural differences impact your relationship with your patients?
 How much do you know about your patient’s culture and language?
 Does your understanding of culture take into consideration values, communication styles,
spirituality, language ability, literacy, and family definitions?
Facts about Health Disparities

Government-funded insurance consumers face many barriers to receiving timely care.

Households headed by Hispanics are more likely to report difficulty in obtaining
care.

Consumers are more likely to experience long wait times to see healthcare
providers.

African American Medicaid consumers experience longer waits in emergency
departments and are more likely to leave without being seen.

Consumers are less likely to receive timely prenatal care, more likely to have low
birth weight babies and have higher infant and maternal mortality.

Consumers that are children are less likely to receive childhood
immunizations.

Patient race, ethnicity, and socioeconomic status are important indicators of the
effectiveness of healthcare.

Health disparities come at a personal and societal price.
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Access and Coordination of Care
Provider Access Standards
Sunflower Health Plan Members may access behavioral health and substance use disorder
services through several mechanisms. Members do not need a referral from their Primary Care
Physician (PCP) to access covered behavioral health and covered substance use disorder
services. Caregivers or medical consenters may self-refer Members for behavioral health and
substance use disorder services.
Cenpatico adheres to National Committee for Quality Assurance (NCQA) and State of Kansas
accessibility standards for Member appointments. Network Providers must make every effort to
assist Cenpatico in providing appointments within the following timeframes:
Type of Care
Office Wait Time
Appointment Availability
Not to exceed 45 minutes from the
scheduled appointment time
Emergent Care
An assessment and/or treatment
shall be provided within 3 hours for
outpatientbehavioral health
services, and within 1 hour from
referral for an emergent
concurrent utilization review
screen.
Urgent Care
within 48 hours from referral for
outpatient behavioral health
services, and within 24 hours from
referral for an urgent concurrent
utilization review screen.
Routine Outpatient
Assessment and/or treatment
within 9 working days from referral;
10 working days from previous
treatment
Inpatient Psychiatric
An assessment and/or
treatment within 5 working days
from referral
Discharge from Inpatient
Aftercare appointments within
seven (7) calendar days after
hospital discharge
Emergency Care
Provided immediately at the
nearest facility available.
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Post Stabilization
within 1 hour from referral for poststabilization services (both
inpatient and outpatient) in an
emergency room.
Substance Use Disorder Services
Emergent services, for Members
who are unsafe or whose
condition is deteriorating, must be
available immediately or
Member referred to a hospital.
For urgent (non-emergent) care,
An assessment must be given
within 24 hours of initial contact
and services delivered within 24
hours from assessment. Pregnant
women shall be placed in the
urgent category. In routine
situations, Members shall receive
an assessment within 14 days of
initial contact and treatment
within 14 days from the
assessment, without resultant
deterioration in the Member’s
functioning or condition.
IV Drug User
Members who have used IV drugs
within the last 6 months and who
are not considered Emergent or
Urgent, shall receive treatment
within 14 days of initial contact.
Urgent Pregnant Substance Users
IVDU Pregnant & Pregnant
women are considered Urgent.
This population must be assessed
in 24 and offered treatment
within 24 hours of the assessment.
If the program lacks capacity,
SAPT interim services should be
offered.
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“Screening" defined as the process performed by a
participating community behavioral health center, to
determine whether a person, under either voluntary
or involuntary procedures, can be evaluated or
treated, or can be both evaluated and treated, in the
community or should be referred to the appropriate
inpatient psychiatric hospital or state psychiatric
hospital for such treatment or evaluation or for both
treatment and evaluation.

Urgent-already admitted to a
hospital with a psych unit (24
hrs)

Post stabilization-at a
hospital without a psych unit
(1 hr)

Emergency-anywhere
else (3 hours)

PRTF initial (7 days)

PRTF extension (7 days)

PRTF emergency
exception- (48 hours)
If you cannot offer an appointment within these timeframes, please refer the Member to
Cenpatico at 866-896-7293 so that the Member may be rescheduled with an alternative
provider who can meet the access standards and Member’s needs.
Network Providers shall ensure that services provided are available on a basis of twenty-four (24)
hours a day, seven (7) days a week, 365 days a year as the nature of the Member’s behavioral
health condition dictates. These services include all covered behavioral health services provided
by Cenpatico’s Network Providers that are congruent with the Member’s treatment plan and
presenting behavioral health issues. Network Providers will offer hours of operation that are no less
than the hours of operation offered to commercial insurance members and shall ensure Members
with disabilities are afforded access to care by ensuring physical and communication barriers do
not inhibit Members from accessing services.
Network Providers should call the Cenpatico Provider Relations department at 866-944-7588 if
they are unable to meet these access standards on a regular basis. Please note that the
repeated inability to accept new Members or meet the access standards can result in
suspension and/or termination from the network. All changes in a Network Provider’s status will
be considered in the re- credentialing process.
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Cenpatico Access Standards
Cenpatico ensures network adequacy and promotes quality of care and service to Members in
part, by establishing, implementing, and evaluating standards for Member geographic access
to Network Provider and facility services. Cenpatico will strive to meet the following accessibility
requirements:

For all behavioral health services, including substance use disorder services,
members will travel no more than 30 miles for urban areas, 45 miles for densely settled
rural areas and 60 miles for rural and frontier areas.
Exceptions to these standards will be in the western and southwestern regions of Kansas, where
health care providers and services are scarce overall, and travel distance standards would
default to the closest available providers or community standards.
After Hours Access Standards
Network Providers must have coverage for their practice twenty-four (24) hours per day, seven (7)
days per week, 365 days a year. This type of coverage may include a published after hours
telephone number, pager, or answering service. Members must be given instructions for what to
do and whom they can call after hours; voicemail alone after hours is not acceptable.
No Show Appointments
A “no show” is defined as a failure to appear for a scheduled appointment without notification
to the Provider with at least twenty-four (24) hours advance notice. No show appointments
must be recorded in the Member record.
A “no show” appointment may never be applied against a Member’s benefit maximum.
Sunflower State Health Plan Members may not be charged a fee for a “no show” appointment.
Network Providers may contact Cenpatico via email or telephone to inform Cenpatico about
Members who do not keep appointments. Cenpatico Care Coordinators will contact the
Member to reinforce the importance of attending appointments; assess and help address
barriers such as transportation; and assist in rescheduling if needed.
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No New Referral Periods
Network Providers are required to notify Cenpatico when they are not available for
appointments. Network Providers may place themselves in a “no referral” hold status for a set
period of time without jeopardizing their overall network status. “No referral” is set up for
Network for the following reasons:
 Vacation

Full practice

Personal leave

Other personal reasons
Network Providers must call or write to the Cenpatico Provider Relations department to set up
a “no referral” period. The Cenpatico Provider Relations department can be reached as
follows:
Fax: 866-263-6521
Network Providers must have a start date and an end date indicating when they will be available
again for referrals. A “no referral” period will end automatically on the set end date.
Coordination between Sunflower Health Plan and Cenpatico
Sunflower Health Plan and Cenpatico work together to assure quality behavioral health services,
including substance use disorder services, are provided to all Members. This coordination
includes participation in Quality Improvement (QI) activities for both organizations and planned
focus studies conducted conjointly for physical and behavioral healthcare services.
In addition, Cenpatico works to educate and assist physical health and behavioral health
providers in the appropriate exchange of medical information. Behavioral health utilization
reporting is prepared and provided to Sunflower Health Plan on a monthly basis and is shared
with Sunflower Health Plan’s management and executive leadership quarterly. Provider
performance is compared to state and national performance thresholds and benchmarks to
assess for over and underutilization of services, quality of service provision, and areas for
improvement. Performance on any standard that does not meet performance thresholds
and/or exhibits continued poor performance will result in a corrective action plan (CAP).
Cenpatico works with its Providers on CAP development and interim reporting to resolve
performance issues and improve Member quality of care.
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Quality Improvement
Cenpatico’s Quality Improvement (QI) Program is based on the principles of Continuous
Performance Improvement (CPI) and utilizes the Plan, Do, Study Act (PDSA) model of CPI in the
development and evaluation of quality activities. All quality activities are designed to improve
the quality of care to Sunflower Health Plan Members. The QI Program is data driven and
incorporates data feeds from all Cenpatico functional units, creating a culture of quality
throughout the organization. The Cenpatico QI Program includes clinical, network, customer
service, and service utilization and provider complaints as core business metrics. Further, the
Cenpatico QI program coordinates with the Sunflower Health Plan QI program to support
continuity, coordination and improved integration of Member care.
Cenpatico is committed to providing quality care and clinically appropriate services for our
Members. In order to meet our objectives, Network Providers must participate and adhere
to our programs and guidelines.
Monitoring Clinical Quality
What does Cenpatico monitor?

Access to care standards;

Adherence to Clinical Practice Guidelines;

Communication with PCPs and other behavioral health providers;

Critical Incidents;

Quality of Care (QOC) concerns;

Member confidentiality;

High-risk Member identification, management and tracking;

Inpatient discharge follow-up care;

Inpatient admissions, readmissions and lengths of stay;

Member grievances;

Provider grievances;

Service utilization patterns;

Provider satisfaction; and,

Member satisfaction
How does Cenpatico monitor quality?
Cenpatico evaluates available administrative data (claims and service authorizations) along
with Member and Provider surveys as methods to monitor quality. Hybrid methods (those that
include administrative as well as medical record review) occur as a result of trends in critical
incidents, Provider complaints and QOCs.
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Results of ongoing quality monitoring are communicated to Network Provider groups for technical
assistance and in the development of performance improvement and Corrective Action Plan
(CAPs). Trends in performance and results of CAPs are evaluated and reviewed by Cenpatico
during the re- credentialing process.
Network Provider Participation in the QI Process
Cenpatico Providers are expected to monitor and evaluate their own compliance with
performance requirements to assure the quality of care and service provided.
Providers are expected to meet Cenpatico’s performance requirements and ensure Member
treatment is efficient and effective by:
• Cooperating with medical record reviews and reviews of telephone and appointment
accessibility;
• Cooperating with Cenpatico’s complaint review process;
• Participating in Provider satisfaction surveys; and
• Cooperating with reviews of quality of care issues and critical incident reporting.
In addition, Providers are invited to participate in Cenpatico’s QI Committees and in local focus
groups.
Confidentiality and Release of Member Information
Cenpatico abides by applicable Federal and State laws which govern the use and disclosure of
behavioral health information and alcohol/ substance use disorder treatment records.
Similarly, Cenpatico Network Providers are independently obligated to comply with applicable
laws and shall hold confidential all Member records and agree to release them only when
permitted by law, including but not limited to 42 CFR et seq., when applicable.
Communication with the Primary Care Physician
Sunflower Health Plan encourages primary care physicians (PCPs) to consult with their patients’
behavioral health Network Providers. In many cases the PCP has extensive knowledge about
the Member's medical condition, mental status, psychosocial functioning, and family situation.
Communication of this information at the point of referral or during the course of treatment is
encouraged with Member consent, when required.
Network Providers should communicate not only with the Member’s PCP whenever there is a
behavioral health problem or treatment plan that can affect the Member’s medical condition
or the treatment being rendered by the PCP, but also with other behavioral health clinicians
who may also be providing service to the Member.
Network Providers are encouraged to complete a health status screen, at the initial point of
contact and as part of the re-assessment process for Members in treatment. Network Providers
must refer Members with physical health conditions (as indicated by the screen) to their primary
care provider for evaluation and treatment of the physical health condition.
Cenpatico developed a PCP Communication template that may be used by Network Providers
in coordination of care activities for a Member, if the Provider does not have an existing form.
The form is a template that incorporates key clinical information that should be shared with
each Member’s PCP. The PCP Communication template is located on our website at
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www.cenpatico.com. Network Providers can identify the name and number for a Member’s
PCP on the front-side of the Member ID Card.
Network Providers should screen for the existence of co-occurring behavioral health and
substance use disorder conditions and make appropriate referrals. Network Providers should refer
Members with known or suspected untreated physical health problems or disorders to the PCP
for examination and treatment. If the Members’ assigned PCP is not local (e.g. in the event of a
RTC/PRTF facility) and the Member is in need of medical assistance, Sunflower Health Plan staff
will be able to assist the Network Provider with linking the Member to provider closer
geographically.
Cenpatico requires that Network Providers report specific clinical information to the Member's
PCP in order to preserve the continuity of the treatment process. With appropriate written
consent, when required under State and/or Federal law, it is the Network Provider's responsibility
to keep the Member's PCP abreast of the Member's treatment status and progress in a
consistent and reliable manner. If the Member requests this information not be given to their
PCP, the Network Provider must document this refusal in the Member’s treatment record. Such
consent shall meet the requirements set forth in 42 CFR et seq., when applicable. If the Member
requests this information not be given to their PCP, the Network Provider must document this
refusal in the Member’s treatment record, and if possible, the reason why. The following
information is valuable to include in the report to the PCP:

A copy of the behavioral health intake assessment;

Identified barriers to Member’s success with current treatment plan, if applicable;

The results of an initial psychiatric evaluation;

Current psychotropic medications, including initiation of and major changes in
medication regime, within fourteen (14) days of the visit or medication order;

The results of functional assessments; and

Member’s functional and clinical status upon completion of treatment.
Consent for Disclosure
Cenpatico recognizes communication as the link that unites all the service components and a
key element in any program’s success. To further this objective, Network Providers shall obtain
consent from Members or their authorized representatives when required by state and/or federal
law to exchange confidential information, including but not limited to the disclosures to behavioral
health providers and between the behavioral health provider and the Member’s physical health
provider.
Anytime consent to release information is required and the Member whose information is the
subject of the release refuses to provide consent for the release, the Network Provider shall
document the refusal along with the reasons for declination in the medical record. Cenpatico
monitors compliance by its Network Providers with medical record documentation requirements,
including but not evidence of a note in a Member’s record if he/she declined to give consent
for a release, and whether the Network Provider sends regular to the primary care provider (PCP)
or other behavioral health providers for treatment and care coordination.
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Critical Incident Reporting
A Critical Incident is defined as any occurrence which is not consistent with the routine
operation of a Network Provider. It includes, but is not limited to: injuries to Members, a suicide/
homicide attempt by a Member while in treatment, death due to suicide/ homicide, sexual
battery, medication errors, Member escape or elopement, altercations involving medical
interventions or any other unusual incident that has high risk management implications. A
Critical Incident Report must be completed for any Cenpatico Member by the Network
Provider within twenty four (24) hours of, or notification of, such an occurrence.
The Critical Incident Report Form is located on Cenpatico’s website at
www.cenpatico.com/providers/forms/kansas. Submit completed Critical Incident Reports to
the following address:
Cenpatico
Suite 400
Austin, TX 78759
Fax: 866-694-3649
Abuse and Neglect Reporting
Providers are required to report all incidents that may include abuse and neglect consistent
with the Department of Human Services Act, the Adults with Disabilities Domestic Abuse
Intervention Act and the Abused and Neglect Child Reporting Act. Reports regarding elderly
Members who are over the age of 60 with domestic/community abuse will be reported to
Kansas Department for Aging and Disability Services at 800-922-5330. Reports regarding elderly
Members for abuse by a nursing home, hospital, home health agency, etc., abuse or neglect
should call the Kansas Department of Health and Environment Bureau of Health Facilities,
Phone: 800-842-0078. Reports concerning children and adults should be directed to the
Kansas Protection Report Center, Phone: 800-922-5330, The Kansas Protection Report Center
staffs this hotline 24 hours a day, 7 days a week, 365 days a year.
Cenpatico will offer training to Providers about the signs of abuse or neglect.
Member Concerns about Network Providers
Members who have concerns about Cenpatico Network Providers should contact Sunflower
Health Plan to register their concern. All concerns are investigated, and feedback is provided
on a timely basis. It is the Network Provider’s responsibility to provide supporting
documentation to Cenpatico if requested. Any validated concern will be taken into
consideration when re-credentialing occurs, and can be cause for termination from
Cenpatico’s Provider Network. This process is referenced in your Provider Agreement with
Cenpatico. Cenpatico alerts a Network Provider through written and oral communication
when a complaint has been lodged against a Provider. Cenpatico asks for the Network
Provider to submit any and all documentation to support or refute the complaint as part of the
complaint investigation process. Cenpatico provides documentation with the complaint
resolution to the Provider.
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Records and Documentation
Network Providers need to retain all books, records and documentation related to services
rendered to Members as required by law and in a manner that facilitates audits for regulatory
and contractual reviews.
The Network Provider will provide Cenpatico, Sunflower Health Plan and other regulatory
agencies access to these documents to assure financial solvency and healthcare delivery
capability, to investigate complaints and grievances, and to meet the reporting requirements
specified in the contract between Sunflower Health Plan and KanCare, subject to regulations
concerning confidentiality of such information.
Access to documentation must be provided upon reasonable notice for all inpatient care. This
provision shall survive the termination and or non-renewal of a Provider Agreement with
Cenpatico.
Reporting and Metric Requirements
Network Providers may be required to submit timely to Cenpatico reports or performance metrics
as required by Sunflower Health Plan’s contract with KanCare, and/or Cenpatico’s requirements
for NCQA accreditation. Such metrics shall include but not be limited to provider rosters by
service location, average number of days to receive an emergent appointment, average
number of days to receive a routine appointment, network adequacy and complaint trends.
Cenpatico and Network Providers shall work together to find solutions when performance
standards are not met.
Record Keeping and Retention
The clinical record is an important element in the delivery of quality treatment because it
documents the information to provide assessment and treatment services. Sample forms are
located on our website at www.cenpatico.com and Network Providers are encouraged to use
for Members.
As part of our ongoing Quality Improvement program, clinical records may be audited to assure
the quality and consistency of Network Provider documentation, as well as the appropriateness
of treatment. Before charts can be reviewed or shared with others, the Member must sign an
authorization for release. Chart Audits of Member records will be evaluated in accordance with
these criteria.
Clinical records require documentation of all contacts concerning the Member, relevant
financial and legal information, consents for release/ disclosure of information, release of
information to the Member’s PCP, documentation of Member receipt of the Statement of
Member’s Rights and Responsibilities, the prescribed medications with refill dates and quantities,
including clear evidence of the informed consent, and any other information from other
professionals and agencies. If the Network Provider is able to dispense medication, the Network
Provider must conform to drug dispensing guidelines set forth in the Sunflower Health Plan drug
formulary.
Network Providers shall retain clinical records for Members for as long as is required by applicable
law. These records shall be maintained in a secure manner, but must be retrievable upon
request.
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Cenpatico Compliance Program
The Cenpatico President/CEO and Compliance Department share responsibility and authority
for carrying out the provisions of the compliance program. In collaboration with Sunflower
Health Plan, Cenpatico is committed to conducting activities in an ethical manner consistent
with applicable laws, contracts and regulatory requirements.
The Network Providers shall cooperate fully in making personnel and/or subcontractor personnel
available in person for interviews, consultation, grand jury proceedings, pre-trial conferences,
hearings, trials and in any other process, including investigations by Sunflower Health Plan.
The Cenpatico Compliance Program includes a system for identifying and reporting waste,
abuse and fraud and for safeguarding the privacy of confidential information as follows;
Waste, Abuse and Fraud (WAF) System
Cenpatico is committed to the detection, investigation and prosecution of waste, abuse
and fraud (WAF). WAF is defined as follows:
Waste – Use of healthcare benefits or dollars without a real need. For example, prescribing a
medication for thirty (30) days with a refill when it is not known if the medication will be needed.
Abuse – Practices that are inconsistent with sound fiscal, business or medical practices, and
result in unnecessary cost to the health plan program, including, but not limited to practices that
result in unnecessary cost to the Health Care program for services that are not Medically
Necessary, or that fail to meet professionally recognized standards for healthcare. It also
includes Member practices that result in unnecessary cost to the health plan program.
Fraud – An intentional deception or misrepresentation made by a person or corporation with the
knowledge that the deception could result in some unauthorized benefit under the health plan
program to himself, the corporation, or some other person. It also includes any act that constitutes
fraud under applicable federal orsState healthcare fraud laws. Examples of Provider fraud
include: lack of referrals by PCPs to specialists, improper coding, billing for services never
rendered, inflating bills for services and/or goods provided, and Providers who engage in a
pattern of providing and/or billing for medically unnecessary services. Examples of Member fraud
include improperly obtaining prescriptions for controlled substances and card sharing.
Reporting Provider or Member Waste, Abuse or Fraud
If you suspect a Member (a person who receives benefits) or a Provider (e.g., doctor, counselor,
etc.) has committed waste, abuse or fraud, you have a responsibility and a right to report it.
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Network Providers can report Providers and Members to Cenpatico by mailing or contacting
Cenpatico’s Special Investigations Unit (SIU) at:
Cenpatico
Attn: Special Investigations Unit
7711Carondelet Ave.
St. Louis, MO 63105
Phone: 866-685-8664
When reporting a Provider (e.g., doctor, dentist, counselor, etc.) please provide the following:

Name, address, and phone number of Provider;

Name and address of the facility (hospital, nursing home, home health agency, etc.);

Type of Provider (physician, physical therapist, pharmacist, etc.);


Names and phone numbers of other witnesses who can aide in the investigation;

Summary of what happened
Dates of events; and
When reporting a Member (a person who receives benefits through Sunflower Health Plan)
please provide the following:

The Member’s name;

The Member’s date of birth, social security number, or case number (if available);

The city where the Member resides; and

Specific details about the waste or abuse.
To report waste, abuse or fraud, gather as much information as possible.
Federal and States Laws Governing the Release of Information
The release of certain information is governed by a myriad of federal and/or state laws.
These laws often place restrictions on how specific types of information may be disclosed,
including, but not limited to, behavioral health, alcohol/substance use disorder treatment and
communicable disease records.
For example, the federal Health Insurance Portability and Accountability Act (HIPAA) requires
that covered entities, such as health plans and providers, release protected health information
only when permitted under the law, such as for treatment, payment and operations activities,
including care management and coordination.
However, a different set of federal rules place more stringent restrictions on the use and
disclosure of alcohol and substance use disorder treatment records (42 CFR Part 2 or ―Part 2).
These records generally may not be released without consent from the individual whose
information is subject to the release. Still other laws at the state level place further restrictions on
the release of certain information, such as behavioral health, communicable disease, etc.
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For more information about any of these laws, refer to following:
 HIPAA - please visit the Centers for Medicare & Medicaid Services (CMS) website at:
www.cms.hhs.gov and then select ―Regulations and Guidance and ―HIPAA – General
Information‖;

Part 2 regulations - please visit the Substance Abuse and Mental Health Services
Administration (within the U.S. Department of Health and Human Services) at:
http://www.samhsa.gov/

State laws - consult applicable statutes to determine how they may impact the release of
information on patients whose care you provide.
Cenpatico Network Providers are independently obligated to know, understand and comply
with these laws.
Cenpatico takes privacy and confidentiality seriously. We have established processes, policies
and procedures to comply with HIPAA and other applicable federal and/or state confidentiality
and privacy laws.
Please contact the Cenpatico Privacy Officer at 512-406-7200 or in writing (refer to address
below) with any questions about our privacy practices.
Cenpatico Compliance Department
Suite 400
Austin, TX 78759
Please instruct any Member to contact our Customer Services team with any questions about
our privacy practices.
Treatment Record Guidelines
Cenpatico requires treatment records to be maintained in a manner that is current, detailed
and organized and which permits effective and confidential patient care and quality review.
Treatment record standards are adopted that are consistent with the National Committee for
Quality Assurance. The adopted standards facilitate communication, coordination and
continuity of care and promote efficient, confidential and effective treatment. Medical records
must be prepared in accordance with all applicable State and Federal rules and regulations
and signed by the medical professional rendering the services.
Cenpatico’s minimum standards for Provider medical record keeping practices include medical
record content, medical record organization, ease of retrieving medical records, and
maintaining confidentiality of patient information. The following thirteen (13) elements reflect a
set of commonly accepted standards for behavioral health treatment record documentation:
1.
2.
Each page in the treatment record contains the patient’s name or ID number.
Each record includes the patient’s address, employer or school, home and work
telephone numbers including emergency contacts, marital or legal status, appropriate
consent forms and guardianship information, if relevant.
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
All entries in the treatment record are dated and include the responsible clinician’s name,
professional degree and relevant identification number, if applicable.
The record is legible to someone other than the writer.
Medication allergies, adverse reactions and relevant medical conditions are clearly
documented and dated. If the patient has no known allergies, history of adverse
reactions or relevant medical conditions, this is prominently noted.
Presenting problems, along with relevant psychological and social conditions affecting
the patient’s medical and psychiatric status and the results of a mental status exam, are
documented.
Special status situations, when present, such as imminent risk of harm, suicidal
ideation or elopement potential, are prominently noted, documented and revised
in compliance with written protocols.
Each record indicates what medications have been prescribed, the dosages of
each and the dates of initial prescription or refills.
A medical and psychiatric history is documented, including previous treatment
dates, Provider identification, therapeutic interventions and responses, sources of
clinical data and relevant family information. For children and adolescents, past
medical and psychiatric history includes prenatal and perinatal events, along with a
complete developmental history (physical, psychological, social, intellectual and
academic). For patients 12 and older, documentation includes past and present
use of cigarettes and alcohol, as well as illicit, prescribed and over-the-counter
drugs.
A DSM- diagnosis is documented, consistent with the presenting problems, history, mental
status examination and/or other assessment data.
Treatment plans are consistent with diagnoses, have both objective, measurable goals and
estimated timeframes for goal attainment or problem resolution, and include a preliminary
discharge plan, if applicable. Continuity and coordination of care activities between the
primary clinician, consultants, ancillary providers and health care institutions are included, as
appropriate.
Informed consent for medication and the patient’s understanding of the treatment
plan are documented.
Progress notes describe patient strengths and limitations in achieving treatment plan
goals and objectives and reflect treatment interventions that are consistent with those
goals and objectives. Documented interventions include continuity and coordination
of care activities, as appropriate. Dates of follow-up appointments or, as applicable,
discharge plans are noted.
Preventative Behavioral Health Programs
Cenpatico, in conjunction with Sunflower Health Plan, offers the Perinatal Depression Screening
Program as a preventative behavioral health program for our Members. The Perinatal
Depression Screening Program offers depression screening to Members who are pregnant via a
brief, easy to answer survey, in order to identify Members who would benefit from behavioral
health services. Members can complete the surveys in their PCP offices, CMHC, or submit the
survey directly to Cenpatico. If completed at a Provider’s office, the Provider submits the
screening to Cenpatico for scoring and analysis. Each Member who participates receives
communication from Cenpatico regarding the outcome of their survey answers and resources
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available to them. If a Member screens positive for depression while pregnant or after delivery, a
Cenpatico clinical staff person will call to attempt to outreach and engage the Member in
services and/or finding community resources. Cenpatico communicates the survey findings
and outreach attempts to the Member’s medical provider as well to support coordination of
care.
Cenpatico appreciates your assistance in promoting this preventative behavioral health
program. You can refer your Members to the program directly when you assess a Member is
at risk for, or screened positive for, depression while pregnant or post-delivery. If you would
like more information about the program or if you have suggestions as to how we can
improve our preventative behavioral health program, please contact the Quality
Improvement department at 512-406-7200.
Complaints, Grievances and Appeals
Member Grievances and Provider Complaints
Grievances
A Member grievance is defined as any Member expression of dissatisfaction about any matter
other than an “adverse action”. A Provider complaint is any Provider expression of dissatisfaction
about any matter other than a claims dispute.
Note: Throughout this Manual, we will consider the term “grievance” to refer to both Member
grievances and Provider complaints as the resolution processes are the same. Provider
complaints include disputes regarding policies, procedures or any aspect of Sunflower Health
Plans’ administrative functions including proposed actions.
The grievance process allows the Member, or the Member’s authorized representative (Provider,
family Member, etc.) acting on behalf of the Member, to file a grievance either orally or in
writing within 180 calendar days of the event covering the dissatisfaction. Sunflower State Health
Plan shall acknowledge receipt of each grievance in writing within 5 working days of receipt of
the grievance. A Provider MAY NOT file a grievance or appeal on behalf of a Member without
written consent by the Member or the Member’s representative. Any individual who makes a
decision on grievances will not be involved in any previous level of review or decision making. In
any case where the reason for the grievance involves clinical issues or relates to denial of
expedited resolution of an appeal, Sunflower Health Plan shall ensure that the decision makers
are health care professionals with the appropriate clinical expertise in treating the Member’s
condition or disease. Sunflower Health Plan values its Providers and will not take punitive action
against Providers who file a grievance on a Member’s behalf. To file a complaint, please call:
866-896- 7293. A Cenpatico Customer Service Representative will assist you in filing a grievance.
Acknowledgement
Staff receiving grievances orally will acknowledge the grievance and attempt to resolve them
immediately. Staff will document the substance of the grievance. For informal grievances,
defined as those received orally and resolved immediately to the satisfaction of the Member,
representative or Provider, the staff will document the resolution details. Member notification of
the grievance resolution shall be made in writing within two business days of the resolution. The
Grievance and Appeals Coordinator (GAC) will date stamp written grievances upon initial
receipt and send an acknowledgment letter, which includes a description of the grievance
procedures and resolution time frames, within five business days of receipt of the written
grievance.
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Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the Member’s health condition requires, not
toexceed thirty (30) calendar days from the date of the initial receipt of the grievance.
Grievances will be resolved by the GAC, in coordination with other Sunflower State Health Plan
staff as needed. In our experience, most grievances are resolved at the staff level to the
satisfaction of the Member, representative or Provider filing the grievance. Expedited grievance
reviews will be available for Members in situations deemed urgent, such as a denial of an
expedited appeal request, and will be resolved within 24 hours.
Sunflower Health Plan may extend the resolution of a grievance by up to 14 calendar days if the
Member or a Member representative requests the extension or if Sunflower Health Plan
determines that there is a need for additional information and the extension is in the Member’s
interest. For any extension not requested by the Member, Sunflower Health Plan will give the
Member written notice of the reason for the extension within two working days of the decision to
extend the timeframe.
Notice of Resolution
The GAC will provide written resolution to the Member, representative or Provider within 30
calendar days of receipt. The letter will include, but need not be limited to: all information
considered in investigating the grievance, findings and conclusions, the deposition of the
grievance, and the right to a second level review by the Grievance Appeal Committee (GAC) if
the Member is not satisfied.
The grievance response shall include, but not be limited to, the decision reached by Sunflower
Health Plan, the reason(s) for the decision, the policies or procedures which provide the basis for
the decision, and a clear explanation of any further rights available to the Member. A copy of
verbal complaints logs and records of disposition or written grievances shall be retained for five
years.
Grievances may be submitted by written notification to:
Cenpatico
Suite 400
Austin, TX 78759
Fax: 866-704-3063
Appeals
An appeal is the request for review of a “Notice of Adverse Action”. A “Notice of Adverse
Action” is the denial or limited authorization of a requested service, including the type or level of
service; the reduction, suspension, or termination of a previously authorized service; the denial,
in whole or part of payment for a service excluding technical reasons; the failure to render a
decision within the required timeframes; or the denial of a Member’s request to exercise his/her
right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Cenpatico/Sunflower Health
Plan Network. The review may be requested in writing or orally within thirty (30) calendar days of
receiving the Notice of Adverse Action; an oral request, must be followed up with a written,
signed appeal. Requests for appeals within the standard timeframe must be resolved within
fourteen (14) days of receipt of the appeal, with a fourteen (14) day extension possible if
additional information is required. The legal guardian of the Member (for minors or
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incapacitated adults), a representative of the minor designated in writing, or a Provider acting
on behalf of the Member with the Member’s written consent, has the right to file an appeal of
an action on behalf of the Member. Sunflower Health Plan shall provide written notice that the
appeal has been received within three business days of its receipt, including the expected date
of resolution. Members may request that Sunflower State Health Plan review the Notice of
Adverse Action to verify if the right decision has been made. Cenpatico ensures that the
Cenpatico decision makers on grievance and appeals were not involved in previous levels of
review or decision making and are health care professionals with clinical expertise in treatment
of the Member’s conditions.
If a Member is receiving authorized services that are now denied and wishes to keep getting
these services, an appeal must be submitted in writing within 10 calendar days of the denial
letter. The request must clearly state that the Member wishes to keep getting the denied
services. The Member can keep getting these services until the appeal decision is rendered. If
the appeal decision upholds Sunflower Health Plan’s denial, the Member may have to pay for
the services.
Expedited Appeals
Expedited appeals may be filed when either Sunflower Health Plan or the Member’s Provider
determines that the time expended in a standard resolution could seriously jeopardize the
Member’s life or health or ability to attain, maintain, or regain maximum functioning. No punitive
action will be taken against a Provider that requests an expedited resolution or supports a
Member’s appeal. In instances where the Member’s request for an expedited appeal is denied,
the appeal must be transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals are issued as expeditiously as the Member’s health condition
requires, not exceeding three working days from the initial receipt of the appeal. Sunflower
Health Plan may extend this timeframe by up to an additional 14 calendar days if the Member
requests the extension or if Sunflower Health Plan provides evidence satisfactory to the State
that a delay in rendering the decision is in the Member’s interest. For any extension not
requested by the Member, Sunflower Health Plan shall provide written notice to the Member of
the reason for the delay. Sunflower Health Plan shall make reasonable efforts to provide the
Member with prompt verbal notice of any decisions that are not resolved wholly in favor of the
Member and shall follow-up within two calendar days with a written notice of action.
Written notice shall include the following information:
(a) The decision reached by Sunflower Health Plan;
(b) The date of decision;
(c) For appeals not resolved wholly in favor of the Member, the right to request a State
fair hearing and information as to how to do so; and
(d) The right to request to receive benefits while the hearing is pending and how to
make the request, explaining that the Member may be held liable for the cost of those
services if the hearing decision upholds the Sunflower Health Plan decision;
(e) Notification that in the State Fair Hearing the member may represent him/herself or
use legal counsel, a relative, a friend, or a spokesperson;
(f) Any other information required by Kansas Statute that relates to a managed care
organization’s notice of disposition of an appeal.
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Grievances may be submitted verbally or in writing to:
Cenpatico
Grievance and Appeals Coordinator
Suite 400
Austin, TX 78759
Phone: 866-896-7293
Fax: 866-714-7991
State Fair Hearing Process
Sunflower Health Plan will include information in the Member Handbook, online and via the
appeals process to Members of their right to appeal directly to the State. The Member has the
right to appeal to the State at the same time they appeal to Sunflower Health Plan, after
exhausting appeal rights with Sunflower Health Plan, or instead of appealing to Sunflower Health
Plan.
Any adverse action or appeal that is not resolved wholly in favor of the Member by Sunflower
Health Plan may be appealed by the Member or the Member’s authorized representative to the
State for a fair hearing. Sunflower Health Plans denial of payment for Kansas Medicaid covered
services and failure to act on a request for services within required timeframes may also be
appealed. Appeals must be requested in writing by the Member or the Member’s
representative within 90 days of the Member’s receipt of notice of adverse action.
Sunflower Health Plan shall comply with the State’s Fair hearing decision. The State’s decision in
these matters shall be final and shall not be subject to appeal by Sunflower Health Plan.
Reversed Appeal Resolution
If Sunflower Health Plan or the State fair hearing decision reverses a decision to deny, limit, or
delay services, where such services were not furnished while the appeal was pending, Sunflower
Health Plan will authorize the disputed services promptly and as expeditiously as the Member’s
health condition requires. Additionally, in the event that services were continued while the
appeal was pending, Sunflower Health Plan will provide reimbursement for those services in
accordance with the terms of the final decision rendered by the States and applicable
regulations.
To request a State Fair Hearing, you must file a written request with the Office of Administrative
Hearings, 1020 S. Kansas Avenue, Topeka, KS 66612 within 30 days of the written notice. If KDHEDHCF mailed the notice of denial to you, K.S.A. 77- 531 allows you an additional three days to file
such a request.
Or the request for fair hearing can be faxed to:
Office of Administrative Hearings
Phone: 785-296-2433
Fax: 785-296-4848
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Member Rights and Responsibilities
Sunflower Health Plan Member Rights and Responsibilities
Sunflower Health Plan Members have the right to:
1.
Respect, dignity, privacy, confidentiality and nondiscrimination;
2.
3.
4.
5.
6.
Receive information on available treatment options and alternatives;
Consent for or refusal of treatment and active participation in decision choices;
Assistance with Medical Records in accordance with applicable federal and state laws;
Be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation; and,
Freely exercise these rights without adversely affecting the way the
Sunflower Health Plan and its Providers or the State agency treat the Member.
It is the responsibility of Sunflower Health Plan Members to:
1.
Provide, to the extent possible, information needed by Providers in caring for the Member;
2.
Contact their Primary Care Provider (PCP) as their first point of contact when needing
medical care;
3.
4.
Follow appointment scheduling processes; and
Follow instructions and guidelines given by Providers.
In addition to the Member Rights and Responsibilities provided by Sunflower Health Plan,
Cenpatico believes that members also have the following Rights and Responsibilities:
Cenpatico Member Rights and Responsibilities
Member Rights
1.
A right to receive information about the organization, its services, its Providers and
Member rights and responsibilities.
2.
A right to participate with providers in making decisions about their health care.
3.
A right to a candid discussion of appropriate or medically necessary treatment
options for their conditions, regardless of cost or benefit coverage.
4.
A right to voice complaints about the organization or the care it provides.
5.
A right to make recommendations regarding the organization's Member Rights and
Responsibilities Policy.
Member Responsibilities
1.
A responsibility to supply information (to the extent possible) that the organization
and its providers need in order to provide care.
2.
A responsibility to follow plans and instructions for care that they have agreed to
with their providers.
3.
A responsibility to understand their health problems and participate in developing mutually
agreed-upon treatment goals, to the degree possible.
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Civil Rights
Cenpatico provides covered services to all eligible Members regardless of: Age, Race, Religion,
Color, Disability, Sex, Sexual Orientation, National Origin, Marital Status, Arrest or Conviction
Record, or Military Participation.
All Medically Necessary covered services are available to all Members. All services are provided
in the same manner to all Members. All persons or organizations connected with Cenpatico who
refer or recommend Members for services shall do so in the same manner for all Members.
Customer Service
The Cenpatico Customer Service Department
Cenpatico operates a toll free emergency and routine Behavioral Health Services Hotline,
answered by a live voice and staffed by trained personnel, Monday through Friday 8:00 a.m. to
5:00 p.m. Central Time. After hours services are available during evenings, weekends and
holidays. The after-hours service is staffed by customer service representatives with registered
nurses and behavioral health clinicians available 24/7 for urgent and emergent calls.
The Cenpatico Customer Service Department supports the Mission Statement in providing quality,
cost-effective behavioral health services to our customers. We strive for customer satisfaction on
every call by doing the right thing the first time and we show our integrity by being honest,
reliable and fair.
The Customer Service department’s primary focus is to facilitate the authorization of
covered services for Members for treatment with a specific clinician or clinicians.
The Cenpatico Customer Service department assists Network Providers with the following:





Verifying Member eligibility;
Verifying Member benefits;
Providing authorization information;
Referrals; and,
Troubleshooting any issues related to eligibility, authorizations, referrals, or researching
prior services.
Verifying Member Enrollment
Network Providers are responsible for verifying eligibility every time a Member schedules an
appointment, and when they arrive for services.
Network Providers should use either of the following options to verify Member enrollment:

Access the Kansas Medical Assistance program (KMAP) website at
https://www.kmap-state-ks.us/Public/Provider.asp or call 800-933-6593

Contact Cenpatico Customer Service at 866-896-7293

Access the Cenpatico Provider Website at www. cenpatico.com
42
www.cenpatico.com
Until the actual date of enrollment with Sunflower Health Plan, Cenpatico is not financially
responsible for services the prospective Member receives. In addition, Cenpatico is not
financially responsible for services Members receive after their coverage has been terminated.
The Provider must implement a policy prior to providing non-emergency services to an adult
KanCare Member that requests and inspects the adult Member’s KanCare identification card
(or other documentation provided by the state agency demonstrating KanCare eligibility) and
health plan membership card. If the adult Member does not produce their health plan
membership card, and the Provider verifies eligibility and health plan enrollment, the Provider
may provide service.
Sunflower Health Plan Member ID Cards
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Page 43
Interpretation/Translation Services
Cenpatico is committed to ensuring staff are educated, aware and sensitive to the linguistic
needs and cultural differences of its Members. In order to meet this need, Cenpatico’s
Customer Service team is staffed with Spanish and English bilingual personnel. Trained
professional language interpreters, including those proficient in American Sign Language, can
be made available face-to-face at your office. Interpreters are also available telephonically to
assist Providers with discussing technical, medical, or treatment information with Members as
needed. Cenpatico requests a five-day prior notification for face-to-face services.
To access TDD access for Members who are hearing impaired, contact Kansas Relay Customer
Service:
TTY:
800-766-3777
Voice:
800-766-3777
Key Information: To access interpreter services for Sunflower Health Plan Members, contact
Customer Service at 866-896-7293.
NurseWise
NurseWise is Cenpatico’s after-hours nurse referral line which is a bilingual care line consisting of
both Customer Service Representatives and Registered Nurses who respond to inquiries from
eligible individuals and their eligible dependents. Verification of eligibility for service,
demographic information verification and administrative questions may be answered by
NurseWise representatives. NurseWise provides after-hours phone coverage seven (7) days per
week including holidays.
NurseWise provides after hours assistance with the following:






emergency and urgent care matters;
health questions and identification and treatment of health issues;
eligibility verification;
notification of primary care and other Providers when warranted;
coordination of appropriate transportation for health services; and
questions regarding participating status of Providers.
Benefit Overview
Cenpatico covers all behavioral health services, including substance use disorder services,
defined in the KanCare comprehensive benefit package. Services for Sunflower Health Plan
Members include, but are not limited to the following;






Inpatient Mental Health Hospitalization & Medical Detoxification
Observation
Intensive Outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Electroconvulsive Therapy (ECT)
Crisis Intervention
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Page 44









Outpatient Mental Health Services including medication management
Community Mental Health Center services
Substance Use Disorder (SUD) Services
HCBS SED Waiver Services
Autism Waiver Services
1915 (b) 3 Services
Federally Qualified Health Center (FQHC) and Rural Health Center (RHC) behavioral
health services
Positive Behavioral Support (PBS) Services
Screening, Brief Intervention and Referral for Treatment (SBIRT) for Alcohol and Drug
Use Services
For a listing of service codes and authorization requirements, please refer to the Covered
Professional Services & Authorization Guidelines located in this Manual. Network Providers
should refer to their Provider Agreement with Cenpatico to identify which services they are
contracted and eligible to provide.
Please note that all services performed must be medically necessary.
Behavioral Health Covered Services & Authorization Guidelines
Please note that the listing below may not fully comprise all Cenpatico KanCare covered services.
Please refer to your Provider Agreement with Cenpatico to identify additional services you are
contracted and eligible to provide. All services provided by non-participating providers require
prior authorization.
Covered diagnoses codes are generally in the ICD range of 290 through 319.
V codes cannot be billed as primary diagnosis codes in most situations, but may be used as
secondary diagnosis. Diagnosis code 780.99 is allowed for home and community based services
(HCBS) waiver services and Screening, Brief Intervention and Referral for Treatment for Alcohol and
Drug Use (SBIRT) only.
Facility Behavioral Health Services
Service Description
Inpatient Admission –
Behavioral Health
Billable Provider
Type(s)
Billing Codes
Auth Required
Hospital
100, 101, 114, 124,
134, 144, 154, 204
Yes
Hospital
116, 126, 136, 146,
156
Yes
Inpatient admissions to an
Institute for Mental Disorders
(IMD) is only covered for age
21 and under or over age 65
Substance use
Disorder/Detox
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Page 45
Service Description
Eating Disorders
Billable Provider
Type(s)
Billing Codes
Auth Required
120, 130, 140, 150
Yes
T2048
Yes
Hospital
Hospital
901
760, 761, 762
Yes
No
Hospital
905, 906
Yes
Hospital
912, 913
Yes
Hospital
513
No
Hospital
Primary diagnosis must be in
the following range: 307.1
through 307.19, 307.50
through 307.59.
Psychiatric Residential Hospital
Treatment Facility
Admission
Service must be billed on a
CMS-1500 claim form with the
HCPCS code T2048.
ECT
Observation
Covered up to 2 consecutive
days..
Intensive Outpatient
Program (IOP)
CMS-1450 claim form and
must include the HCPCS
code H0015.
Partial Hospitalization
Program (PHP)
code H0018.
Discharge
Consultation
Appointment
code 99366.
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Professional Behavioral Health Services
Professional services provided by a Psychiatrist or Nurse Practitioner in an inpatient setting do not
require prior authorization. Only Psychiatrists and Nurse Practitioners are allowed to bill for
inpatient services. Please see covered services below to determine which services are allowed in
an inpatient setting.
Services listed with GT modifier as allowed are also covered as telemedicine services.
*Benefit table reflects the 2013 CPT coding changes in effect January 1, 2013. New codes are
subject to approval or modification by the Kansas KanCare Program.
Service Description
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
Psychiatric diagnostic interview
– no medical services
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
90791
Blank
No
MD/DO,
ARNP
90792
Unlimited benefit based on medical
necessity.
Maximum of 1 unit per rolling 6 months
without authorization. Only 1 unit per day
allowed. 1 unit = 1 visit
90791 also
allowed with
GT modifier
*90801 and 90802 have been terminated
Psychiatric diagnostic interview
– with medical services
Blank
No
90792 also
allowed with
GT modifier
necessity.
Maximum of 1 unit per rolling 6 months
without authorization. Only 1 unit per day
allowed. 1 unit = 1 visit
*90801 and 90802 have been terminated
Interactive Complexity
Add-on service subject to meeting
interactive complexity criteria
Billable in combination with 90791, 90792,
90832, 90834, 90837, 90833, 90836,
90838, 90853
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MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
Page 47
90785
Blank
No
Service Description
Individual psychotherapy
necessity.
Maximum of 1 unit of 90832, 90833,
90834, 90836, 90837, 90838 per day. 1
unit = 1 visit. Amount of time spent per
visit is specified by standard coding
definitions.
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
90832,
90834,
90837
Blank
No
MD/DO,
ARNP
90833,
90836,
90838
90832, 90834,
and 90837 are
also allowed
with GT
modifier
*90804, 90806, 90808, 90810, 90812,
90814, 90816, 90818, 90821, 90823,
90826, 90828 have been terminated
Individual psychotherapy with
medication management – add
on services
Unlimited benefit. Must be billed in
combination with the appropriate E&M
code. Time billed represents time spent
in psychotherapy separately and distinctly
from time spent in medication and medical
examination.
Blank
No
90833, 90836,
and 90838
also allowed
with GT
modifier
90834, 90836, 90837, 90838 per day. 1
unit = 1 visit. Amount of time spent per
visit is specified by standard coding
definitions.
*90805, 90807, 90809, 90811, 90813,
90815, 90817, 90819, 90822, 90824,
90827, 90829 have been terminated.
Family psychotherapy
necessity.
Maximum of 1 unit per day. 1 unit = 1
visit
Group Psychotherapy
necessity.
visit.
Electroconvulsive therapy
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
MD/DO
90846,
90847,
90849
Blank
No
90853
90847 also
allowed with
HK and GT
modifier
Blank
No
90870
Blank
Yes
necessity.
visit
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Page 48
Service Description
Psychological testing
necessity.
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
MD/DO, PhD,
LCP, LMLP,
ARNP
96101
Blank
Yes – if more
than 6 hours
per member
lifetime
Maximum of 6 units per day. 1 unit = 1
hour
Psychological testing
PhD, LCP,
LMLP, ARNP
96102,
96103
Blank
necessity.
hour
Assessment of Aphasia
(includes assessment of
expressive/repetitive
speech/language)
ARNP
96105
Blank
necessity.
visit
Developmental testing
ARNP
96110,
96111
Blank
necessity.
hour
Neurobehavioral status exam
MD/DO, PhD,
LCP, LMLP,
ARNP
necessity.
Blank
Note: 6 hours
is a combined
count with all
testing codes
Yes – if more
than 6 hours
per member
lifetime
Note: 6 hours
is a combined
count with all
testing codes
Yes – if more
than 6 hours
per member
lifetime
Note: 6 hours
is a combined
count with all
testing codes
Yes – if more
than 6 hours
per member
lifetime
Note: 6 hours
is a combined
count with all
testing codes
*96116 effective for dates of service as of
1/20/2014 and after
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96116
Note: 6 hours
is a combined
count with all
testing codes
Yes – if more
than 6 hours
per member
lifetime
Page 49
Service Description
Neuropsychological testing
necessity.
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
MD/DO, PhD,
LCP, LMLP,
ARNP
96118
Blank
Yes – if more
than 6 hours
per member
lifetime
hour
Neuropsychological testing
necessity.
MD/DO, PhD,
LCP, LMLP,
ARNP
96119,
96120
Blank
hour
Health and behavioral
assessment
Unlimited benefit.
visit
Injection
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
96150
Blank
Note: 6 hours
is a combined
count with all
testing codes
No
MD/DO,
ARNP
96372
Blank
No
Blank
Not payable
with J2794 on
same date of
service
No
Unlimited benefit.
Maximum of 1 unit per day. 1 unit = 1 visit
Risperidone, long acting, 0.5
mg
MD/DO,
ARNP
J2794
Not payable
with 96372 on
same date of
service
Unlimited benefit.
Max of 1 per day. Must include NDC# and
# of units.
Office emergency care
Note: 6 hours
is a combined
count with all
testing codes
Yes – if more
than 6 hours
per member
lifetime
ARNP
99058
Blank
No
Unlimited benefit.
visit.
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Page 50
Service Description
Office visits/Medication
Management – new patient
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
MD/DO,
ARNP
99201 –
99205
Blank or GT
No
MD/DO,
ARNP
99211 –
99215
Blank or GT
No
MD/DO,
ARNP
99221 99223,
99231 99233,
99238,
99239
9921799220,
9923499236
Blank
No
Blank
No
PhD, LSCSW,
LCPC, LCP,
LCMFT,
LMLP, LMHP
99510
Blank
No
MD/DO,
ARNP
90839,
90840
Blank
No
Unlimited benefit. No more than 3 units
per 3 years
Maximum of 1 unit of any 99xxx code per
day. 1 unit = 1 visit.
New 2013 coding replaces 90862
Office visits/ Medication
Management – established
patient
Unlimited benefit.
Hospital care
Unlimited benefit.
Observation care
MD/DO,
ARNP
Unlimited benefit.
Home visit
Unlimited benefit.
Crisis Psychotherapy
necessity
90840 is 30 minute add-on service
New CPT code for 2013, subject to
modification by KanCare program
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Page 51
Community Mental Health Center (CMHC) Services
Providers at the CMHCs shall only perform services in accordance with regulations of their
licensure or certification.
Community Based Services (Billing Codes H0036-HA, H2017, H2017-TJ, H2011, H2011-HK, H2011-HO,
H0038 & H0038-HQ) delivered to children (under the age of 19) are interventions intended
for Members with a behavioral health and/or substance use disorder diagnosis or children with
significant functional impairments resulting from an identified behavioral health and/or substance
use disorder diagnosis. In order to qualify for Community Based Services, a Member must have a
behavioral health
and/or substance use use disorder diagnosis, and/or exhibit functional impairments. Evidence of
this determination of SED, SPMI, or PRE must be in the Members medical record. Community Based
Services must be medically necessary as determined by Cenpatico’s Medical Necessity Criteria
for Community Based Services.
Service Description
Psychiatric diagnostic
interview – no medical
services
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth Required
CMHC
90791
Blank
No
90791 also
allowed with
GT modifier
necessity.
Maximum of 1 unit per rolling 6
months. Only 1 unit per day allowed.
1 unit = 1 visit
*90801 and 90802 have been
terminated
Psychiatric diagnostic
interview – with medical
services
CMHC
90792
Blank
No
90792 also
allowed with
GT modifier
necessity.
Maximum of 1 unit per rolling 6
month. Only 1 unit per day allowed.
1 unit = 1 visit
*90801 and 90802 have been
terminated
Interactive Complexity
CMHC
90785
Blank
No
Add-on service subject to meeting
interactive complexity criteria
Billable in combination with 90791,
90792, 90832, 90834, 90837, 90833,
90836, 90838, 90853
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Service Description
Outpatient individual
psychotherapy
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth Required
CMHC
90832,
90834,
90837
Blank
No
necessity.
90834, 90836, 90837, 90838 per day.
1 unit = 1 visit. Amount of time spent
per visit is specified by standard
coding definitions.
90832,
90834, and
90837 are
also allowed
with GT
modifier
*90804, 90806, 90808, 90810,
90812, 90814, 90816, 90818, 90821,
90823, 90826, 90828 have been
terminated
Outpatient individual
psychotherapy with
medication management –
add on services
CMHC
90833,
90836,
90838
Unlimited benefit. Must be billed in
combination with the appropriate
E&M code. Time billed represents
time spent in psychotherapy
separately and distinctly from time
spent in medication and medical
examination.
Blank
No
90833,
90836, and
90838 also
allowed with
GT modifier
90834, 90836, 90837, 90838 per day.
1 unit = 1 visit. Amount of time spent
per visit is specified by standard
coding definitions.
*90805, 90807, 90809, 90811,
90813, 90815, 90817, 90819, 90822,
90824, 90827, 90829 have been
terminated.
Family psychotherapy
CMHC
90847
Blank or GT
No
necessity.
Maximum of 1 unit per day. 1 unit =
1 visit
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Page 53
Service Description
Family psychotherapy in the
home
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth Required
CMHC
90847
HK
No
CMHC
90853
Blank
No
CMHC
96101,
96102,
96118,
96119
Blank
Yes – if more than 6
hours per member
lifetime
necessity.
Home family therapy requirements
must be completed in advance
Maximum of 2 units per day. 1 unit =
1 visit. May bill 2 units per day for
extended sessions (>90 minutes).
Group Psychotherapy
necessity.
1 visit.
Psychological and
neuropsychological testing
Unlimited benefit.
Maximum of 6 units per day. 1 unit =
1 hour
Psychological and
neuropsychological testing
CMHC
96103,
96120
Blank
Note: 6 hours is a
combined count with all
testing codes
hours per member
lifetime
Unlimited benefit.
CMHC
96150
Blank
Note: 6 hours is a
combined count with all
testing codes
No
CMHC
96372
Blank
No
1 session
Health and behavioral
assessment
Unlimited benefit.
1 visit.
Injection
Unlimited benefit.
Not payable with J2794
on same date of service
1 visit.
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Page 54
Service Description
Risperidone, long acting, 0.5
mg
Billable
Provider
Type(s)
MD/DO,
ARNP
Billing
Codes
Allowed
Modifiers
Auth Required
J2794
Blank
No
Not payable with 96372
on same date of service
Unlimited benefit.
Max of 1 per day. Must include NDC#
and # of units.
Management – new patient
CMHC
99201 –
99205
Blank or GT
No
CMHC
99211 –
99215
Blank or GT
No
CMHC
Blank
No
CMHC
99221 99223,
9923199233,
99238,
99239,
99304 99310
H0036
HA, HB, HH,
HJ, or HK
Effective11/1/2013,
CBH’s benefit for CPST
(H0036) will be changing
from “no auth required”
to “auth required if > 48
units over 3 calendar
months.” See note*.
CMHC
H0038
Blank, GT,
or HQ
Yes – if more than 1,000
units per member
lifetime
CMHC
H2011
Blank
units per episode
Unlimited benefit.
Maximum of 1 unit of any 99xxx code
per day. 1 unit = 1 visit.
Management – established
patient
Unlimited benefit.
Inpatient or nursing facility
care/consultation
Unlimited benefit.
Community psychiatric
support and treatment
necessity.
1 unit = 15 minutes.
Peer support
Unlimited benefit.
Crisis intervention
necessity.
Maximum of 96 units per day. 1 unit
= 15 minutes
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Service Description
Comprehensive community
support services
(consolidated FSS)
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth Required
CMHC
H2015
Blank
Yes
CMHC
H2017
Blank, HQ,
or TJ
Yes – if more than 3,000
units per member
lifetime
CMHC
T1017
Blank
units in one calendar
quarter
CMHC
T1023
Blank
No
CMHC
H0032
HA
No
Benefit limited to 400 units per fiscal
year.
Maximum of 12 units per day. 1 unit
= 15 minutes.
Psychosocial rehabilitation,
Individual or Group
necessity.
Targeted case management
necessity.
State Hospital Screening
Assessment
necessity.
1 unit = 1 visit.
Community Based Services
Team (CBST)
Assessment/screening
necessity.
1 unit = 1 visit
Note*: Effective 11/1/2013, Cenpatico Behavioral Health’s benefit for Community Psychiatric
Support and Treatment (H0036) will be changing from “no authorization required” to
“authorization required if more than 48 units over 3 calendar months.” Additional units (over the 48
units every 3 calendar months) would then be available based on the review and approval
of an Outpatient Authorization Treatment Request. If it is determined that the Member meets
medical necessity criteria for continued CPST services, past the 48 units available every three
calendar months, Cenpatico will authorize additional services up to 3 months at a time. The
number of units being authorized past the 48 units will be based on the Member’s individualized
needs. If an OTR is not submitted, and an authorization is not obtained, claims for units beyond
the 48 per three calendar months will be denied for ‘no authorization on file.’ CPST services
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provided prior to 10/1/2013 will not count towards the member’s totals. This benefit will mirror
processes already in place for Targeted Case Management. This decision was made after
obtaining input from KDADS and is expected to bring our benefit limits in line with other
expectations pertaining to KanCare benefits for behavioral health services.
Positive Behavioral Support (PBS) Services
Providers of PBS services will be enrolled as provider type 11 (Mental Health Provider) and (new)
provider specialty 239 (Positive Behavior Support). Providers of PBS services must have successfully
completed Kansas Institute for Positive Behavior Support (KIPBS) training and have received a
certificate of completion and PBS Facilitator identification number. A PBS Prior authorization form
can be located on the Cenpatico Website and must be submitted prior to rendering services.
Services prior to 4/1/2014 must be billed to Sunflower.
Service Description
PBS Environmental
Assessment
Billable Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
Must be PBS
certified
H2027
Blank
Yes
Must be PBS
certified
H2027
U3
Yes
Must be PBS
certified
90882
22
Yes
1 unit = 15 minutes
Maximum of 120 units
PBS Treatment
1 unit = 15 minutes
Maximum of 240 units
PBS Person-Centered
Planning
1 unit = 1 hour
Maximum of 40 units
Screening, Brief Intervention and Referral for Treatment
(SBIRT) for Alcohol and Drug Use
Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based approach to
identifying patients who use alcohol and other drugs at risky levels, with the goal of reducing and
preventing related health consequences, disease, accidents and injuries. The goal of SBIRT is not
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Page 57
to identify alcohol or other drug dependent individuals. SBIRT is intended to meet the public
health goal of reducing the harms of societal costs associated with risky use.
Approved providers must have a certificate of completion with a score of 70% or greater from an
approved SBIRT training in order to provide SBIRT services. The State of Kansas will maintain an
approved SBIRT training list.
Service Description
Alcohol and /or drug screening
Limited to 1 annual screening
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
Must be
SBIRT
certified
H0049
Blank
No
Must be
SBIRT
certified
H0050
Blank
No
Must be
SBIRT
certified
99408
Blank
No
Must be
SBIRT
certified
99409
Blank
No
Maximum of 1 unit. 1 unit = 1 hour
Alcohol and/or drug service, brief
intervention, per 15 minutes
1 Unit = 15 mins.
Limited to four (4) units or one (1) hour of service
per day.
Limited to sixteen (16) per enrollment year or
rolling 12 months based on plan type
Alcohol and/or substance use
disorder structured screening, and
brief intervention services 15-30
minutes
Maximum of 1 unit. 1 unit = 15-30 minutes
Intervention counts as 1 toward the 16 per
enrollment year limit
Alcohol and/or substance use
disorder structured screening, and
brief intervention services; greater
than 30 minutes (Full Screen)
Maximum of 1 unit. 1 unit = > 30 minutes
Intervention counts as 1 toward the 16 per
enrollment year limit
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Substance Use Disorders Services
Licensed Clinical Addictions Counselors are only eligible to bill independently for places of service
11 (office) and 12 (home).
Any practitioner providing and billing substance use disorder services must meet the Behavioral
Sciences Review Board (BSRB) requirements for such services.
Any staff performing substance use disorder services at a facility such as a Substance Abuse
Treatment Facility/Substance Use Disorder Facility (SATF), a Community Mental Health Center
(CMHC), or similar, may provide these services within their scope of practice.
Any reference to CMHC below is intended for facilities that may hold multiple licensures within
Kansas and under one of their licensures they are eligible to offer these services below.
As of 1/1/2014, H0004 and H0005 no longer require prior authorization but must be entered in to
the KCPC system for tracking purposes.
Service Description
Assessment /referral
Billable
Provider
Type(s)
CMHC,
SATF, LCAC
Billing
Codes
H0001
Allowed
Modifiers
Blank or GT
necessity.
Auth
Required
Yes -if
more than 1
in 6 rolling
months
V71.09 will be accepted as a primary
diagnosis. LAC must practice within a
facility.
visit.
Individual counseling
necessity.
CMHC,
SATF, LCAC
H0004
Blank or GT
No
CMHC,
SATF, LCAC
H0005
Blank or GT
No
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
CMHC,
SATF, LCAC
H0006
Blank or GT
Yes
LAC must practice within a facility.
Group counseling
necessity.
Service Description
Case management
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Page 59
Unlimited benefit.
Crisis intervention
Unlimited benefit.
CMHC,
SATF, LCPC,
LCAC
H0007
Blank or GT
Yes – if
more than
288 units per
episode
SATF
H0011
Blank
Yes –if more
than 5 days
CMHC,
SATF, LCAC
H0015
Blank or HA
Yes – if
more than
45 days over
15 weeks
SATF
H0018
Blank
Yes – if
more than
14 days
SATF
H0019
Blank
Yes – if
more than
30 days
CMHC, SATF
(rendering
practitioners
must meet
AAPS
requirements)
H0038
HF or
HQ-HF
Yes –if more
than 1000
units
Acute detoxification
Unlimited benefit. 1 unit = 1 day.
Intensive outpatient program
(IOP)
necessity.
Maximum of 1 unit per day.1 unit = 1 day.
Intermediate (short term
residential)
necessity.
day.
Reintegration (long term
residential)
necessity.
day.
Peer support
Unlimited benefit.
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HCBS SED Waiver Services
“CMHC” in the table below represents any facility, clinic, community health center, etc. that is
eligible by their licensure to conduct the SED waiver services.
Service Description
Parent support and training
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
CMHC
S5110
Blank or TJ
Yes – If more
than 8 units
per member
lifetime
CMHC
T2038
Blank
Yes – If more
than 2 units
per member
lifetime
CMHC
S5150
Blank
Yes – If more
than 12 units
per member
lifetime
CMHC
H2021
Blank
Yes – If more
than 12 units
per member
lifetime
CMHC
S9485
Blank
Yes – If more
than 1 unit per
member
lifetime
CMHC
T1019
HK
Yes – If more
than 12 units
per member
lifetime
necessity.
Independent living/skills building
necessity.
1 unit = 1 service.
Short term respite care
Benefit limited to 1,200 units per calendar
year. Not covered on same day as
professional resource family care.
Wrap around facilitation
necessity.
Professional resource family
care
necessity. Not covered on same day as
short term respite care.
Maximum of 1 unit per day. 1 unit = 1 day.
Attendant care [1915(c)]
necessity.
Please note that the Targeted Case Management Service will continue to be provided within the
Community Mental Health Center, however, authorizations for services above the stated limits for
TCM must be approved by Cenpatico. Sunflower Health Plan Members who are recipients of
HCBS SED Waiver services will have access to the MCO’s Care Coordination/Intensive Care
Coordination program as an additional resource for the coordination of care and access to
Member resources.
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Upon the initiation of HCBS SED Waiver Services, the provider should submit the Member’s Interim
Budget and any other supporting documentation for initial approval of continued services over
the limits referenced in the SED Waiver Services Section of this Manual. Ongoing services related
to the HCBS SED Waiver will be authorized based medical necessity and guidance outlined in the
HCBS SED Waiver Manual. All SED waiver services are to be requested via the Outpatient
Treatment Request form and faxed into Cenpatico; the plan of care is to be entered into the
Lucidity System.
1915(b)(3) Services
Only Members who have been determined to be part of the target population, SPMI or SED, can
access 1915 (b) (3) services.
Service Description
Billable
Provider
Type(s)
Attendant care
Billing
Codes
Allowed
Modifiers
Auth
Required
CMHC
T1019
HE
CMHC-non
hospital
based or
non CMHC
provider
99366,
99367,
99368
Blank or GT
Yes – if more
than 2,000
units per
member
lifetime
Yes – if more
than 32 units
per member
lifetime
necessity.
Case conference
necessity.
Maximum of 1 unit per day. 1 unit = 1 visit.
HCBS Autism Waiver Services
Speech/language services for Interpersonal Communication Therapy provided under the HCBS
Autism Waiver should be billed to Sunflower Health Plan for reimbursement. The STRS OTR is
available on the Cenpatico website.
Service Description
Consultative clinical and
therapeutic services
necessity.
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
Autism
specialist,
CMHC
H2015
Blank
Yes – if more
than 200
units per
calendar
year
KMAPenrolled
provider for
parent
support
and
T1027
Blank or HQ
Yes
Parent support and training
necessity.
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Service Description
Family Adjustment Counseling
necessity.
Intensive individual supports
necessity.
Respite
necessity.
Billable
Provider
Type(s)
training,
CMHC
KMAPenrolled
provider for
family
adjustment
counseling,
CMHC
KMAPenrolled
provider for
intensive
individual
supports,
CMHC
KMAPenrolled
provider for
respite
care,
CMHC
Billing
Codes
Allowed
Modifiers
Auth
Required
S9482
Blank or HQ
Yes
H2019
Blank
Yes
T1005
Blank
Yes
Please note that members on the Autism Waiver will continue to receive their Targeted Case
Management services through their Autism Specialist as well as an assigned care coordinator
through Cenpatico.
Sunflower Heath Plan will ensure completion of the Health Risk Assessment.
Kan-be-Healthy Services
Service Description
Evaluation and assessment
Unlimited benefit.
Maximum of 1 unit per day. 1 unit = 1 visit.
Service plan development
Unlimited benefit.
www.cenpatico.com
Billable
Provider
Type(s)
Billing
Codes
Allowed
Modifiers
Auth
Required
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP,
LMHPCMHC
MD/DO,
ARNP, PhD,
LSCSW,
LCPC, LCP,
LCMFT,
LMLP,
LMHPCMHC
H0031
Blank
No
H0032
Blank
No
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Federally Qualified Health Center and Rural Health Clinic Services
Service Description
Encounter
Billable
Provider
Type(s)
Clinic
Maximum of 1 unit per day.
Billing
Codes
Allowed
Modifiers
Auth
Required
Regular
Service
Codes
Blank
No
Modifier Definitions:
The modifier list below contains commonly billed modifiers. Please refer to Covered
Services and Authorization Grid to identify required/accepted modifiers for each
covered service.
Modifier
GT
HA
HB
HF
HH
HJ
HK
HQ
TJ
Definition/State Use
Telehealth Services
Child/adolescent program
Adult program
Substance use disorder program
Integrated behavioral health/substance use disorder program
Employee assistance program
Specialized behavioral health program for high-risk populations
Group setting
Program group, child and/or adolescent
Location Definitions:
The location list below contains commonly billed locations. Please refer to Covered
Services and Authorization Grid to identify accepted locations for each covered
service.
Code
3
4
11
12
13
14
Description
School
Homeless shelter
Provider’s office
Home
Assisted living facility
Group home
15
Mobile unit
20
Urgent care facility
21
Inpatient hospital
22
Outpatient hospital
23
Emergency room – hospital
31
Skilled nursing facility
32
Nursing facility
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33
Custodial care facility
49
Independent clinic
50
Federally qualified health center
51
Inpatient psychiatric facility
52
Psychiatric facility partial hospitalization
53
Community mental health center
54
Intermediate care facility/mentally retarded
55
Residential substance use disorder treatment center
56
Psychiatric residential treatment center
57
Non-residential substance use disorder treatment facility
61
Comprehensive inpatient rehab facility
62
Comprehensive outpatient rehab facility
71
State or local public health clinic
72
Rural health clinic
99
Other place of service
Specialty Therapy and Rehabilitative Services (STRS)
Cenpatico offers Sunflower Health Plan Members access to all covered, medically necessary
outpatient home health, physical, occupational and speech therapy services.
Prior authorization is required for outpatient home health, physical, occupational, or speech
therapy services and prior authorization requests should be submitted to Cenpatico Specialty
Therapy and Rehabilitative Services (STRS) using the Outpatient Treatment Request (OTR) form
located at www.cenpatico.com.
Cenpatico STRS Outpatient Therapies Prior Authorization
Fax: 1-866-264-4452
Cenpatico STRS created and applies medical necessity criteria developed using Clinical Practice
Guidelines of the physical, occupational and speech Professional Associations, as well as
InterQual Criteria for both adult and pediatric guidelines. The criteria can be found on the
Cenpatico website at: www.cenpatico.com. Cenpatico STRS utilizes Physical, Occupational and
Speech Therapists to process Outpatient Treatment Requests. Our specialized approach allows
for interaction in real time with the Provider to best meet the overall therapeutic needs of the
Members.
In the event that the Provider is unable to provide timely access for a Member, Cenpatico will
assist in securing authorization to a Provider to meet the Member’s needs in a timely manner.
For more detailed information about Specialty Therapy and Rehabilitative Services, please read
the provider manual on the Sunflower Health Plan website at www.sunflowerhealthplan.com . For
additional questions, please contact Cenpatico STRS at 877-644-4623.
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Utilization Management
The Utilization Management Program
The Cenpatico Utilization Management department’s hours of operation are Monday through
Friday (excluding holidays) from 8:00 a.m. to 5:00 p.m., local time. Additionally, clinical staff is
available after hours if needed to discuss urgent UM issues. UM staff can be reached via our
toll-free number at 866-896-7293. The Cenpatico Utilization Management team is comprised of
qualified behavioral health professionals whose education, training and experience are
commensurate with the Utilization Management reviews they conduct.
Cenpatico is committed to compliance with the Mental Health Parity and Addiction Equity Act
(MHPAEA) of 2008 and the Interim Final Rule and subsequent Final Ruling.
Cenpatico will ensure compliance with MHPAEA requiring parity of both quantitative limits
(QTLS) applied to MH/SUD benefits and non-quantitative limits (NQTLS). Cenpatico administers
benefits for Substance Use Disorder (SUD) and/or behavioral health conditions as designated
and approved by the State contract and Plan benefits. MHPAE does not preempt state law,
unless law limits application of the act. We support access to care for individuals seeking
treatment for behavioral health conditions as well as Substance Use Disorders and believe in a
“no wrong door” approach. Our strategies, evidentiary standards and processes for reviewing
treatment services are no more stringent than those in use for medical/surgical benefits in the
same classification when determining to what extent a benefit is subject to NQTLs.
The Cenpatico Utilization Management Program strives to ensure:





Member care meets Medical Necessity Criteria;
Treatment is specific to the Member’s condition, is effective and is provided at the
least restrictive, most clinically appropriate level of care;
Services provided are of high clinical quality;
Utilization Management policies and procedures are systematically and consistently
applied; and
Focus on Member and family recovery, resiliency and hope.
Cenpatico’s utilization review decisions are made in accordance with currently accepted
behavioral healthcare practices, taking into account special circumstances of each case that
may require deviation from the norm stated in the screening criteria. Medical Necessity Criteria
are used for the review and approval of treatment. Plans of care that do not meet Medical
Necessity guidelines are referred to a licensed physician advisor or psychologist for review and
peer to peer discussion.
Cenpatico conducts utilization management in a timely manner to minimize any disruption in the
provision of behavioral healthcare services. The timeliness of decisions adheres to specific and
standardized time frames yet remains sufficiently flexible to accommodate urgent situations.
Utilization Management files includes the date of receipt of information and the date and time
of notification and resolution.
Cenpatico’s Utilization Management Department is under the direction of our licensed Medical
Director. The Utilization Management Staff regularly confer with the Medical Director or
physician designee on any cases where there are questions or concerns.
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Member Eligibility
Establishing Member eligibility for benefits and obtaining an authorization before treatment is
essential for the claims payment process. It is the responsibility of the Network Provider to
monitor the Member’s ongoing eligibility during the course of treatment.
Network Providers should use either of the following methodologies to verify Member eligibility;
Contact Cenpatico Customer Service at 866-896-7293 Access the Provider web portal at
www.cenpatico.com
Outpatient Notification Process
Network Providers need to adhere to the Covered Professional Services & Authorization
Guidelines set forth in this Manual when rendering services. Please refer to the Covered
Professional Services & Authorization Guidelines to identify which services require prior
authorization. Cenpatico does not retroactively authorize treatment.
Please see the Covered Professional Services and Authorization Guidelines grid to get detailed
information about the authorization limits.
Outpatient Treatment Request (OTR)/ Requesting Additional Sessions
When requesting additional sessions for those outpatient services that require authorization, the
Network Provider must complete an Outpatient Treatment Request (OTR) form and fax the
completed form to Cenpatico at 866-694-3649, The OTR is located on our website at
www.cenpatico.com. Network Providers may call Customer Service at 866-896-7293, Network
Providers should allow up to two (2) to fourteen (14) calendar days to process non-urgent
requests.
IMPORTANT:
The OTR must be completed in its entirety. The diagnosis (es), as well as all other clinical
information, must be evident. Failure to complete an OTR in its entirety can result in
authorization delay and/or denials.
Retro Authorization
Retrospective review is an initial review of both inpatient and outpatient services provided to a
Member, but for which authorization and/or timely notification to Cenpatico was not
obtained. If this is due to extenuating circumstances (i.e. Member was unconscious at time of
presentation, Member did not have their Medicaid card or otherwise indicated Medicaid
coverage, services authorized by another payer who subsequently determined Member was
not eligible at the time of service), the requests for retrospective review must be within 30
business days of the Network Provider knowing that the Member had Sunflower Health Plan
coverage. For those services, both inpatient and outpatient, where the Member was given
Medicaid coverage after the service occurred, the requests for retrospective review must be
submitted to Cenpatico within thirty (30) business days of the Medicaid card issue date. A
decision on retrospective reviews will be made within thirty (30) calendar days following receipt
of the request.
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Network Providers must submit their Retroactive Authorization request to:
Cenpatico
Attn: Appeals Department
Suite 400
Austin, TX 78759
Fax: 866-714-7991
Retro Authorizations will only be granted in rare cases, such as eligibility issues. All requests for
retro authorizations must be submitted within 180 days of the date of service and should
include a cover letter explaining why authorization was not obtained. You should provide
medical records that will be used to determine if medical necessity was met for the services
provided.
Repeated requests for Retro Authorizations will result in termination from the Cenpatico Provider
Network due to inability to follow policies and procedures.
Failure to submit a completed OTR can result in delayed authorization and may negatively
impact your ability to meet the timely filing deadlines which will result in payment denial.
Guidelines for Psychological Testing
Prior authorization is required for psychological testing must be prior-authorized, for either
inpatient or outpatient services. Testing, with prior- authorization, may be used to clarify
questions about a diagnosis as it directly relates to treatment.
It is important to note that;


Testing will not be authorized by Cenpatico for ruling out a medical condition.
Testing is not used to confirm previous results that are not expected to change.
A comprehensive initial assessment (90791 and 90792) may be conducted by the requesting
Psychologist prior to requesting authorization for testing. No authorization is required for this
assessment if the provider is contracted and credentialed with Cenpatico.
Network Providers should submit a request for Psychological Testing that includes the specific
tests to be performed. Cenpatico’s Psychological Testing Authorization Request form is located
on our website at www.cenpatico.com.
Guidelines for Requesting SED Waiver Services
When a Member qualifies for the SED Waiver Services the Network Provider is to submit the budget
and all required components into Lucidity prior to service delivery. Network Providers must also fax
the Member’s Plan of Care (POC) including signature page the same day. The number of units
allowed prior to submission of the POC is outlined in the Covered Services and Authorization
Guideline Grid, located within the Provider Manual.
In the event that an SED Waiver Services Member was not assigned to an MCO at the time of their
clinical eligibility determination, but was later assigned to Sunflower Health Plan, Cenpatico would
perform a retrospective review back to the date of Medicaid eligibility. If a Member is already
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assigned to Sunflower Health Plan, Cenpatico would require the Network Provider to follow the
Covered Services and Authorization Guidelines Grid to determine when the request needs to be
submitted.
SED WAIVER PROCESSING UPDATES
Member participation in treatment planning is a very important part of the treatment process. It
greatly enhances treatment success because it guarantees that the Member has a voice. The
ability to be heard increases the Member’s engagement in their treatment and healing process.
Cenpatico and the State of Kansas expect that all Members, age 5 years and above, shall attend
treatment planning sessions unless there is a mitigating reason why such Member should not be
present for their Plan of Care reviews. (Reference SED Waiver Manual page 19).
In order to facilitate successful treatment planning sessions, Cenpatico recommends:

Meetings should take place during times and at specific locations that are convenient for
the Member.

Natural support systems will be identified by the facilitator and those supports will be
incorporated into the meetings.
If a member presents with challenging behaviors, Cenpatico suggests that the CMHC’s explore
the following options in an effort to increase the Member’s participation in treatment planning
meetings. These may include:

Provision of natural supports

Attendant care

Allowing the member to attend part of the meeting to verbalize what will help them be
successful in their treatment and help to individualize the goals
If a member is unable to attend treatment planning after reasonable accommodations have
been provided, there must be documentation on the signature line of the treatment plan and
also documented in the progress notes as to why the member was unable to participate.
Inability of a member to participate may include:

Illness of the member

Documentation that indicates participation in treatment planning would be emotionally
harmful to the member. Note the risk of this should be evaluated on a continued basis to
assess readiness to participate in future treatment planning.
The Plan of Care (POC) update must be submitted within 2 weeks of the meeting date in order to
be considered for approval of the entire timeframe. The POC should be faxed the same day that
the budget is entered into Lucidity along with supporting documentation. Cenpatico will only
backdate fourteen (14) calendar days. This timeframe excludes the initial plan of care which
remains the same. If the budget has been entered into Lucidity and if all required documentation
has been submitted timely, then backdating guidelines would not apply when there are financial
eligibility issues.
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Plans of Care should be completed at least every 90 days. If it is greater than ninety (90) days
since the last review, a request for authorization will not be approved for days where there is no an
active Plan of Care.
Cenpatico does not require a signature page or Plan of Care review for SED Waiver Services if the
provider is only seeking an increase in the number of units of a service. Please indicate in the note
section of Lucidity what types of units are being increased (monthly, crisis, post crisis budget etc.).
Also, specify the type of additional services that are being requested. This process is not to be
used if there is an addition or deletion of a service as this would be a significant clinical change.
Cenpatico will process the request and add the units in to the existing authorization.
Guidelines for SUD Authorizations
Network Providers requesting authorization for SUD services must utilize the KCPC system. The
Network Provider will request the services and units via KCPC, and Cenpatico staff will review the
authorization in the KCPC system. Beginning January 1, 2014, H0004 and H0005 no longer require
prior authorization but must be entered in to the KCPC system for tracking.
Guidelines for the Autism Waiver Services
Providers who are requesting authorization for Autism Waiver Services are to request these services
via the Autism Waiver Outpatient Treatment Request Form, located on the Cenpatico website.
Guidelines for Inpatient Screening and Admission to PRTF
Members who are in need of inpatient hospitalization are to receive an inpatient screening from
the local CMHC. The Network Provider conducting the screening is to arrange the hospitalization
and submit the screening to Cenpatico by the next business day. Once the Member arrives at the
facility, the facility is to notify Cenpatico within 24 hours of admission. Concurrent reviews will occur
with the Cenpatico Utilization Manager. The screening for inpatient hospitalization will be honored
for up to five (5) days post the date of the screen.
Members who are in need of PRTF placement are to receive a screening assessment from the
CMHC. The CMHC will notify Cenpatico of the outcome of the screen and invite Cenpatico case
management staff to participate in the CBST meeting. Screenings for PRTF placement will be
honored for up to fifteen (15) days post the date of the screen.
Medical Necessity
Member coverage is not an entitlement to utilization of all covered benefits, but indicates
services that are available when medical necessity criteria (MNC) are satisfied. Network
Providers are expected to work closely with Cenpatico’s Utilization Management Department in
exercising judicious use of a Member’s benefit and to carefully explain the treatment plan to the
Member in accordance with the Member’s benefits offered by Sunflower Health Plan. Utilization
management will review OTR’s based on MNC, and will outreach to the Provider for further
clinical information as needed.
Cenpatico uses InterQual Criteria for behavioral health services, both adult and pediatric
guidelines. InterQual is a nationally recognized instrument that provides a consistent, evidencebased platform for care decisions and promotes appropriate use of services and improved
health outcomes. Cenpatico utilizes the American Society of Addiction Medicine Patient
Placement Criteria (ASAM) for substance use disorder Medical Necessity Criteria. For Substance
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Use Disorder (SUD) Providers who are currently utilizing KCPC, Cenpatico will continue to utilize the
KCPC system. Additionally, Cenpatico has adopted the Kansas State Medicaid Manual service
descriptions and medical necessity guidelines for all community based services.
ASAM and the InterQual criteria sets are proprietary and cannot be distributed in full; however, a
copy of the specific criteria relevant to any individual need for authorization is available upon
request. Community-Based Services criteria can be found on the Cenpatico website at:
www.cenpatico.com.
ASAM, InterQual and our Community Based Services criteria are reviewed on an annual basis by
the Cenpatico Provider Advisory Committee that is comprised of Network Providers as well as
Cenpatico clinical staff.
Cenpatico is committed to the delivery of appropriate service and coverage, and offers no
organizational incentives, including compensation, to any employed or contracted UM staff
based on the quantity or type of utilization decisions rendered. Review decisions are based only
on appropriateness of care and service criteria, and UM staff is encouraged to bring
inappropriate care or service decisions to the attention of the Medical Director.
Concurrent Review
Cenpatico’s Utilization Management Department will concurrently review the treatment and
status of all Members in inpatient (including crisis stabilization units) and partial hospitalization
through contact with the Member’s attending physician or the facility’s Utilization and
Discharge Planning departments. The frequency of review for all higher levels of care will be
determined by the Member’s clinical condition and response to treatment. The review will
include evaluation of the Member’s current status, proposed plan of care and discharge plans.
Peer Clinical Review Process
If the Utilization Manager is unable to certify the requested level of care based on the
information provided, they will initiate the peer review process.
For continued stay requests, the physician or treating provider is notified about the opportunity
for a telephonic peer-to-peer review with the Peer Reviewer to discuss the plan of treatment.
The Peer Reviewer initiates at least three (3) telephone contact attempts within twenty-four (24)
hours prior to issuing a clinical determination. All attempts to reach the requestor are
documented in the Utilization Management Record. If the time period allowed to provide the
information expires without receipt of additional information, a decision is made based on the
information available. When a determination is made where no peer-to-peer conversation has
occurred, a Provider can request to speak with the Peer Reviewer who made the determination
within one (1) business day. Providers should contact Cenpatico at 866-896-7293 to discuss UM
denial decisions.
The Peer Reviewer consults with qualified board certified sub-specialty psychiatrists when the
Peer Reviewer determines the need, when a request is beyond his/ her scope, or when a
healthcare provider submits good cause in writing.
As a result of the Peer Clinical Review process, Cenpatico makes a decision to approve or deny
authorization for services.
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Notice of Action (Adverse Determination)
When Cenpatico determines that a specific service does not meet criteria and will therefore not
be authorized, Cenpatico will submit a written notice of action (or denial) notification to the
treating Network Provider, Providers rendering the service(s) and the Member. The notification
will include the following information/ instructions:
1. The reason(s) for the proposed action in clearly understandable language;
2. A reference to the criteria, guideline, benefit provision, or protocol used in the decision,
communicated in an easy to understand summary;
3. A statement that the criteria, guideline, benefit provision, or protocol will be provided
upon request;
4. Information on how the Provider may contact the Peer Reviewer to discuss decisions and
proposed actions. When a determination is made where no peer-to-peer conversation
has occurred, the Peer Reviewer who made the determination (or another Peer
Reviewer if the original Peer Reviewer is unavailable) will be available within one (1)
business day of a request by the treating Provider to discuss the determination;
5. Instructions for requesting an appeal including the right to submit written comments or
documents with the appeal request; the Member’s right to appoint a representative to
assist them with the appeal, and the timeframe for making the appeal decision;
6. For all urgent precertification and concurrent review clinical adverse decisions,
instructions for requesting an expedited appeal; and
7. The right to have benefits continues pending resolution of the appeal, how to request
that benefits be continued, and the circumstances under which the Member may be
required to pay the costs of these services.
Discharge Planning
Follow up after hospitalization is one of the most important markers monitored by Cenpatico to
help Members remain stable and to reduce preventable readmissions into acute levels of care.
Follow up after discharge is monitored closely by the National Committee for Quality Assurance
(NCQA), which has developed and maintains the Health Care Effectiveness Data Information
Set (HEDIS). Even more importantly, increased compliance with this measure has been proven to
minimize no-shows in outpatient treatment, thereby improving Member engagement in
behavioral health services.
While a Member is in an inpatient facility receiving acute care services, Cenpatico’s Utilization
and Case Managers work with the facility’s treatment team to make arrangements for
continued care with outpatient Network Providers. Every effort is made to collaborate with the
outpatient Network Providers to assist with transition back to the community and a less
restrictive environment as soon as the Member is stable. Discharge planning should be initiated
on admission.
Prior to discharge from an inpatient setting, an ambulatory follow-up appointment must be
scheduled within seven (7) days after discharge. Cenpatico Coordination/Case Management
staff will follow-up with the Member prior to this appointment to remind him/her of the
appointment. If a Member does not keep his/her outpatient appointment after discharge,
Network Providers should inform Cenpatico as soon as possible. Upon notification of a no-show,
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Care Coordination staff will follow up with the Member and assist with rescheduling the
appointment and provide resources as needed to ensure appointment compliance.
Continuity of Care
When Members are newly enrolled and have previously received behavioral health services,
Cenpatico will authorize care as needed to minimize disruption and promote continuity of
care. Cenpatico will work with non-participating Providers (those that are not contracted and
credentialed in Cenpatico’s Provider Network) to continue treatment or create a transition
plan to facilitate the transfer of a Member’s care to a participating Network Provider.
In addition, if Cenpatico determines that a Member is in need of services that are not covered
benefits, the Member will be referred to an appropriate Provider and Cenpatico will continue
to coordinate care including discharge planning.
Cenpatico will ensure appropriate post-discharge care when a Member transitions from a State
institution, and will ensure appropriate screening, assessment and crisis intervention services are
available in support of Members who are in the care and custody of the State.
Clinical Practice Guidelines
Cenpatico has adopted many of the clinical practice guidelines published by the American
Psychiatric Association and the American Academy of Child and Adolescent Psychiatry as well
as evidence-based practices for a variety of services. Clinical practice guidelines adopted
include but are not limited to: Treatment of Bipolar Disorder, Treatment of Major Depressive
Disorder, Treatment of Schizophrenia, and Post Traumatic Stress Disorder. Clinical practice
guidelines may be accessed through our web site, www.cenpatico.com, or you may request a
paper copy of the guidelines by contacting your network representative or by calling 866-8967293. Copies of our evidence based practices can be obtained in the same manner.
.Cenpatico uses associated HEDIS measures for assessing Provider compliance with the
Treatment of Major Depressive Disorder and Treatment of ADHD clinical practice guidelines.
Cenpatico encourages Network Providers to review the full suite of Cenpatico clinical practice
guidelines to support the Network Provider’s clinical treatment strategy.
Advance Directives
Cenpatico is committed to ensuring that Sunflower Health Plan Members know of, and are able
to avail themselves of their rights to execute Advance Directives. Cenpatico is equally
committed to ensuring that its Network Providers and office staff are aware of, and comply with
their responsibilities under federal and State law regarding Advance Directives.
Network Providers must ensure Members or Member representatives over the age of eighteen
(18) years receive information on Advance Directives and are informed of their right to execute
Advance Directives. Network Providers must document such information in the permanent
Member medical record.
Case Management Program
The Cenpatico/ Sunflower Health Plan case management model uses an integrated team of
registered nurses, licensed behavioral health professionals, social workers and non-clinical staff.
The model is designed to help Members obtain needed services and assist them in coordination
of their healthcare needs whether they are covered within the Sunflower Health Plan or
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Cenpatico array of covered services, from the community, or from other non-covered venues.
We recognize that multiple co-morbidities will be common among our membership. The goal of
our program is to collaborate with the Member and all treating Providers to assist our Members to
achieve the highest possible levels of wellness, functioning, and quality of life.
The program includes a systematic approach for early identification of members’ needs through
screening and assessment. In partnership with our Members, we will develop and implement an
individualized care plan that is comprehensive and will incorporate the full range of needed
services we identify with our Members. Our teams will engage Members to be fully participatory
in their health decisions and offer education as well as support for achieving Member goals.
Care plans will be shared with all treating Providers and our Care Coordinators will serve to
facilitate exchange of information between Providers and with Members.
Members who are eligible for the waiver programs and have either an SED TCM through the
community mental health center, or a TCM through Sunflower Health Plan are eligible for this
care coordination/intensive care coordination program as appropriate and the Cenpatico staff
will work collaboratively with the Community TCM or the Sunflower Health Plan TCM.
We look forward to hearing from you about any Sunflower Health Plan Members you think can
benefit from outreach by a case management team member.
To contact a case manager please call Cenpatico at 866-896-7293.
Disease Management
Cenpatico offers Disease Management programs to Sunflower Health Plan Members with
depression to provide a coordinated approach in managing the disease and improve the health
status of the Member. This is accomplished by identifying and providing the most effective and
efficient resources, enhancing collaboration between medical and behavioral health providers
and ongoing monitoring of outcomes of treatment. Cenpatico’s Disease Management programs
are based on clinical practice guidelines and include research evidence-based practices.
Multiple communication strategies are used in Disease Management programs to include written
materials, telephonic outreach, and web-based information, in person outreach through
MemberConnections program and case managers, and participation in community events.
Claims
Cenpatico Claims Department Responsibilities
Cenpatico’s claims processing responsibilities are as follows:

Reimburse Clean Claims (see Clean Claim section below) within the timeframes
outlined by the Prompt Payment Statute.

Reimburse interest on claims in accordance with the guidelines outlined in the Prompt
Pay Statute.
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Claims eligible for payment must meet the following requirements:

The Member is effective (eligible for coverage through Sunflower Health Plan) on
the date of service;

The service provided is a covered service (benefit of Sunflower Health Plan) on
the date of service; and

Cenpatico’s prior-authorization processes were followed.
Cenpatico’s reimbursement is based on clinical licensure, covered service billing codes and
modifiers, and the compensation schedule set forth in the Network Provider’s Agreement with
Cenpatico. Reimbursement from Cenpatico will be accepted by the Network Provider as
payment in full, not including any applicable copayments or deductibles.
It is the responsibility of the Network Provider to collect any applicable copayments
or deductibles from the Member.
CENPATICO DOES NOT ACCEPT BLACK OR COPIED FORMS. Providers need to use
only original forms that meet CMS requirements. The only acceptable claim forms
are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of
the CMS-1500 form can be downloaded, the copies of the form cannot be used for
submission of claims, since your copy may not accurately replicate the scale and
OCR color of the form.
Clean Claim
A clean claim is a claim submitted on an approved or identified claim format (CMS-1500 or
CMS-1450 [“UB-04”] or their successors or electronic equivalents) that contains all data fields
required by Cenpatico and the State, for final adjudication of the claim. A clean claim has no
defect, impropriety, lack of any required substantiating documentation, or particular
circumstance requiring special treatment that prevents timely payment. The required data
fields must be complete and accurate. A Clean Claim must also include Cenpatico’s published
requirements for adjudication, such as: NPI Number, Tax Identification Number, or medical
records, as appropriate. Clean Claims do not include claims submitted by or on behalf of a
Provider who is under investigation for fraud or abuse, or a claim that is under review for
medical necessity.
Claims lacking complete information are returned to the Network Provider for completion
before processing or information may be requested from the Provider on an Explanation of
Benefit (EOB) form. This will cause a delay in payment.
Explanation of Payment (EOP)
An Explanation of Payment (EOP) is provided with each claim payment or denial. The EOP will
detail each service being considered, the amount eligible for payment, copayments/
deductibles deducted from eligible amounts, and the amount reimbursed.
If you have questions regarding your EOP, please contact Cenpatico’s Claims Customer
Service department at 866-896-7293.
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Network Provider Billing Responsibilities
Please submit claims immediately after providing services. Claims must be received within one
hundred and eighty (180) days of the date the service(s) are rendered. Claims submitted after
this period will be denied payment for untimely filing.
Claim Submission Options
Network Providers are strongly encouraged to utilize our available electronic means for
claim submission. Electronic claim submission results in improved processing accuracy as
well as quicker claim adjudication and payment.
Web Portal Claim Submission
Cenpatico’s website provides an array of tools to help you manage your business needs and
to access information of importance to you.
The following information is available on www.cenpatico.com:







Provider Directory
Frequently Used Forms
EDI Companion Guides
Billing Manual
Secure Web Portal Manual
Provider Manual
Managing EFT
Cenpatico also offers our all Providers and their office staff the opportunity to register for our
Secure Web Portal. You may register by visiting www.cenpatico.com and creating a username
and password. Once registered you may begin utilizing these additional available services:

Submit Professional and Institutional claims individually or as batches





Submit corrected claims
View and check claim status
View and download payment history
View and print Member eligibility
Contact us securely and confidentially
We are continually updating our website with the latest news and information. Be sure to
bookmark www.cenpatico.com to you favorites and check back often.
EDI Clearinghouses
Cenpatico’s network Providers may choose to submit their claims through a clearinghouse.
Cenpatico accepts EDI transactions through the following vendors:
Emdeon (866-369-8805)
Cenpatico’s Payor ID Number is 68068
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For further information regarding electronic submission, contact the Cenpatico EDI Department
at 800-225-2573, ext. 25525 or email at ediba@centene.com
Paper Claim Submission
All paper claims and encounters or claims that have been corrected for resubmission, or claims
for which the Provider is requesting reconsideration should be mailed or submitted to the below
address. All claims must be filed on a CMS-1500 Form or a CMS-1450 Form (“UB-04”) or their
successors.
KanCare
Office of the Fiscal Agent
P.O. Box 3571
Topeka, KS 66601-3571
Imaging Requirements for Paper Claims
Cenpatico uses an imaging process for claims retrieval. To ensure accurate and timely claims
capture, please observe the following claims submission rules:
Do:

Use original red claim forms

Submit all claims in a 9” x 12” or larger envelope

Complete forms correctly and accurately with black or blue ink only (or typewritten)

Ensure typed print aligns properly within the designated boxes on the claim form

Submit on a proper form; CMS-1500 or CMS-1450 (“UB04”)

Whenever possible refrain from submitting hand written claims
Do Not:

Use red ink on claim forms

Circle any data on claim forms

Add extraneous information to any claim form field

Use highlighter on any claim form field

Submit carbon copied claim forms

Submit claim forms via fax
Common Claim Processing Issues
It is the Network Provider’s responsibility to obtain complete information from Cenpatico and
the Member and then to carefully review the CMS-1500, or its successor claim form and/or CMS1450 (“UB-04”), or its successor claim form, prior to submitting claims to Cenpatico for payment.
This prevents delays in processing and reimbursement.
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Some common problem areas are as follows:

Failure to obtain prior-authorization

Federal Tax ID number not included

Provider’s NPI number not included in field 24J (CMS-1500) or field 56 (CMS-1450)

Insufficient Member ID Number. Network Providers are encouraged to call Cenpatico to
request the Member’s Medicaid ID prior to submitting a claim

Visits or days provided exceed the number of visits or days authorized

Date of service is prior to or after the authorized treatment period

Network Provider is billing for unauthorized services, such as the using the wrong CPT
Code

Insufficient or unidentifiable description of service performed

Member exceeded benefits

Claim form not signed by Network Provider

Multiple dates of services billed on one CMS-1500 claim form are not listed on separate
claim detail lines

Diagnosis code is incomplete or not specified to the highest level available –
be sure to use 4th and 5th digit when applicable

Hand written claims are often illegible and require manual intervention, thereby
increasing the risk of error and time delay in processing claims.
Services that require prior-authorization may be denied if authorization was not obtained.
Cenpatico reserves the rights to deny payment for services provided that are not medically
necessary.
Electronic Funds Transfer and Electronic Remittance
Cenpatico and PaySpan Health are in a partnership to provide an innovative web based
solution for Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). This
service is provided at no cost to Providers and allows online enrollment.
Using this free service, Providers can take advantage of EFTs and ERAs to settle claims
electronically, without making an investment in additional software. Following a fast online
enrollment, you will be able to receive ERAs and import the information directly into your
Practice Management or Patient Accounting System, eliminating the need to key remittance
data off of paper advices.
Visit www.payspanhealth.com to enroll, or call PaySpan Health at 1-877-331-7154.
Cenpatico Billing Policies
Member Hold Harmless
Under no circumstances is a Member to be balance billed for covered services or supplies. If
the Network Provider uses an automatic billing system, bills must clearly state that they have
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been filed with the insurer and that the participant is not liable for anything other than specified
un-met deductible or copayments (if any).
Please Note:

A Network Provider’s failure to authorize the service(s) does not qualify/ allow the
Network Provider to bill the Member for service(s).

Sunflower Health Plan Members may not be billed for missed sessions (“No-Show”).
Non-Covered Services
If a Network Provider renders a non-covered service to a Member, the Network Provider may
bill the Member only if he/ she has obtained written acknowledgement from the Member, prior
to rendering such non-covered service, that the specific service is not a covered benefit under
Sunflower Health Plan or Cenpatico, and that the Member understands they are responsible
for reimbursing the Network Provider for such services.
Claims Payment and Member Eligibility
Cenpatico’s Network Providers are responsible for verifying Member eligibility for each referral
and service provided on an ongoing basis.
When Cenpatico refers a Member to a Network Provider, every effort has been made to obtain
the correct eligibility information. If it is subsequently determined that the Member was not
eligible at the time of service (Member was not covered under Sunflower Health Plan or
benefits were exhausted), a denial of payment will occur and the reason for denial will be
indicated on the Explanation of Payment (EOP) accompanying the denial.
In this case, the Network Provider should bill the Member directly for services rendered while
the Member was not eligible for benefits.
It is the Member’s responsibility to notify the Network Provider of any changes in his/her insurance
coverage and/or benefits.
Coordination of Benefits
Coordination of benefits will be done for all Members with two or more types of insurance
coverage. The insurance plan that is primary pays its full benefits first. The primary insurance
carrier’s explanation of payment (EOP) or explanation of benefits (EOB) is then sent to the
secondary carrier (Cenpatico) for coordination of benefits. The EOP or EOB will explain the
primary’s payment or denial process. Cenpatico will coordinate benefits for Members as the
secondary payer.
Claims requiring coordination of benefits must be submitted to Cenpatico within 365 calendar
days from the date of disposition (final determination) of the primary payer. Claims received
outside of this timeframe will be denied for untimely submission.
For Medicare cross-over claims, Cenpatico shall coordinate benefits for dual eligible Members
by paying the lesser amount of: Cenpatico’s allowed amount minus the Medicare payment, or
the Medicare co-insurance and deductible up to Cenpatico’s allowed amount. For services
that are not covered by Medicare, or other primary payer, Cenpatico will process claims as
primary payer so long as other insurance information has been supplied on the claim.
Cenpatico follows KMAP TPL policy. All KMAP TPL billing requirements still apply. Please refer to
KMAP General TPL Payment Provider manual.
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Claim Status
Please do not submit duplicate bills for previously submitted services. If your Clean Claim has not
been adjudicated within thirty (30) days, please call Cenpatico’s Claims Customer Service
department at 866-896-7293 to determine status of the claim.
To expedite your call, please have the following information available when you contact
Cenpatico’s Claims Customer Service department:

Member Name

Member Date of Birth

Member ID Number

Date of Service

Procedure Code Billed

Amount Billed

Cenpatico Authorization Number

Network Provider’s Name

Network Provider’s NPI Number

Network Provider’s Tax Identification Number
Resolving Claims Issues
Claim Reconsideration
If a claim discrepancy is discovered, in whole or in part, the following action may be taken:
1. Call Cenpatico Customer Service at 866-896-7293. The majority of issues regarding
claims can be resolved through Customer Service.
2. When a Provider has submitted a claim and received a denial due to incorrect or
missing information, a corrected claim should be submitted within 180 days from date of
original EOP either electronically or on paper. If submitting a paper claim for review or
reconsideration of the claims disposition, the claim must clearly be marked as
RESUBMISSION along with the original claim number written at the top of the claim.
Failure to mark the claim may result in the claim being denied as a duplicate. Corrected
paper claim resubmissions should be sent to the following address:
KanCare
Office of the Fiscal Agent
P.O. Box 3571
Topeka, KS 66601-3571
3. For cases where authorization has been denied because the case does not meet the
necessary criteria, the Appeals Process, described in the denial letter is the appropriate
means of resolution. If a claim was denied due to no authorization on file, please send a
request in writing for a retroactive authorization, explaining in detail the reason for
providing services without an authorization. Cenpatico contracts with physicians who are
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Page 80
not Network Providers to resolve claims disputes related to denial on the basis of medical
necessity that remain unresolved subsequent to a Provider appeal. The physician
resolving the dispute will hold the same specialty or a related specialty as the appealing
Provider. Mail requests to the following address:
Cenpatico Care
Management
Suite 400
Austin, TX 78759
Retro authorizations will only be granted in rare cases. Repeated requests for retro
authorizations will result in termination from the network due to inability to follow policies
and procedures. If the authorization contains unused visits, but the end date has
expired, please call Cenpatico Customer Service and ask the representative to extend
the end date on your authorization.
4. If a resubmission has been processed and the Network Provider is dissatisfied with
Cenpatico’s response, an appeal of this decision may be filed by writing to the address
listed below. Note: Appeals must be filed in writing. Place APPEAL within the request. In
order for Cenpatico to consider the appeal it must be received within 90 days of the
date on the EOP which contains the service line(s) being appealed, unless otherwise
stated in the Network Provider’s contract.
Cenpatico Appeals
PO Box 6000
Farmington, MO 63640-3809
5. Network Providers unable to resolve specific claims issues through these avenues may
initiate the Payment Dispute Process. Please contact the Cenpatico Provider
Relations Representative about the specific issue. Provide detailed information about
efforts to resolve the payment issue. Making note of which staff spoken with will help
Cenpatico assist you. Steps 1-4 should be followed prior to initiating the Payment
Dispute Process. After contacting Provider Relations at the address below, the dispute
will be investigated.
Network Providers can contact their Cenpatico Provider Relations Specialist as follows:
Telephone: 866-944-7588
Fax: 866-263-6521
Email: ProviderRelationsKS@cenpatico.com
National Provider Identifier (NPI)
Cenpatico requires all claims be submitted with a Network Provider’s National Provider Identifier
(NPI). This will be required on all electronic and paper claims. Network Providers must ensure
Cenpatico has their correct NPI Number loaded in their system profile. Typically, each Network
Provider’s NPI Number is captured through the credentialing process.
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Applying for an NPI
Providers can apply for an NPI via the web or by mail.

To Register Online:
To register for an NPI using the web-based process, please visit the following website
www.nppes.cms.hhs.gov/NPPES
Click on the link that says “If you are a healthcare provider, the NPI is your unique
identifier. ”Then click on the link that says “Apply online for an NPI.” This should be the
first link. Follow the instructions on the web page to complete the process.

To Register By Mail
To obtain an NPI paper application, please call 800-465-3203 (NPI Toll- Free).
Submitting Your NPI to Cenpatico
Please visit www.cenpatico.com to submit your NPI number. Network Providers may elect to
contact the Cenpatico Provider Relations Representative by telephone or email to submit their
NPI.
Taxonomy Codes
Network Providers that submit Cenpatico claims through KMAP should include their Taxonomy
Code. Claims billed without a Taxonomy Code may be routed to Sunflower Health Plan and
subsequently denied payment.
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CMS 1500 (2/12) Claim Form Instructions
Required (R) fields must be completed on all claims. Conditional (C) fields must be
completed if the information applies to the situation or the service provided.
NOTE: Claims with missing or invalid Required (R) field information will be rejected
or denied.
FIELD#
FIELD DESCRIPTION
1
Insurance Program
Identification
1a
INSURED I.D. NUMBER
2
PATIENT’S NAME (Last
Name, First Name,
Middle Initial)
3
PATIENT’S BIRTH DATE /
SEX
4
INSURED’S NAME
5
PATIENT'S ADDRESS
(Number, Street, City,
State, Zip code)
Telephone (include area
code)
6
PATIENT’S RELATION TO
INSURED
www.cenpatico.com
INSTRUCTION OR COMMENTS
REQUIRED OR
CONDITIONAL
Check only the type of health coverage
applicable to the claim. This field indicates the
payer to whom the claim is being filed. Select
"D", other.
The 10-digit Medicaid identification number on
the Member’s CENPATICO I.D. card.
Enter the patient's name as it appears on the
member's Cenpatico I.D. card. Do not use
nicknames.
Enter the patient’s 8-digit date of (MMDDYYYY)
and mark the appropriate box to indicate the
patient’s sex/gender.
M = male
F = female
Enter the patient's name as it appears on the
member's Cenpatico I.D. card.
Enter the patient's complete address and
telephone number including area code on the
appropriate line.
 First line – Enter the street address. Do not
use commas, periods, or other punctuation
in the address (e.g., 123 N Main Street 101
instead of 123 N. Main Street, #101).
 Second line – In the designated block, enter
the city and state.
 Third line – Enter the zip code and phone
number. When entering a 9-digit zip code
(zip+4 code), include the hyphen. Do not
use a hyphen or space as a separator
within the telephone number (i.e.
(803)5551414). Note: Patient’s Telephone
does not exist in the electronic 837
Professional 4010A1.
Always mark to indicate self.
Page 83
Not Required
R
R
R
R
R
C
FIELD#
FIELD DESCRIPTION
7
INSURED'S ADDRESS
(Number, Street, City,
State, Zip code)
Telephone (include area
code)
8
RESERVED FOR NUCC USE
OTHER INSURED'S NAME
(LAST NAME, FIRST NAME,
MIDDLE INITIAL)
9
*OTHER INSURED’S
POLICY OR GROUP
NUMBER
INSURANCE PLAN NAME
OR PROGRAM NAME
9a
9b
9c
9d
10a, b,
c
10d
11
11a
11b
11c
11d
REQUIRED OR
CONDITIONAL
Enter the patient's complete address and
telephone number including area code on the
appropriate line.
 First line – Enter the street address. Do not
use commas, periods, or other punctuation
in the address (e.g., 123 N Main Street 101
instead of 123 N. Main Street, #101).
 Second line – In the designated block, enter
the city and state.
 Third line – Enter the zip code and phone
(803)551414). Note: Patient’s Telephone
does not exist in the electronic 837
Professional 4010A1.
Please leave blank
Refers to someone other than the patient.
REQUIRED if patient is covered by another
insurance plan. Enter the complete name of
the insured. NOTE: COB claims that require
attached EOBs must be submitted on paper.
REQUIRED if # 9 is completed. Enter the policy
of group number of the other insurance plan.
Not Required
Not Required
C
C
Please leave blank
Please leave blank
REQUIRED if # 9 is completed. Enter the other
insured’s (name of person listed in box 9)
insurance plan or program name.
Enter a Yes or No for each category/line (a, b,
and c). Do not enter a Yes and No in the same
category/line.
Not Required
Not Required
CLAIM CODES
(DESIGNATED BY NUCC)
Please leave blank
Not Required
INSURED’S POLICY
GROUP OR FECA
NUMBER
INSURED’S DATE OF BIRTH
/ SEX
OTHER CLAIM ID
(DESIGNATED BY NUCC)
INSURANCE PLAN NAME
OR PROGRAM NAME
IS THERE ANOTHER
HEALTH BENEFIT PLAN
REQUIRED when other insurance is available.
Enter the policy, group, or FECA number of the
other insurance.
C
IS PATIENT'S CONDITION
RELATED TO:
www.cenpatico.com
Same as field 3.
R
C
Please leave blank
Not Required
Enter name of the insurance Health Plan or
program.
Mark Yes or No. If Yes, complete # 9a-d and
#11c.
Page 84
C
C
R
FIELD#
FIELD DESCRIPTION
12
PATIENT’S OR
AUTHORIZED PERSON’S
SIGNATURE
Enter “Signature on File”, “SOF”, or the actual
legal signature. The Provider must have the
Member’s or legal guardian’s signature on file
or obtain their legal signature in this box for the
release of information necessary to process
and/or adjudicate the claim.
13
INSURED OR AUTHORIZED
PERSON’S SIGNATURE
DATE OF CURRENT:
ILLNESS (First symptom)
OR INJURY (ACCIDENT)
OR PREGNANCY (LMP)
14
15
REQUIRED OR
CONDITIONAL
Not Required.
Enter the 6-digit (MMDDYY) or 8-digit
(MMDDYYYY) date reflecting the first date of
onset for the:
 Present illness
 Injury
 LMP (last menstrual period) if pregnant
OTHER DATE
16
17
17a
17b
DATES PATIENT UNABLE
TO WORK IN CURRENT
OCCUPATION
NAME OF REFERRING
PROVIDER OR OTHER
SERVICE
ID number of referring
PROVIDER
NPI number of referring
physician
HOSPITALIZATION DATES
RELATED TO CURRENT
SERVICES
ADDITIONAL CLAIM
INFORMATION
(DESIGNATED FOR NUCC)
OUTSIDE LAB / CHARGES
18
19
20
21 A-L
DIAGNOSIS OR NATURE
OF ILLNESS OR INJURY.
www.cenpatico.com
Required
C
C
Not Required
Enter the name of the referring physician or
professional (First name, middle initial, last
name, and credentials).
Required if 17 is completed. Use ZZ qualifier for
Taxonomy code.
Required if 17 is completed. If unable to obtain
referring NPI, servicing NPI may be used.
C
C
C
Not Required
Please leave blank
Not Required
Not Required
Enter the diagnosis or condition of the patient
using the appropriate release/update of ICD-9CM Volume 1 for the date of service. Diagnosis
codes submitted must be a valid ICD-9 codes
for the date of service and carried out to its
highest digit – 4th or“5”. "E" codes are NOT
acceptable as a primary diagnosis. NOTE:
Claims missing or with invalid diagnosis codes
will be denied for payment.
Page 85
R
FIELD#
FIELD DESCRIPTION
RESUBMISSION CODE /
ORIGINAL REF.NO.
22
Prior authorization
number
23
24A-J
Gener
al
Inform
ation
24A-G
Shade
d
24A
Unshade
d
REQUIRED OR
CONDITIONAL
For re-submissions or adjustments, enter the 12character DCN (Document Control Number) of
the original claim. A resubmitted claim MUST be
marked using large bold print within the body of
the claim form with “RESUBMISSION” to avoid
denials for duplicate submission. NOTE: Resubmissions may NOT currently be submitted via
EDI.
Enter the Cenpatico authorization or referral
number. Refer to the Cenpatico Provider
Manual for information on services requiring
referral and/or prior authorization.
C
Not Required
Box 24 contains 6 claim lines. Each claim line is split horizontally into shaded and un-shaded
areas. Within each un-shaded area of a claim line there are 10 individual fields labeled A-J.
Within each shaded area of a claim line there are 4 individual fields labeled 24A-24G, 24H, 24J
and 24J. Fields 24A through 24G are a continuous field for the entry of supplemental
information. Instructions are provided for shaded and un-shaded fields.
 The shaded area for a claim line is to accommodate the submission of supplemental
information, EPSDT qualifier, Provider Medicaid Number qualifier, and Provider Medicaid
Number.
 Shaded boxes a-g is for line item supplemental information and is a continuous line that
accepts up to 61 characters. Refer to the instructions listed below and in Appendix 4 for
information on how to complete.
 The un-shaded area of a claim line is for the entry of claim line item detail.
The shaded top portion of each service claim
line is used to report supplemental information
for:
 NDC
 Anesthesia Start/Stop time & duration
supplemental
 Unspecified, miscellaneous, or unlisted CPT
C
information
and HCPC code descriptions.
 HIBCC or GTIN number/code.
DATE(S) OF SERVICE
www.cenpatico.com
For detailed instructions and qualifiers refer to
Appendix 4 of this manual.
Enter the date the service listed in 24D was
performed (MMDDYY). If there is only one
date enter that date in the “From” field. The
“To” field may be left blank or populated with
the “From” date. If identical services (identical
CPT/HCPC code(s)) were performed within a
date span, enter the date span in the “From”
and “To” fields. The count listed in field 24G for
the service must correspond with the date span
entered.
Page 86
R
FIELD#
FIELD DESCRIPTION
24B
Unshade
d
PLACE OF SERVICE
24C
Unshade
d
EMG
REQUIRED OR
CONDITIONAL
Enter the appropriate 2-digit CMS standard
place of service (POS) code. A list of current
POS codes may be found on the CMS website
or the following link:
http://www.cms.hhs.gov/PlaceofServiceCodes/
Downloads/placeofservice.pdf
Enter Y (Yes) or N (No) to indicate if the service
was an emergency.
R
R
Enter the 5-digit CPT or HCPC code and 2character modifier– - if applicable. Only one
CPT or HCPC and up to 4 modifiers may be
entered per claim line. Codes entered must be
valid for date of service. Missing or invalid
codes will be denied for payment.
24D
Unshade
d
PROCEDURES, SERVICES
OR SUPPLIES CPT/HCPCS
MODIFIER
Only the first modifier entered is used for pricing
the claim. Failure to use modifiers in the correct
position or combination with the procedure
code, or invalid use of modifiers, will result in a
rejected, denied, or incorrectly paid claim.
R
The following modifiers are recognized as
modifiers that will impact the pricing of your
claim. Modifiers that indicate licensure level
must be placed in the first modifier position for
correct pricing.
24E
Unshade
d
DIAGNOSIS CODE
24F
Unshade
d
CHARGES
www.cenpatico.com
HA
HE
HN
HO HQ
HR
HT
SA
TF
TG
Enter the numeric single digit diagnosis pointer
(1,2,3,4) from field 21. List the primary diagnosis
for the service provided or performed first
followed by any additional or related diagnosis
listed in field 21 (using the single digit diagnosis
pointer, not the diagnosis code.) Do not use
commas between the diagnosis pointer
numbers. Diagnosis codes must be valid ICD-9
codes for the date of service or the claim will
be rejected/denied.
Enter the charge amount for the claim line item
service billed. Dollar amounts to the left of the
vertical line should be right justified. Up to 8
characters are allowed (i.e. 199,999.99). Do not
enter a dollar sign ($). If the dollar amount is a
whole number (i.e. 10.00), enter 00 in the area
to the right of the vertical line.
Page 87
R
R
FIELD#
24G
Unshade
d
24H
Shade
d
24H
Unshade
d
24I
Shade
d
FIELD DESCRIPTION
DAYS OR UNITS
Enter quantity (days, visits, units). If only one
service provided, enter a numeric value of 1.
R
EPSDT (CHCUP) Family
Planning
Leave Blank
Not Required
EPSDT (CHCUP) Family
Planning
ID QUALIFIER
24Ja
Shade
d
Non-NPI PROVIDER ID#
24Jb
Unshade
d
NPI PROVIDER ID
26
FEDERAL TAX I.D.
NUMBER SSN/EIN
PATIENT’S ACCOUNT NO.
27
ACCEPT ASSIGNMENT?
28
TOTAL CHARGES
25
www.cenpatico.com
REQUIRED OR
CONDITIONAL
Enter the appropriate qualifier for EPSDT visit
C
Use ZZ qualifier for Taxonomy
C
Enter as designated below the Medicaid ID
number or taxonomy code.
 Typical Providers:
Enter the Provider taxonomy code or
Medicaid Provider ID number that
corresponds to the qualifier entered in 24I
shaded. Use ZZ qualifier for taxonomy
code.
 Atypical Providers:
Enter the 6-digit Medicaid Provider ID
number.
Typical Providers ONLY: Enter the 10-character
NPI ID of the provider who rendered services.
Providers that are contracted with Cenpatico
under a “Facility Provider Agreement” should
enter the organization’s NPI number, not the NPI
number of the Provider rendering the service.
Enter the Provider or supplier 9-digit Federal Tax
ID number and mark the box labeled EIN.
Enter the Provider's billing account number.
Enter an X in the YES box. Submission of a claim
for reimbursement of services provided to a
Medicaid recipient using Medicaid funds
indicates the Provider accepts Medicaid
assignment. Refer to the back of the CMS 1500
(12-90) form for the section pertaining to
Medicaid Payments.
Enter the total charges for all claim line items
billed – claim lines 24F. Dollar amounts to the
left of the vertical line should be right justified.
Up to 8 characters are allowed (i.e. 199,999.99).
Do not enter a dollar sign ($). If the dollar
amount is a whole number (i.e. 10.00), enter 00
in the area to the right of the vertical line.
Page 88
R
R
R
Not Required
R
R
FIELD#
FIELD DESCRIPTION
REQUIRED OR
CONDITIONAL
REQUIRED when another carrier is the primary
payer. Enter the payment received from the
primary payer prior to invoicing Cenpatico.
Medicaid programs are always the payers of
last resort.
29
AMOUNT PAID
30
RSVD FOR NUCC USE
Please leave blank
31
SIGNATURE OF
PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR
CREDENTIALS
If there is a signature waiver on file, you may
stamp, print, or computer-generate the
signature. Note: does not exist in the electronic
837P.
REQUIRED if the location where services were
rendered is different from the billing address
listed in field 33.
Dollar amounts to the left of the vertical line
should be right justified. Up to 8 characters are
allowed (i.e. 199,999.99). Do not enter a dollar
sign ($). If the dollar amount is a whole number
(i.e. 10.00), enter 00 in the area to the right of
the vertical line.
C
Not Required
R
Enter the name and physical location. (P.O. Box
#’s are not acceptable here.)
First line – Enter the business/facility/practice
name.
 Second line– Enter the street address. Do
not use commas, periods, or other
punctuation in the address (e.g., 123 N Main
Street 101 instead of 123 N. Main Street,
#101).
 Third line – In the designated block, enter
the city and state.
 Fourth line – Enter the zip code and phone
(zip+4 code), include the hyphen.
Typical Providers ONLY: REQUIRED if the
location where services were rendered is
different from the billing address listed in field
33.

32
SERVICE FACILITY
LOCATION
INFORMATION
32a
NPI – SERVICES
RENDERED
C
C
Enter the 10-character NPI ID of the facility
where services were rendered.
www.cenpatico.com
Page 89
FIELD#
FIELD DESCRIPTION
REQUIRED OR
CONDITIONAL
REQUIRED if the location where services were
rendered is different from the billing address
listed in field 33.
Typical Providers
Enter the 2-character qualifier ZZ followed
by the taxonomy code (no spaces).
 Atypical Providers
Enter the 2-character qualifier 1D followed
by the 6-character Medicaid Provider ID
number (no spaces).
Enter the billing Provider’s complete name,
address (include the zip + 4 code), and phone
number.

32b
OTHER PROVIDER ID
First line – Enter the business/facility/practice
name.
 Second line– Enter the street address. Do
not use commas, periods, or other
punctuation in the address (e.g., 123 N Main
Street 101 instead of 123 N. Main Street,
#101).
 Third line – In the designated block, enter
the city and state.
 Fourth line – Enter the zip code and phone
(803)551414).
Typical Providers ONLY: REQUIRED if the
location where services were rendered is
different from the billing address listed in field
33.
C

33
BILLING PROVIDER INFO
& PH #
33a
GROUP BILLING NPI
33b
GROUP BILLING OTHER ID
www.cenpatico.com
Enter the 10-character NPI ID.
Enter as designated below the Billing Group
Medicaid ID number or taxonomy code.
 Typical Providers:
Enter the Provider taxonomy code. Use ZZ
qualifier.
 Atypical Providers:
Enter the 6-digit Medicaid Provider ID
number.
Page 90
R
R
R
UB-04 Claim Form Instructions
Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if
the information applies to the situation or the service provided.
NOTE: Claims with missing or invalid Required (R) field information will be rejected or
denied.
FIELD
FIELD
Description
Required or
Conditional
*
Instructions and Comments
Line 1: Enter the complete provider name.
Line 2: Enter the complete mailing address.
1
(UNLABELED
FIELD)
Line 3: Enter the City, State, and zip+4 code (include hyphen). NOTE: the 9-digit zip
(zip + 4 code) is a requirement for paper and EDI claims.
R
Line 4: Enter the area code and phone number.
2
(UNLABELED
FIELD)
Enter the facility patient account/control number
3a
PATIENT
CONTROL NO.
MEDICAL
RECORD
NUMBER
Enter the facility patient medical or health record number.
3b
Not
Required
Enter the Pay-To Name and Address.
Not
Required
R
Enter the appropriate 3-digit type of bill (TOB) code as specified by the NUBC UB-04
Uniform Billing Manual minus the leading “0” (zero). A leading “0” is not needed. Digits
should be reflected as follows:
4
TYPE OF BILL
1st digit - Indicating the type of facility.
R
2nd digit - Indicating the type of care
3rd digit - Indicating the billing sequence.
Enter the 9-digit number assigned by the federal government for tax reporting
purposes.
5
FED. TAX NO.
6
Enter begin and end or admission and discharge dates for the services billed. Inpatient
STATEMENT
and outpatient observation stays must be billed using the admission date and discharge
R
COVERS PERIOD date. Outpatient therapy, chemotherapy, laboratory, pathology, radiology and dialysis
FROM/THROUGH may be billed using a date span. All other outpatient services must be billed using the
actual date of service. (MMDDYY)
www.cenpatico.com
Page 91
R
FIELD
7
FIELD
Description
(UNLABELED
FIELD)
Required or
Conditional
*
Not
Not Used
Required
8a – Enter the patient’s 13-digit Medicaid identification number on the member’s
Sunflower I.D. card.
8
a-b
PATIENT NAME
Not
Required
8b – Enter the patient’s last name, first name, and middle initial as it appears on the
Sunflower Health Plan ID card. Use a comma or space to separate the last and first
names.
Titles (Mr., Mrs., etc.) should not be reported in this field.
Prefix: No space should be left after the prefix of a name e.g. McKendrick. H
Hyphenated names: Both names should be capitalized and separated by a hyphen (no
space).
Suffix: A space should separate a last name and suffix.
Enter the patient’s complete mailing address of the patient.
Line a: Street address
R
R
9
a-e
PATIENT
ADDRESS
Line b:
Line c:
Line d:
Line e:
10
BIRTHDATE
Enter the patient’s date of birth (MMDDYYYY)
R
11
SEX
Enter the patient's sex. Only M or F is accepted.
R
12
Enter the date of admission for inpatient claims and date of service for outpatient
ADMISSION DATE claims.
13
ADMISSION
HOUR
City
State
ZIP code
Country Code (NOT REQUIRED)
(except line
9e)
Enter the time using 2-digit military time (00-23) for the time of inpatient admission or
time of treatment for outpatient services.
00-12:00 midnight to 12:59
12- 12:00 noon to 12:59
01- 01:00 to 01:59
13- 01:00 to 01:59
02- 02:00 to 02:59
14- 02:00 to 02:59
03- 03:00 to 03:39
15- 03:00 to 03:59
04- 04:00 to 04:59
16- 04:00 to 04:59
05- 05:00 to 05:59
17- 05:00 to 05:59
06- 06:00 to 06:59
07- 07:00 to 07:59
08- 08:00 to 08:59
09- 09:00 to 09:59
10- 10:00 to 10:59
11- 11:00 to 11:59
R
R
18- 06:00 to 06:59
19- 07:00 to 07:59
20- 08:00 to 08:59
21- 09:00 to 09:59
22- 10:00 to 10:59
23- 11:00 to 11:59
Required for inpatient admissions (TOB 11X, 118X, 21X, 41X). Enter the 1-digit code
indicating the priority of the admission using one of the following codes:
14
15
1
ADMISSION TYPE 2
3
4
5
ADMISSION
SOURCE
Emergency
Urgent
C
Elective
Newborn
Trauma
Enter the 1-digit code indicating the source of the admission or outpatient service using
one of the following codes:
For Type of admission 1,2,3 or 5
1
2
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Physician Referral
Clinic Referral
Page 92
FIELD
FIELD
Description
Required or
Conditional
*
3
4
5
6
7
8
9
Health Maintenance Referral (HMO)
Transfer from a hospital
Transfer from Skilled Nursing Facility (SNF)
Transfer from another healthcare facility
Emergency Room
Court/Law enforcement
Information not available
For type of admission 4 (newborn):
1
2
3
4
5
16
DISCHARGE
HOUR
Normal Delivery
Premature Delivery
Sick Baby
Extramural Birth
Information not available
Enter the time using 2-digit military time (00-23) for the time of inpatient or outpatient
discharge. Do not enter a dis charge hour if patient status is “30 – Still a patient”.
00-12:00 midnight to 12:59
12- 12:00 noon to 12:59
01- 01:00 to 01:59
13- 01:00 to 01:59
02- 02:00 to 02:59
14- 02:00 to 02:59
03- 03:00 to 03:39
15- 03:00 to 03:59
04- 04:00 to 04:59
16- 04:00 to 04:59
C
05- 05:00 to 05:59
17- 05:00 to 05:59
06- 06:00 to 06:59
07- 07:00 to 07:59
08- 08:00 to 08:59
09- 09:00 to 09:59
10- 10:00 to 10:59
11- 11:00 to 11:59
18- 06:00 to 06:59
19- 07:00 to 07:59
20- 08:00 to 08:59
21- 09:00 to 09:59
22- 10:00 to 10:59
23- 11:00 to 11:59
REQUIRED for inpatient claims. Enter the 2-digit disposition of the patient as of the
“through” date for the billing period listed in field 6 using one of the following codes:
01 Routine Discharge
2 Discharged to another short-term general hospital
3 Discharged to SNF
04 Discharged to ICF
5 Discharged to another type of institution
6 Discharged to care of home health service organization
07 Left against medical advice
8 Discharged/transferred to home under care of a Home IV provider
9 Admitted as an inpatient to this hospital (only for use on Medicare outpatient
hospital claims)
20 Expired or did not recover
17
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C
Page 93
PATIENT STATUS 30 Still patient (To be used only when the client has been in the facility for 30
consecutive days if payment is based on DRG)
40 Expired at home (hospice use only)
41 Expired in a medical facility (hospice use only)
42 Expired—place unknown (hospice use only)
43 Discharged/Transferred to a federal hospital (such as a Veteran’s Administration
[VA] hospital)
50 Hospice—Home
51 Hospice—Medical Facility
61 Discharged/ Transferred within this institution to a hospital-based Medicare
approved
swing bed
62 Discharged/ Transferred to an Inpatient rehabilitation facility (IRF), including
rehabilitation distinct part units of a hospital
www.cenpatico.com
Page 94
FIELD
FIELD
Description
Required or
Conditional
*
63 Discharged/ Transferred to a Medicare certified long-term care hospital (LTCH)
64 Discharged/ Transferred to a nursing facility certified under Medicaid but not
certified under Medicare
65 Discharged/ Transferred to a Psychiatric hospital or psychiatric distinct part unit of
a hospital
66 Discharged/transferred to a critical access hospital (CAH)
18-28
CONDITIO
N CODES
REQUIRED when applicable. Condition codes are used to identify conditions relating to
the bill that may affect payer processing.
Each field (18-24) allows entry of a 2-character code. Codes should be entered in
alphanumeric sequence (numbered codes precede alphanumeric codes).
C
For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing
Manual.
29
30
31-34
a-b
35-36
a-b
ACCIDENT
STATE
Not
Required
Not
Required
(UNLABELED
FIELD)
Not Used
OCCURRENCE
CODE and
OCCURENCE
DATE
Occurrence Code: REQUIRED when applicable. Occurrence codes are used to identify
events relating to the bill that may affect payer processing.
Each field (31-34a) allows entry of a 2-character code. Codes should be entered in
C
Manual.
Occurrence Date: REQUIRED when applicable or when a corresponding Occurrence
Code is present on the same line (31a-34a). Enter the date for the associated
occurrence code in MMDDYYYY format.
OCCURRENCE
SPAN CODE
and
OCCURRENCE
DATE
Occurrence Span Code: REQUIRED when applicable. Occurrence codes are used to
identify events relating to the bill that may affect payer processing.
Each field (31-34a) allows entry of a 2-character code. Codes should be entered in
Manual.
www.cenpatico.com
Page 95
C
FIELD
FIELD
Description
Required or
Conditional
*
Occurrence Span Date: REQUIRED when applicable or when a corresponding
Occurrence Span code is present on the same line (35a-36a). Enter the date for the
associated occurrence code in MMDDYYYY format.
37
38
39-41
a-d
(UNLABELED
FIELD)
REQUIRED for re-submissions or adjustments. Enter the DCN (Document Control
Number) of the original claim. A resubmitted claim MUST be marked using large bold
print within the body of the claim form with “RESUBMISSION” to avoid denials for
duplicate submission.
RESPONSIBLE
PARTY NAME
AND ADDRESS
VALUE CODES
CODES and
AMOUNTS
C
Not
Required
Code: REQUIRED when applicable. Value codes are used to identify events relating to
the bill that may affect payer processing.
Each field (39-41) allows entry of a 2-character code. Codes should be entered in
Up to 12 codes can be entered. All “a” fields must be completed before using “b” fields,
all “b” fields before using “c” fields, and all “c” fields before using “d” fields.
Manual.
Amount: REQUIRED when applicable or when a Value Code is entered. Enter the
dollar amount for the associated value code. Dollar amounts to the left of the vertical
line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not
enter a dollar sign ($) or a decimal. A decimal is implied. If the dollar amount is a whole
number (i.e. 10.00), enter 00 in the area to the right of the vertical line.
C
General
Informatio
SERVICE LINE
n
DETAIL
Fields
42-47
The following UB-04 fields – 42-47:
Have a total of 22 service lines for claim detail information.
Fields 42, 43, 45, 47, 48 include separate instructions for the completion of lines 1-22 and line 23.
42
REV CD
Line 1-22
Enter the appropriate revenue codes itemizing accommodations, services, and items
furnished to the patient. Non-covered revenue codes listed in the KanCare Hospital
Provider Manual will be denied. Refer to the NUBC UB-04 Uniform Billing Manual for a
R
complete listing of revenue codes and instructions.
Enter accommodation revenue codes first followed by ancillary revenue codes. Enter
codes in ascending numerical value.
www.cenpatico.com
Page 96
FIELD
FIELD
Description
Required or
Conditional
*
Rev CD
Enter 0001 for total charges.
R
DESCRIPTION
Enter a brief description that corresponds to the revenue code entered in the service
line of field 42.
R
42
Line 23
43
Line 1-22
43
Line 23
44
PAGE
OF
HCPCS/RATES
Enter the number of pages. Indicate the page sequence in the “PAGE” field and the
total number of pages in the “OF” field. If only one claim form is submitted enter a “1” in R
both fields (i.e. PAGE “1” OF “1”).
REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the
service line revenue code billed. The field allows up to 9 characters. Only one
CPT/HCPC and up to two modifiers are accepted. When entering a CPT/HCPCS with a
modifier(s) do not use a spaces, commas, dashes or the like between the CPT/HCPC
C
and modifier(s)
Refer to the NUBC UB-04 Uniform Billing Manual for a complete listing of revenue
codes and instructions.
Please refer to the Kansas Hospital Provider Manual.
45
Line 1-22
45
Line 23
46
SERVICE DATE
REQUIRED on all outpatient claims. Enter the date of service for each service line
C
billed. (MMDDYY) Multiple dates of service may not be combined for outpatient claims
CREATION DATE
Enter the date the bill was created or prepared for submission on all pages submitted.
(MMDDYY)
R
SERVICE UNITS
Enter the number of units, days, or visits for the service. A value of at least “1” must be
entered. For inpatient room charges, enter the number of days for each
accommodation listed.
R
47
Line 1-22
47
Line 23
TOTAL CHARGES Enter the total charge for each service line.
R
TOTALS
Enter the total charges for all service lines.
R
Enter the non-covered charges included in field 47 for the revenue code listed in field
42 of the service line. Do not list negative amounts.
C
TOTALS
Enter the total non-covered charges for all service lines.
C
(UNLABELED
FIELD)
Not Used
48
NON-COVERED
Line 1-22 CHARGES
48
Line 23
49
www.cenpatico.com
Not
Required
Page 100
FIELD
50
A-C
51
A-C
FIELD
Description
PAYER
Required or
Conditional
*
Enter the name for each Payer from which reimbursement is being sought in the order
of the Payer liability. Line A refers to the primary payer; B, secondary; and C, tertiary.
HEALTH PLAN
IDENTIFICATION
NUMBER
R
Not
Required
REL. INFO
REQUIRED for each line (A, B, C) completed in field 50. Release of Information
Certification Indicator. Enter “Y” (yes) or “N” (no).
Providers are expected to have necessary release information on file. It is expected
that all released invoices contain "Y”.
R
53
ASG. BEN.
Enter “Y" (yes) or "N" (no) to indicate a signed form is on file authorizing payment by
the payer directly to the Provider for services.
R
54
PRIOR
PAYMENTS
Enter the amount received from the primary payer on the appropriate line when
Medicaid/ Sunflower Health Plan is listed as secondary or tertiary.
C
55
EST. AMOUNT
DUE
56
NATIONAL
PROVIDER
IDENTIFIER or
PROVIDER ID
Required: Enter Provider’s 10-character NPI ID.
R
57
OTHER
PROVIDER ID
a. Enter the numeric Provider Medicaid identification number assigned by the Medicaid
program.
b. Enter the TPI number (non -NPI number) of the billing Provider
R
58
For each line (A, B, C) completed in field 50, enter the name of the person who carries
INSURED'S NAME the insurance for the patient. In most cases this will be the patient’s name. Enter the
name as last name, first name, middle initial.
R
59
PATIENT
RELATIONSHIP
Not
Required
60
INSURED’S
UNIQUE ID
61
GROUP NAME
Not
Required
62
INSURANCE
GROUP NO.
Not
Required
63
TREATMENT
Enter the Prior Authorization or referral when services require pre-certification.
AUTHORIZATION
CODES
C
52
A-C
64
DOCUMENT
CONTROL
NUMBER
65
EMPLOYER
NAME
Not
Required
REQUIRED: Enter the patient's Insurance/Medicaid ID exactly as it appears on the
patient's ID card. Enter the Insurance /Medicaid ID in the order of liability listed in field
50.
R
Enter the 12-character Document Control Number (DCN) of the paid HEALTH claim
when submitting a replacement or void on the corresponding A, B, C line reflecting
Cenpatico from field 50.
C
Applies to claim submitted with a Type of Bill (field 4) Frequency of “7” (Replacement of
Prior Claim) or Type of Bill Frequency of “8” (Void/Cancel of Prior Claim).
* Please refer to reconsider/corrected claims section
www.cenpatico.com
Not
Required
Page 101
FIELD
FIELD
Description
66
DX VERSION
QUALIFIER
Required or
Conditional
*
Not
Required
Enter the principal/primary diagnosis or condition using the appropriate release/update
of ICD-9/10-CM Volume 1& 3 for the date of service.
67
PRINCIPAL
DIAGNOSIS
CODE
Diagnosis code submitted must be a valid ICD-9/10 code for the date of service and
R
carried out to its highest level of specificity– 4th or“5” digit. "E" and most “V” codes are
NOT acceptable as a primary diagnosis. Please refer to the Covered Diagnosis section
of this manual for more information.
Note: Claims with missing or invalid diagnosis codes will be denied
67
A-Q
OTHER
DIAGNOSIS
CODE
Enter additional diagnosis or conditions that coexist at the time of admission or that
develop subsequent to the admission and have an effect on the treatment or care
received using the appropriate release/update of ICD-9/10-CM Volume 1& 3 for the
date of service.
Diagnosis codes submitted must be a valid ICD-9 codes for the date of service and
C
carried out to its highest level of specificity – 4th or“5” digit. "E" and most “V” codes are
Note: Claims with incomplete or invalid diagnosis codes will be denied.
68
69
(UNLABELED)
ADMITTING
DIAGNOSIS
CODE
Not
Required
Not Used
Enter the diagnosis or condition provided at the time of admission as stated by the
physician using the appropriate release/update of ICD-9/10-CM Volume 1& 3 for the
date of service.
Diagnosis codes submitted must be a valid ICD-9/10 codes for the date of service and
R
carried out to its highest level of specificity – 4th or“5” digit. "E" codes and most “V” are
Note: Claims with missing or invalid diagnosis codes will be denied.
70
PATIENT
Enter the ICD-9/10-CM code that reflects the patient’s reason for visit at the time of
outpatient registration. 70a requires entry, 70b-70c are conditional.
Diagnosis codes submitted must be valid ICD-9/10 codes for the date of service and
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Page 102
R
a,b,c
REASON CODE
FIELD
FIELD
Description
carried out to its highest digit – 4th or“5”. "E" codes and most “V” are NOT acceptable as
a primary diagnosis. Please refer to the Covered Diagnosis section of this manual for
more information.
Required or
Conditional
*
Note: Claims with missing or invalid diagnosis codes will be denied
71
PPS / DRG CODE
Not
Required
72
a,b,c
EXTERNAL
CAUSE CODE
Not
Required
73
(UNLABELED)
Not
Required
74
PRINCIPAL
PROCEDURE
CODE / DATE
REQUIRED on inpatient claims when a procedure is performed during the date span of
the bill.
CODE: Enter the ICD-9/10 procedure code that identifies the principal/primary
procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code. It
C
is implied.
DATE: Enter the date the principal procedure was performed (MMDDYY).
REQUIRED for EDI Submissions.
74
a-e
OTHER
PROCEDURE
CODE DATE
75
(UNLABELED)
REQUIRED on inpatient claims when a procedure is performed during the date span of
the bill.
CODE: Enter the ICD-9 procedure code(s) that identify significant a procedure(s)
performed other than the principal/primary procedure. Up to 5 ICD-9 procedure codes
C
may be entered. Do not enter the decimal between the 2nd or 3rd digits of code. It is
implied.
DATE: Enter the date the principal procedure was performed (MMDDYY).
Not
Required
Enter the NPI and Name of the physician in charge of the patient care:
NPI: Enter the attending physician 10-character NPI ID.
76
ATTENDING
PHYSICIAN
Taxonomy Code: Enter valid taxonomy code
QUAL: Enter one of the following qualifier and ID number
0B – State License #
1G – Provider UPIN
G2 – Provider Commercial #
ZZ – Taxonomy Code
R
LAST: Enter the attending physician’s last name
FIRST: Enter the attending physician’s first name.
REQUIRED when a surgical procedure is performed:
NPI: Enter the operating physician 10-character NPI ID.
Taxonomy Code: Enter valid taxonomy code
77
OPERATING
PHYSICIAN
ZZ – Taxonomy Code
C
LAST: Enter the operating physician’s last name
FIRST: Enter the operating physician’s first name.
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78 & 79
OTHER
PHYSICIAN
Enter the Provider Type qualifier, NPI, and Name of the physician in charge of the
patient care:
(Blank Field): Enter one of the following Provider Type Qualifiers:
DN – Referring Provider
C
ZZ – Other Operating MD
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Page 104
FIELD
FIELD
Description
Required or
Conditional
*
82 – Rendering Provider
NPI: Enter the other physician 10-character NPI ID.
LAST: Enter the other physician’s last name.
FIRST: Enter the other physician’s first name.
80
Not
REMARKS
Required
81
CC
A: Taxonomy of billing Provider. Use ZZ qualifier
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Page 105
C

Cenpatico Provider Manual Kansas KanCare Plan www.cenpatico.com

Transcription

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