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Provider Manual

ConnectiCare Commercial Provider Manual

Introduction

Please Note:

ConnectiCare, directly and through its affiliated companies, offers a variety of fully insured and self-insured products (plans administered by ConnectiCare). The use of the term "member" in this manual refers to all covered lives in ConnectiCare’s plans.

This Physician & Provider Manual is not intended to be a complete explanation of all services, benefits, limitations, and exclusions of ConnectiCare’s products. Any conflict which might arise between the Manual and the applicable member plan document, policy, or the Administrative Services Agreement (Plan documents) will be resolved in favor of and governed by the terms and provisions of those documents.

In addition, the Physician & Provider Manual is not intended to be a complete explanation of all provider rights and responsibilities. Please refer to your provider agreement for specific information. The relationship between ConnectiCare and its contracted providers is that of independent contractors and neither ConnectiCare nor any participating provider is an employee or agent of the other.

 

PPM/11.11

Physician Responsibilities

Overview of physician responsibilities

As part of our continuing quality improvement program and in accordance with applicable NCQA guidelines, ConnectiCare will monitor provider performance against the standards outlined in this section and in accordance with the provider agreement.

 

ConnectiCare Requirements

Primary care providers (PCPs):

  • Act as a health care manager for members to arrange and coordinate their medical care, including but not limited to, routine care, and follow-up care after the receipt of emergency services.
  • Refer members for specialty services as outlined in our Passage plan guidelines.

Specialists:

  • Provide continuity and coordination of care by sending a written report to PCPs regarding any treatment or consultation provided to members, whenever the member receives services from a specialist provider, whether the service was a result of a PCP referral or the member made his/her own arrangements.

All contracted physicians:

  • Schedule appointments in a timely and efficient manner. All providers are expected to follow ConnectiCare’s Access & Availability Requirements.
  • Review policy statements issued through the Physician & Provider Manual or its updates via the Office Visit, our provider newsletter, and adhere to ConnectiCare's policies and administrative requirements.
  • Refund overpayments made to you by ConnectiCare, as indicated in a written notice from ConnectiCare. Such refunds must be made to ConnectiCare within thirty (30) days of receipt of the written notice unless other arrangements are made in writing and accepted by ConnectiCare.
  • Arrange for the provision of medical services to ConnectiCare members by a participating practitioner after hours, on weekends, vacations, and holidays. Services from non-participating covering practitioners may not be covered, unless otherwise approved by ConnectiCare.
  • Help members obtain their benefit coverage by obtaining written preauthorization prior to referring for out-of-plan services, as appropriate.
  • Provide covered benefits that are in accordance with community/national standards of medical care and medical ethics.
  • Facilitate candid discussion with members regarding appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. Such discussion should include complete current information concerning a diagnosis, treatment, and prognosis, in terms that the member (or member's designee) can be expected to understand.
  • Provide to members the information necessary to give informed consent prior to the start of any procedure or treatment.
  • Maintain appropriate liability insurance coverage, as stipulated in the applicable provider agreement(s).
  • Maintain appropriate medical records regarding members and their treatment, recognizing that said records are confidential and ensuring that they are maintained in accordance with legal and ethical requirements concerning confidentiality and security.
  • Cooperate with ConnectiCare or its designee in the resolution of members’ complaints, expedited appeals, appeals and/or grievances.
  • Comply with other administrative requirements as specified in the applicable contract or stipulated in this Physician & Provider Manual or its updates.
  • Promote the efficient delivery of medical services to maximize health care resources and the member’s premium dollar and improve quality of care provided.
  • Services provided by physicians to their own family members will not be reimbursed members.

 

JP62100 6/23

Connecticut State Requirements

INTRODUCTION

The information provided in this appendix pertains to physicians and other health care providers who participate with ConnectiCare as part of our Connecticut-based provider network. The materials presented here are specific to:

  • Physicians and other health care providers who participate with ConnectiCare as a Connecticut-based provider, and
  • Benefit coverage or plan information that is unique to members covered under one of our ConnectiCare, Inc. products.

Physician-related information

I. Physician Responsibility

  • Provide ConnectiCare written notification sixty (60) days in advance of closing your practice to new patients so that ConnectiCare may update our provider directory.
  • Notify the health plan directly, or through the applicable intermediary, of any changes in status, including change of address, retirement or other changes in participation status, at least sixty (60) days in advance of any such change.

II. Practitioner Termination & Physician Appeals Process

Pursuant to applicable law and the applicable provisions of its network participation contracts, ConnectiCare has the right to suspend, restrict, or terminate practitioners whose conduct adversely affects or could adversely affect the health or welfare of a member or members, who fail to remain in compliance with ConnectiCare’s credentialing criteria, who lose privileges with an institutional provider, who has sanctions or restrictions imposed upon licensure, or who has been arrested, convicted, indicted, or charged with any felony charge related to moral turpitude or the practice of medicine.

Physicians have the right to appeal ConnectiCare’s decision to take adverse professional review action in accordance with the Health Care Quality Improvement Act of 1986. For purposes of this policy, “adverse professional review action” means an action or recommendation of ConnectiCare’s Credentialing Committee (i) which is based on the competence or professional conduct of an individual physician whose conduct affects or could affect adversely the health or welfare of a patient and (ii) which reduces, restricts, suspends, revokes, denies, or prevents renewal of the physician’s participation.

ConnectiCare reserves its right to terminate a (i) non-physician’s participation if permitted by the network participation contract and applicable law and (ii) a physician’s participation if permitted by the physician contract and applicable law, to the extent resulting for any reason other than an adverse professional review action. Physicians who are not subject to an adverse professional review action and all other practitioners have no right to appeal such termination; however, a description of the reconsideration process, if applicable, will be included in the termination letter.

Procedure

  1. Should a physician become subject to an adverse professional review action, ConnectiCare shall provide written notice to the practitioner stating:
    • That disciplinary action has been proposed against the physician;
    • The reasons for the proposed action;
    • That the physician has the right to request a hearing on the proposed action;
    • That the physician has thirty (30) business days from the date of the notice within which to request such a hearing; and
    • A summary of the practitioner’s rights in the hearing.
       
  2. If a hearing is requested on a timely basis by a phyisican who receives a notice, within ten (10) business days of its receipt of the physician's request for a hearing, ConnectiCare shall send to the physician a notice providing:
    • The place, time and date of the hearing, which shall be no more than sixty (60), but not less than thirty (30), business days after the date of the notice; and
    • A list of witnesses (if any) expected to testify at the hearing on behalf of ConnectiCare.
       
  3. Within ten (10) business days of the date of the notice sent to the physician, the physician shall provide written notice to ConnectiCare stating:
  • Whether physician will be represented by legal counsel or another representative;
  • What information, including any documents, will be presented; and
  • Whether physician will be presenting any witnesses, including the names and qualifications of each witness.

4. The appeals hearing shall be held before a subcommittee of ConnectiCare’s Quality Improvement Committee (QIC). The subcommittee shall consist of three practitioners who are not in direct economic competition with the practitioner involved.
 

5. The right to an appeals hearing may be forfeited if the physician fails, without good cause, to appear. The practitioner may designate a representative in writing with full authority of himself/herself or through an authorized representative.


6. At the appeals hearing, the physician has the right

  • to representation by an attorney or other person of the physician’s choice;
  • to have a record made of the proceedings, copies of which may be obtained by the physician upon payment of any reasonable charges associated with the preparation thereof;
  • to present evidence determined to be relevant by the subcommittee, regardless of its admissibility in a court of law; and
  • to submit a written statement at the close of the hearing.

7. Within ten (10) business days of the completion of the appeals hearing, the subcommittee shall render its decision. The QIC’s decision shall be final. The decision, along with the basis of its decision, shall be communicated in writing to the physician within five (5) business days of its having reached such decision.

8. In accordance with the requirements of applicable federal and state law, ConnectiCare shall notify the appropriate regulatory authority of any final decision of the QIC to reduce, suspend or terminate a practitioner’s participation for quality-related reasons.
 

9. Nothing in this Termination and Appeals policy shall be interpreted to preclude ConnectiCare from immediately suspending a practitioner, including a physician, for quality-related reasons, subject to subsequent notice and appeal rights, where in ConnectiCare’s sole discretion, it is determined that the failure to take such action could result in an imminent danger to the health of an individual.
 

III. Health Delivery Organization (HDO) terminations

Pursuant to applicable laws and the provisions of its network participation contracts, ConnectiCare has the right to suspend, restrict, or terminate providers whose conduct adversely affects or could adversely affect the health or welfare of a member. Such conduct may include but not be limited to, violations of ConnectiCare’s policies and procedures, failure to remain in compliance with ConnectiCare’s assessment/reassessment criteria, and/or adverse actions taken by state or federal agencies.

Procedure

  1. ConnectiCare shall provide written notice, per network participation agreement, to any HDO terminated under this policy.

  2. A description of the reconsideration process, if applicable, will be included in the termination letter.
     

PPM/11.19

Massachussetts State Requirements

INTRODUCTION

The information provided in this appendix pertains to physicians and other health care providers who participate with ConnectiCare as part of our Massachusetts-based provider network. The materials presented here are specific to:

  • physicians and other health care providers who participate with ConnectiCare as Massachusetts-based providers, and
  • benefit coverage or plan information that is unique to members covered under one of our ConnectiCare of Massachusetts, Inc. products.

 

Physician-Related Information

I. Administrative Appeals:

In accordance with Massachusetts state law, physicians may appeal a claim on behalf of a member. Member appeals are those where the member is responsible for payment for the services rendered, regardless of who initiates the appeal. Member appeals may be submitted orally, by fax, or in writing to:

Member Appeals
P.O. Box 4061
Farmington, CT 06034-4061
Fax 860-674-2866

Requests should include an explanation of why the denial should be overturned, as well as any other relevant information. The appeal must be made as soon as possible after receipt of the denial, but no later than six (6) months after the health service was rendered or the authorization of payment was denied.

ConnectiCare will acknowledge receipt of the appeal within five (5) business days. If the appeal is filed orally, ConnectiCare will put it in writing and give the member a copy within forty-eight (48) hours, unless the member agrees to extend that time period.

II. Pre-service Medical Necessity Review:

In accordance with Massachusetts state law, when a practitioner requests preauthorization for an admission, procedure or service, ConnectiCare must make a decision within two (2) working days of obtaining all necessary information. If approved, the practitioner will be notified by telephone within 24 hours of the decision with written or electronic confirmation to the practitioner and member within two (2) working days thereafter. If denied, the practitioner will be notified by telephone within 24 hours of the decision with written or electronic confirmation to the practitioner and member within one (1) working day thereafter.

For concurrent review determinations, ConnectiCare must make a determination within one (1) working day of obtaining all necessary information. If approved, the practitioner will be notified by telephone within one (1) working day of the decision with written or electronic confirmation to the practitioner and member within one (1) working day thereafter. The approval letter shall include the number of extended days, total number of days or services approved, date of admission or initiation of services, or the date of the next review. If denied, the practitioner will be notified by telephone within 24 hours of the decision with written or electronic confirmation to the practitioner and member within one (1) working day thereafter. The service will continue without liability to the member until the member has been notified of the determination.

III. Physician Responsibility

  • Provide ConnectiCare written notification sixty (60) days in advance of closing your practice to new patients so that ConnectiCare may send written notice to impacted members within required time frames.
  • Notify the health plan directly, or through the applicable intermediary, of any changes in status, including change of address, retirement or other changes in participation status, at least sixty (60) days in advance of any such change.

IV. Practitioner Termination & Physician Appeals Process

Pursuant to applicable law and the applicable provisions of its network participation contracts, ConnectiCare has the right to suspend, restrict, or terminate practitioners whose conduct adversely affects or could adversely affect the health or welfare of a member or members, who fail to remain in compliance with ConnectiCare’s credentialing criteria, who lose privileges with an institutional provider, who has sanctions or restrictions imposed upon licensure, or who has been arrested, convicted, indicted, or charged with any felony charge related to moral turpitude or the practice of medicine.

Physicians have the right to appeal ConnectiCare’s decision to take an adverse professional review action in accordance with the Health Care Quality Improvement Act of 1986. For purposes of this policy, “adverse professional review action” means an action or recommendation of ConnectiCare’s Credentialing Committee (i) which is based on the competence or professional conduct of an individual physician whose conduct affects or could affect adversely the health or welfare of a patient and (ii) which reduces, restricts, suspends, revokes, denies, or prevents renewal of the physician’s participation.

ConnectiCare reserves its right to terminate a (i) non-physician’s participation if permitted by the network participation contract and applicable law and (ii) a physician’s participation if permitted by the physician contract and applicable law, to the extent resulting for any reason other than an adverse professional review action. Physicians who are not subject to an adverse professional review action and all other practitioners have no right to appeal such termination; however, a description of the reconsideration process, if applicable, will be included in the termination letter.

Procedure

  1. Should a physician become subject to an adverse professional review action, ConnectiCare shall provide written notice to the physician stating:
    • That disciplinary action has been proposed against the physician;
    • The reasons for the proposed action;
    • That the physician has the right to request a hearing on the proposed action;
    • That the physician has thirty (30) calendar days from the date of the notice within which to request such a hearing; and
    • A summary of the physician’s rights in the hearing.
       
  2. If a hearing is requested on a timely basis by a physician who receives a notice, within ten (10) business days of its receipt of the physician’s request for a hearing, ConnectiCare shall send to the physician a notice providing:
    • The place, time and date of the hearing, which shall be no more than sixty (60), but not less than thirty (30), business days after the date of the notice; and
    • A list of witnesses (if any) expected to testify at the hearing on behalf of ConnectiCare.
       
  3. Within ten (10) business days of the date of the notice sent to the physician, the physician shall provide written notice to ConnectiCare stating:
    • Whether physician will be represented by legal counsel or another representative;
    • What information, including any documents, will be presented; and
    • Whether physician will be presenting any witnesses, including the names and qualifications of each witness
       
  4. The appeals hearing shall be held before a subcommittee of ConnectiCare’s Quality Improvement Committee (QIC). The subcommittee shall consist of three physicians who are not in direct economic competition with the physician involved.

  5. The right to an appeals hearing may be forfeited if the physician fails, without good cause, to appear. The physician may designate a representative in writing with full authority of himself/herself or through an authorized representative.

  6. At the appeals hearing, the physician has the right
    • To representation by an attorney or other person of the physician’s choice;
    • To have a record made of the proceedings, copies of which may be obtained by the physician upon payment of any reasonable charges associated with the preparation thereof;
    • To present evidence determined to be relevant by the subcommittee, regardless of its admissibility in a court of law; and
    • To submit a written statement at the close of the hearing.
       
  7. Within ten (10) business days of the completion of the appeals hearing, the subcommittee shall render its decision. The QIC’s decision shall be final. The decision, along with the basis of its decision, shall be communicated in writing to the physician within five (5) business days of its having reached such decision.

  8. In accordance with the requirements of applicable federal and state law, ConnectiCare shall notify the appropriate regulatory authority of any final decision of the QIC to reduce, suspend or terminate a practitioner’s participation for quality-related reasons.

  9. Nothing in this Termination and Appeals policy shall be interpreted to preclude ConnectiCare from immediately suspending a practitioner, including a physician, for quality-related reasons, subject to subsequent notice and appeal rights (if applicable), where in ConnectiCare’s sole discretion, it is determined that the failure to take such action could result in an imminent danger to the health of an individual.

V. Health Delivery Organization (HDO) termination

Pursuant to applicable laws and the provisions of its network participation contracts, ConnectiCare has the right to suspend, restrict, or terminate providers whose conduct adversely affects or could adversely affect the health or welfare of a member. Such conduct may include but not be limited to, violations of ConnectiCare’s policies and procedures, failure to remain in compliance with ConnectiCare’s assessment/reassessment criteria, and/or adverse actions taken by state or federal agencies.

Procedure

  1. ConnectiCare shall provide written notice, per network participation agreement, to any HDO terminated under this policy.

  2. A description of the reconsideration process, if applicable, will be included in the termination letter.

 

Member-Related Information

I. COB-Medicare eligibility
All ConnectiCare of Massachusetts, Inc. members who are eligible for Medicare will be treated as if they have Medicare Parts A & B for coordination of benefit (COB) purposes. This is the case even if the member has not elected Medicare.

 

PPM/11.19

Dispute Resolution

For information on Dispute Resolution, visit Coverage Guidelines.

ConnectiCare Medicare Provider Manual

Introduction

Introduction

ConnectiCare will provide you updates to this Manual on a regular basis via Office Visit, our provider newsletter.

If you have any questions or would like assistance with anything discussed in this Manual, please call ConnectiCare's Provider Services at 1-877-224-8230.

Please Note: This Physician & Provider Manual is not intended to be a complete explanation of all services, benefits, limitations and exclusions of the ConnectiCare Medicare Advantage Plans. Any conflict which might arise between the Manual and the applicable member plan documents will be resolved in favor of and governed by the terms and provisions of those documents. The Physician & Provider Manual is not intended to be a complete explanation of all provider rights and responsibilities. Please refer to your provider agreement for specific information. The relationship between ConnectiCare and its contracted providers is that of independent contractors and neither ConnectiCare nor any participating provider is an employee or agent of the other.

 

Medicare PPM/11.11

Physician Responsibilities

OVERVIEW OF PHYSICIAN RESPONSIBILITIES

As part of continuing quality improvement program and in accordance with Centers for Medicare & Medicaid Services (CMS) regulations and applicable National Committee for Quality Assurance (NCQA) guidelines, ConnectiCare will monitor provider performance against the standards outlined in this section and in accordance with the provider agreement.

ConnectiCare requirements

Primary care physicians (PCPs):

  • Act as a health care manager for members to arrange and coordinate their medical care, including but not limited to, routine care, and follow-up care after the receipt of emergency services.

Specialists:

  • Provide continuity and coordination of care by sending a written report to PCPs regarding any treatment or consultation provided to members, whenever the member receives services from a specialist provider, whether the service was a result of a PCP referral or the member making his/her own arrangements.

All contracted physicians:

  • Schedule appointments in a timely and efficient manner. All providers are expected to follow ConnectiCare’s Access & Availability Requirements.
  • Review policy statements issued through the Physician & Provider Manual or its updates via the Office Visit, our provider newsletter, and adhere to ConnectiCare’s policies and administrative requirements.
  • Refund overpayments made to you by ConnectiCare, as indicated in a written notice from ConnectiCare. Such refunds must be made to ConnectiCare within thirty (30) days of receipt of the written notice unless other arrangements are made in writing and accepted by ConnectiCare.
  • Arrange for the provision of medical services to ConnectiCare members by a participating practitioner after hours, on weekends, vacations, and holidays. Services from non-participating covering practitioners may not be covered, unless otherwise approved by ConnectiCare.
  • Help members obtain their benefit coverage by getting written preauthorization for services that require it, and prior to referring for out-of-plan services, as appropriate.
  • Facilitate candid discussion with members regarding appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. Such discussion should include complete current information concerning a diagnosis, treatment, and prognosis, in terms that the member (or designee) can be expected to understand.
  • Provide to members the information necessary to give informed consent prior to the start of any procedure or treatment.
  • Maintain appropriate liability insurance coverage, as stipulated in the applicable provider agreement(s).
  • Maintain appropriate medical records regarding members and their treatment, recognizing that said records are confidential and ensuring that they are maintained in accordance with legal and ethical requirements concerning confidentiality and security.
  • Cooperate with ConnectiCare or its designee in the resolution of members' complaints, expedited appeals, appeals and/or grievances.
  • Comply with other administrative requirements as specified in the applicable contract or stipulated in this Physician & Provider Manual or its updates.
  • Promote the efficient delivery of medical services to maximize health care resources and the member's premium dollar and improve quality of care provided.
  • Refrain from providing treatment to the physician’s own family members.
  • Provide medical information in a culturally competent manner and promote equitable access to all members, including people:

    (i) With limited English proficiency or reading skills.

    (ii) Of ethnic, cultural, racial, or religious minorities.

    (iii) With disabilities.

    (iv) Who identify as lesbian, gay, bisexual, or other diverse sexual orientations.

    (v) Who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex.

    (vi) Living in rural areas and other areas with high levels of deprivation.

    (vii) Otherwise adversely affected by persistent poverty or inequality..

  • Be aware that by seeing a member of our Private Fee-for-Service plan for non-emergency care, you agree to the Terms & Conditions of Payment. (Terms & Conditions are available on our website at www.connecticare.com.)
  • Abide by the rules of the Plan's pharmacy drug program, as set forth in this Manual.
     

NCQA requirements

All contracted physicians:

  • Comply with ConnectiCare medical records policy, quality assurance programs, medical management programs, and HEDIS data collection.

 

CMS marketing guidelines

All contracted physicians:

  • Comply with the CMS Marketing Guidelines for provider-based activities. The guidelines govern how providers can and cannot inform or educate patients about enrollment and plan information.

JP62514 7/23

Dispute Resolution

For information on Dispute Resolution, visit Coverage Guidelines.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.