Updates and Educational Resources for Providers

Billing Cost-Share Protected Individuals 

The state of Florida recognizes patients who are Qualified Medicare Beneficiaries (QMB/QMB+), Specified Low-Income Medicare Beneficiaries (SLMB/SLMB+) and Full Benefit Dual Eligibles (FBDE) as cost-share protected individuals. 

Per CMS regulations and CarePlus provider’s contract agreements, physicians and other healthcare providers should not collect copayments, coinsurance, deductibles and/or other cost-share amounts from any CarePlus-covered patient who qualifies as a cost-share protected individual. 

Please note that CMS could impose sanctions on physicians/healthcare providers who charge such fees to individuals with cost-share protection. 

To help you identify CarePlus-covered patients who are cost-share protected, participating physicians/providers can: 

  • Call the CarePlus Provider Services queue at 1-866-313-7587, Monday – Friday, 8 a.m. – 5 p.m., Eastern time. 
  • Use the Availity Essentials at Availity.com/Essentials
  • Use CarePlus’ Provider Web Services (PWS) at www.CarePlus-hp.com/pws.html
  • Refer to a CarePlus member’s ID card 

If you have general questions about cost-share protected individuals or need other assistance, please contact your provider services executive or call the CarePlus Provider Operations inquiry line at 1-866-220-5448, Monday – Friday, 8 a.m. – 5 p.m., Eastern time. 

Behavioral Health Toolkit for Primary Care Physicians

CarePlus – in collaboration with Carelon Behavioral Health, Inc. (“Carelon”), our statewide behavioral health provider network administrator – is committed to promoting integrations of medical and behavioral health services toward the goal of better overall outcomes for patients.

Carelon has created a toolkit that provides behavioral health information for primary care physicians (PCPs) to use to evaluate, treat, and refer patients to help them get the care they need. To learn more, please visit Provider Toolkit | Carelon Behavioral Health to access their toolkit or contact Carelon at 1-833-227-3757.

Delegated Provider Resources 

CarePlus and its parent company, Humana, are committed to informing you about legislative changes. 

You can find information about new/revised legislation at Delegated Provider Resources

We encourage you to visit this site regularly and implement applicable legislatively required changes. Please note that legislative changes may become part of the delegation compliance oversight process. 

Cultural and Linguistic Competency Resources 

CarePlus recognizes cultural differences and the influence that race, ethnicity, language, and socioeconomic status have on the healthcare experience and health outcomes. We are committed to developing strategies that eliminate health disparities and address gaps in care. Please refer to this document for detailed information: 

Tools to address cultural gaps in care

Clinical Practice Guidelines 

CarePlus’ clinical practice guidelines are derived from national organizations generally accepted in their fields as experts, including but not limited to the American Diabetes Association (ADA); the American College of Cardiology (ACC); the American Heart Association (AHA); the National Heart, Lung, and Blood Institute; the National Kidney Foundation; and the Agency for Healthcare Research and Quality (AHRQ). 

Clinical Practice Guidelines

CarePlus’ clinical practice guidelines in the document listed above were derived from numerous well-respected national sources. These guidelines may have some differences in recommendations. Information contained in the guidelines is not a substitute for a physician’s or other healthcare professional's clinical judgment and is not always applicable to an individual. Therefore, the physician or healthcare professional and patient should work as partners in the decision-making process regarding the patient’s treatment. Furthermore, using clinical practice guidelines will not guarantee a specific outcome for each patient. None of the information in the guidelines is intended to interfere with or prohibit clinical decisions made by a treating physician or other healthcare professional regarding medically available treatment options for patients. Publication of these guidelines is not a promise or guarantee of coverage. Your CarePlus-covered patients should review their Evidence of Coverage for detailed information. 

Provider Crisis Contact/Location Information 

Please complete the form below if a disaster or other crisis requires you to evacuate your geographic area and/or relocate your office(s). CarePlus’ Member Services Department needs your most current contact information so that it can help members locate you during emergencies. If you have any questions about when or how to use this form, contact your provider services executive or call the CarePlus Provider Operations inquiry line at 1-866-220-5448, Monday – Friday, 8 a.m. – 5 p.m., Eastern time. 

Provider Crisis Contact/Location Information

Infection Control and Prevention

CarePlus asks all contracted providers to have written policies for infection control and prevention that are readily available, updated annually and enforced. Please train all personnel in infection control and prevention policies. The Centers for Disease Control and Prevention (CDC) provides standards and guidelines that are appropriate for most patient encounters. Furthermore, the Occupational Safety and Health Administration (OSHA) requires physicians and/or facilities as employers to have processes in place to minimize the risk of their employees’ exposure to blood-borne pathogens or other potentially infectious materials. 

Our “Additional Resources – Infection Control and Prevention” document can assist you and your staff in locating guidelines and best practices to reduce the day-to-day risks of transmission in your facility. 

Additional Resources — Infection Control and Prevention

CMS Transmittals and National Coverage Determinations 

The Centers for Medicare & Medicaid Services (CMS) issues program transmittals to communicate new or changed policies and/or procedures that are being incorporated into a specific CMS program manual. The cover page (or transmittal) summarizes the new material, specifying what has changed. CMS has developed MLN Matters® bulletins that address Medicare coverage and reimbursement rules in a simple format. 

It's important that you remain up to date on all regulatory changes, as it is your responsibility to implement applicable changes. 

To find specific CMS transmittals or MLN Matters® articles, visit the following links: 

CMS Transmittals

MLN Matters articles

CMS occasionally makes changes to Medicare-covered services. These changes are updated via national coverage determinations (NCDs). Visit our NCD information page for details.

Sequestration Reductions for Participating Providers

CarePlus applies CMS sequestration reductions to network and non-network provider payments. All network and nonnetwork providers who are reimbursed according to a fee schedule based on the Medicare payment system, percentage of Medicare Advantage premium or Medicare allowed amount (e.g., resource-based relative value scale [RBRVS], diagnosis-related group [DRG], etc.) will have the sequestration reduction applied as CMS would apply it. This reduction applies to all Medicare Advantage plans. 

The sequestration reduction amount for each affected claim will be identified on the explanation of remittance providers receive from CarePlus. On paper remittances, the sequestration reduction amount will appear for each line item on all affected claims. Each affected claim also will be noted with the following description: "The amount listed in the SEQ.AMT field represents a deduction from the total claim payment. This deduction is a percentage based on the sequestration from the Budget Control Act of 2011. The member shall not be held financially responsible for the sequestration amount." 

Questions can be directed to your provider services executive, or you can call the CarePlus Provider Operations inquiry line at 1-866-220-5448, Monday – Friday, 8 a.m. – 5 p.m., Eastern time. Participating providers also can refer to the CMS Medicare FFS' Provider e-News (dated March 8, 2013) for more information.

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