Coverage determinations and benefit availability for our Hometown Health HMO , PPO , and TPA members , are based on the appropriateness of care , the medical necessity of that care , and any other terms as defined in the members ’ Evidence of Coverage or Summary Benefit Plan Descriptions . Senior Care Plus member are governed by their Evidence of Coverage for the calendar year of service as approved by CMS , and the definition of “ reasonable and necessary ” within Medicare coverage rules and regulations .
Senior Care Plus Medicare Advantage Risk Adjustment Data
The risk adjustment data you submit to us must be accurate and complete and follow these guidelines :
• Risk adjustment is based on ICD-10 diagnosis codes , not CPT codes . Therefore , it is critical for your office to refer to the correct ICD-10 coding manual and code accurately , specifically and completely when submitting claims .
• Diagnosis codes must be supported by the medical record . Therefore medical records must be clear , complete and support all conditions coded on claims or encounters you submit .
• Be sure to code all conditions that co-exist at the time of the patient visit and require or affect patient care , treatment , or management .
• Never use a diagnosis code for a “ probable ” or “ questionable ” diagnosis . Instead , code only to the highest degree of certainty .
• Be sure to distinguish between acute and chronic conditions in the medical record and in coding . Only choose the diagnosis code ( s ) that fully describe the patient ’ s condition and pertinent history at the time of the visit . Do not code conditions that were previously treated and no longer exist .
• Always carry the diagnosis code all the way through to the correct digit for specificity . For example , do not use a 3-digit code if a 5-digit code more accurately describes the patient ’ s condition .
• Please be sure to sign chart entries with credentials .
• CMS or Hometown Health may select certain medical records to review to determine if the documentation and coding are complete and accurate . Please provide any medical records requested in a timely manner .
Retroactive Eligibility Changes
A member ’ s eligibility under a benefit contract may change retroactively if the member ’ s policy / benefit coverage has been terminated or if the eligibility information we receive is later determined to be incorrect .
If you have submitted a claim ( s ) that is affected by a retroactive eligibility change , you are welcome to submit a reconsideration for the claim or to contact Hometown Health for more information concerning that claim and any potential former member liability .
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