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Clinical Trials for Medicare Members

WEB1 No. UM-017 Medicare Clinical Trials Effective Date: 1/1/2020 POLICY AND PROCEDURE Committee Approval: 1/11/23 CMS: Medicare Managed Care Manual …

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URL: https://www-stage.canopyhealth.com/wp-content/uploads/UM-017-Medicare-Clinical-Trials-1.pdf

DMHC TAGs: Utilization Management, Terminal Illness …

WEB2 The Utilization Management staff will flag the referral for health plan verification. The UM Coordinators verify the health plan coverage for this requested service and document

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NCQA Standard: UM 12A and B

WEBNo. UM-018 UM Systems Controls Effective Date: 1/1/2021 POLICY AND PROCEDURE Committee Approval: 01/11/2023 NCQA Standard: UM 12A and B UM System Controls

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Medicare Non-Delegated Appeals Process

WEB2 If a Canopy Health Medical Group/IPA receives a Medicare member grievance or appeal (complaints, appeal, quality of care/service concern, whether oral or written), immediately,

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Medicare Advantage Hospital, SNF and Home Health

WEB1 No. UM-016 Hospital, SNF and Home Health Continued Service Denials and Appeals Policy Effective Date: 01/01/2020 POLICY AND PROCEDURE Committee Approval: …

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Medicare Dismissal or Withdrawal of an Initial Organization

WEB2 iii. An enrollee or the enrollee's representative files a request, but the enrollee dies while the request is pending, and both of the following apply:

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Previous Versions: see revision history on last page

WEBNo. UM-005 Consistency and Timeliness for Utilization Management Decisions Effective Date: 1/1/2023 POLICY AND PROCEDURE Committee Approval: 1/11/23

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No. CD1003 Credentialing Page: 1 of 14 POLICY AND …

WEBNo. CD1003 Credentialing Page: 2 of 14 POLICY AND PROCEDURE MANUAL Effective Date: 01/01/2021 Section: Initial and Recredentialing Committee Approval 01/1 9/2021

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No. UM AER-001 Access to Emergency Services and Post …

WEB3 The medical groups/IPAs do not refuse to cover services because an emergency room provider, hospital or fiscal agent did not notify the member’s PCP or Health Plan about …

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UM-004 Canopy Health Alliance Referral Program

WEBCanopy Health Network Referral Program Overview Canopy Health is committed to creating an integrated healthcare experience where quality care and coverage are …

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Access to Info about UM Processes & Auths Policy UM-001

WEBNo. UM-001 Access to Information About UM Processes and Authorizations Effective Date: 01/1/2022 Committee Approval: 1/11/23 POLICY AND PROCEDURE

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APPEALS AND GRIEVANCES POLICY

WEB7/28/16 M. Durbin Creation date 3/14/18 A. Kmetz Revised to include medical group to health plan timeframes per UHC review. 4/18/2018 M Durbin Added language about …

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No. CD1013 Credentialing Page: 1 of 9 POLICY AND …

WEBNo. CD1013 Credentialing Effective Date: 01/01/2019 Section: Initial and Recredentialing Previous Versions Dated: See revision Appeals Process and Fair Hearing Plan

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UM DECISION MAKING

WEB1 No. UM-008 Referral Policy Effective Date: 1/1/2022 POLICY AND PROCEDURE Committee Approval: 01/11/23 Previous Versions: See revision history on last page

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Canopy Health Provider Manual 2023 Effective Date: …

WEBDRAFT Canopy Health Provider Manual Version 6/1/2023 . Canopy Health Provider Manual 2023 Effective Date: 06/01/2023 . Previous Versions: see revision …

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Provider Appeals and Provider Claims Dispute Resolution Policy

WEBprocess and certain specified information must be included in all notices to providers regarding payment or denial of a claim. A Provider Dispute must be submitted in writing …

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NETWORK ADEQUACY POLICY

WEBNo. UM AA-001 Network Adequacy and Enrollee Access to Care Effective Date: 07/21/2020 POLICY AND PROCEDURE Committee Approval: 1/11/23 Previous Versions: see …

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No. CD-1005 Credentialing Page: 1 of 9 POLICY AND …

WEBNo. CD-1005 Credentialing Page: 2 of 9 POLICY AND PROCEDURE MANUAL Effective Date: 01/01/2019 Section: Initial and Recredentialing Previous Versions Dated: see …

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Provider Directory Previous Versions: see revision history …

WEBDM_US 83191767-2.097612.0015 3 Product – The type of health insurance plan or benefit offered to prospective or existing enrollees of Canopy Health by the upstream health …

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