Health Services for Children. Health Services for Children (HSCSN) with Special Needs, Inc. (HSCSN) Caring. Serving. Empowering. - PDF

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(HSCSN) Caring. Serving. Empowering. Caring. Serving. Empowering Vermont Avenue, NW 12th Floor Washington, DC Main Number: (202) Fax: (202) HSCSN Provider Direc tor y Health
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(HSCSN) Caring. Serving. Empowering. Caring. Serving. Empowering Vermont Avenue, NW 12th Floor Washington, DC Main Number: (202) Fax: (202) HSCSN Provider Direc tor y Health Services for Children with Special Inc. Health ServicesNeeds, for Children (HSCSN) with Special Needs, Inc. Health Services for Children with Special Inc. Health ServicesNeeds, for Children (HSCSN) with Special Needs, Inc. (HSCSN) Caring. Serving. Empowering. Caring. Serving. Empowering. This program is funded in part by the Government of the District of Columbia Department of Health Care Finance. Table of Contents QUICK GUIDE DIRECTORY 2 QUALITY HEALTH CARE FOR CHILDREN WITH SPECIAL NEEDS 3 HSCSN PROVIDERS INCLUDE: 3 CHOOSING THE RIGHT PRIMARY CARE PROVIDER 4 CARE COORDINATION STARTS WITH THE CARE MANAGER 5 HOW TO USE YOUR HSCSN BENEFITS AND SERVICES 6 KEY VALUES OF CARE MANAGEMENT 7 MEMBER RIGHTS 8 MEMBER RESPONSIBILITIES 10 PRIMARY CARE PHYSICIANS ADOLESCENT MEDICINE 13 FAMILY MEDICINE 13 FAMILY NURSE PRACTITIONER 22 GENERAL PRACTITIONER 25 INTERNAL MEDICINE 25 PEDIATRIC NURSE PRACTITIONER 37 PEDIATRICS 37 ALL SPECIALISTS 51 DENTISTS 195 HOSPITALS 205 HEALTH CENTERS 206 BEHAVIORAL HEALTH CENTERS 207 DURABLE MEDICAL EQUIPMENT 208 ANCILLARY 209 HOME HEALTH SERVICES 210 PHARMACIES 211 INDEX 225 1 HSCSN QUICK GUIDE DIRECTORY 1101 VERMONT AVENUE, NW, SUITE 1200, WASHINGTON, DC PRIMARY FAX: MAIN: (202) English (Press 1) Spanish (Press 2) then follow the prompt Providers (Press 1) CUSTOMER CARE hours Enrollee Assistance; Enrollee Benefits; Authorizations; ER Visit Notification; Language Line; Transportation; Claims & Billing Inquiries; Other Topics) CARE COORDINATION fax Utilization Reviews/Appeals; Inpatient Admissions/Discharge/Transfers fax Authorization of Medication Management or Psychotherapy Services fax /7191/7192/ or 7193 CLAIMS AND BILLING fax P.O. Box 29055, Electronic Claims Payor ID Claims Management Clearinghouse: EMDEON COMPLIANCE PRIVACY OFFICER FRAUD, WASTE AND ABUSE OMBUDSMAN PROVIDER SERVICES CREDENTIALS fax Provider Training; In-Services; Status Changes; Recruitment; Concerns/Compliments /6483 fax DENTAL BENEFITS QUALITY PLAN ADMINISTRATOR (QPA) or fax Eastern Avenue, NW #100 Washington, DC Electronic Claims Payor ID CX077 LABORATORY SERVICES (LABCORP) Laboratory Corporation of America (LabCorp) Park Road Herndon, VA HSCSN MLK Outreach, 2124 Martin Luther King, Jr. Avenue, SE, Washington, DC 20020, The HSC Pediatric, 1731 Bunker Hill Road, NE,, , TTY: The HSC Foundation, 1808 Eye Street, NW, Suite 600, Washington, DC 20006, www.hscfoundation.org HSC Home Care, LLC 1731 Bunker Hill Road, NE, , 2 QUALITY HEALTH CARE FOR CHILDREN WITH SPECIAL NEEDS Health Services for Children with Special Needs, Inc. (HSCSN) is here to help each of its enrollees, caregivers, and providers. We serve as partners to you to make sure each special needs child or young people in our network can get quality health care right when it is needed. We, like each of you, want our members to be healthy and able to function at their best. HSCSN enrollees receive regular Medicaid benefits plus outreach services, respite care, 24-hour access to care coordination, a personal care management program, and more. HSCSN thinks about the whole person. We are the only Medicaid health plan that coordinates all areas of physical, mental, behavioral, and developmental care and services. We rate our services on a regular basis and look for ways to improve. We continue to work to improve the health of DC s children and young people with special needs. This is a directory of health care services and providers available to HSCSN enrollees. HSCSN staff work with these providers to make sure each enrollee has access to quality health care. HSCSN Providers include: Primary Care Physicians Dentists District of Columbia s Sub-Acute s and Rehabilitation s Pharmacies Durable Medical Equipment (DME) Vendors Opticians Home Nursing Agencies Occupational Therapists, Physical Therapists, and Speech Therapists Laboratories Mental and Behavioral Health Professionals Mental Health and Substance Abuse Treatment s Medical Equipment and Supply Companies Early Intervention Programs Transportation 3 CHOOSING THE RIGHT PRIMARY CARE PROVIDER HSCSN enrollees pick a doctor from our primary care provider (PCP) network to serve as their medical home. As the medical home, the PCP coordinates all of the enrollee s health care needs. Enrollees should see their PCP each year. He or she will check the enrollee for sickness and order needed services. Enrollees have the right to choose and change their PCP. Care Managers are glad to help members select their PCP. Enrollees should also pick a dentist. Enrollees may use this directory to pick a dentist. PCP s and other HSCSN doctors and dentists have their licenses, hospital privileges, and malpractice histories reviewed on a regular basis. All are required to participate in continuing medical education programs. Making/Canceling Appointments with a PCP or Dentist The enrollee can make or cancel appointments with PCPs or dentists. It is as easy as picking up the phone. The enrollee does not need permission from care managers to make appointments for general medical and dental check-ups. Appointments should be cancelled at least 24 hours (one day) before the appointment or as soon as possible. Making/Canceling Appointments with and Other Providers If the enrollee needs to see a specialist or receive other special services, contact the PCP or care manager. The care manager must approve these types of appointments and transportation arrangements, usually, the PCP or dentist will call the care manager if the enrollee needs specialist services. However, if the care manager does not contact the enrollee within two days, the enrollee should call the care manager. If an appointment needs to be cancelled, the enrollee should call at least 24 hours (one day) before the appointment or as soon as possible. 4 CARE COORDINATION STARTS WITH THE CARE MANAGER Every HSCSN enrollee has a personal HSCSN care manager. Care managers are nurses, social workers or other professionals who have the skills needed to coordinate enrollees medical needs. Nurses and social workers serving as care managers are properly licensed. They also attend continuing education programs about coordinating care for children and teens with special needs. Care managers help enrollees be as healthy as possible. They partner with enrollee families and providers to: Prepare annual care plans Coordinate necessary services and supplies Follow enrollees progress After being assigned to an enrollee, a care manager will call to introduce him/herself and provide his/her direct telephone number. If services are needed before the care manager contacts the member, call (Member Services) for help. Care managers work Monday through Friday from 8:00 a.m. to 5:30 p.m. Help is always available 24 hours a day, 7 days a week. If an enrollee is not satisfied, he or she can change his or her assigned care manager. Contact the Director of Care Management for help changing a enrollee s care manager. Each HSCSN enrollee has a personal care plan. This care plan is developed by the enrollee, the enrollee s family, the PCP, and the care manager. The care manager keeps the plan and makes sure it is carefully followed. The care plan talks about the enrollee s health problems, sets goals, and makes it clear what services are needed for the enrollee to get better. The care plan is revised as needed and updated with the enrollee s family and PCP every six months. The enrollees are encouraged to talk about the care plan with their PCP and care manager. It is the overall guide to the treatments the enrollee will receive. Urgent Care If the enrollee s life is not in trouble, but he or she needs to see a doctor before or after usual office hours, he or she should try to call the PCP. If the PCP can t be reached, call Member Services at Emergency Care If there is an emergency and the enrollee s life or health is in serious trouble, call 911. If the enrollee gets emergency care, contact the assigned care manager within 24 hours (one day). The care manager will make sure the enrollee receives any needed follow-up treatment. 5 HOW TO USE YOUR HSCSN BENEFITS AND SERVICES Filling Prescriptions The enrollee should always have the HSCSN member ID card when filling a prescription. All pharmacies of Caremark can fill HSCSN/ NET member prescriptions at no cost to the member. Transportation If there is a need, HSCSN will provide transportation to and from any health care visit. The enrollee should call Customer Services at The member should also call if he/she needs to cancel the ride. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a benefit available to enrollees of HSCSN and children enrolled in Medicaid. All children and youth under age 22 are required to receive EPSDT (annual medical check-up, including lead screening; immunization; vision and hearing check-up; and dental check-up). Each of the four types of check-ups (screenings) medical, lead (if two years of age or under), vision, hearing and dental must be performed at a set time. Primary Care Providers (PCPs) and care managers can inform the enrollee when it is time for these types of check-ups. Is it time for an EPSDT visit? Has the EPSDT visit been scheduled yet for this year? Contact your care manager immediately for assistance in making the EPSDT appointments. Remember: Transportation is also available. 6 KEY VALUES OF CARE MANAGEMENT The Care Management Program of Health Services for Children with Special Needs, Inc. (HSCSN) coordinates, reviews, and rates medical services needed and used by each of our enrollees. We believe that having a staff focused on coordination and review of treatment promotes better health care for our enrollees. CHOICE HSCSN enrollees are free to choose and change their PCPs and care managers. Enrollees are also encouraged to tell us about doctors they believe meet HSCSN s quality standards. HSCSN invites many of the doctors that enrollees families suggest to join the HSCSN network. That doctor may even serve as the PCP of the family who suggested him or her. THE MEDICAL HOME A medical home is overall health care that is easy to get to, family-centered, constant, and coordinated. It is a place of understanding, and awareness of important features of your cultural group. HSCSN wants to make sure that the PCP and enrollees family work as partners. Care Management staff pay attention to communication, service coordination, effectiveness of care, and the enrollee and medical home s ability to work together. FAMILY CENTERED CARE HSCSN enrollees are under 22 years and the way their family lives can impact each enrollee s health and well-being. For this reason, HSCSN staff talks with and provides health information to the families of its enrollees. We do our best to teach families how to promote a healthy home setting. Care managers also tell families about public and private services that will help improve the family s overall health. EMPOWERMENT HSCSN believes that families should be equal partners in making health care decisions. When families have all of the information, they also have the power to make better health care choices for our enrollees. Empowered enrollees and families also know what HSCSN services are available and how to use them. PREVENTIVE CARE HSCSN enrollees must have a wellness visit, or physical, each year. In addition, enrollees aged three and up must have dental exams twice each year. These exams allow your PCP and dentist make sure you are in good health. If there is a problem, it can be identified and treated early to help you get better faster. 7 ENROLLEE RIGHTS It is the enrollee s and family s right to: A. Be treated in a caring, respectful, culturally-sensitive and professional manner by HSCSN staff and recognition of their dignity and right to privacy. B. Receive information about HSCSN/NET, its services, its care providers, and enrollee rights and responsibilities; and know the names and titles of all healthcare professionals involved in the member s care. C. Make recommendations regarding the organization s enrollee rights and responsibilities. D. Be notified in writing whenever circumstances occur that affect your membership or benefits 30 days prior to potential change; methods for notifying enrollees will be mailings, enrollee newsletter and loop tape messages. E. Choose and change the child s PCP or care manager to meet the child s needs. F. Understand the child or youth s health problems and consent to treatment before it is provided. G. Understand prior authorization procedures. H. To have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. I. Be a part of the decision making process regarding the child or youth s health care, and the right to say yes or no to treatment before it is given to the enrollee. Enrollees have the right to seek a second opinion and/or to refuse proposed treatment. J. If an appropriately qualified provider is not available within the Network, HSCSN shall arrange for a second opinion outside the Network at no charge to the enrollee. K. Help develop and receive a current copy of your child or youth s plan of treatment. L. Be transported to all medically necessary appointments. M. Receive information about your child s treatment and HSCSN s policies in a language that allows you to understand and make decisions; N. Voice concerns, complaints, and grievances to HSCSN staff and receive a timely response. O. Contact the DC Medicaid ombudsman and/or receive a Fair Hearing about concerns, complaints or grievances at any time without fear of retribution, even receiving assistance 8 ENROLLEE RIGHTS cont. from HSCSN or DC Medicaid staff if needed. P. Designate Advance Directives about your child s care in situations where there is danger of death, and create Advance Directives stating what you want done if you are unable to make your own medical decisions, if you are 18 years of age or older, chronologically and functionally; Q. Have the child s or youth s medical records kept confidential and released generally only with written permission from a parent, legal guardian, or emancipated minor. R. Be able to request and receive a copy of his or her medical records, and request that they be amended or corrected as specified in 45 C.F.R. sec and S. If required by law, be notified in writing within ten (10) days, when information concerning your child s care has been released in response to an attorney request, subpoena and/or court order. T. Have the child or youth receive considerate health care with privacy during treatment, interviews and any care planning meetings; U. Have access to HSCSN s health care services for the child or youth 24 hours a day, every day of the year. V. Enrollees and/or their authorized caregivers have the right not to be subjected to intimidation, coercion, discrimination or retaliation for any reason. W. Every newly eligible or current enrollee with limited English proficiency or no English (LEP) will receive an oral interpreter and translation service free of charge when requested. X. Have all vital documents translated in other languages available to newly eligible and current enrollees approved by DC MAA. Y. An enrollee with LEP has the right to file a complaint or grievance if oral and translation services are not provided in a timely manner. Z. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience and/or retaliation. AA. BB. CC. Have knowledge of HSCSN s financial condition, structure and operation. Description of HSCSN s prescription drug formulary, the Dispense as Written (DAW) policy, and the enrollee s right to have a prescription filled, while a prescription is being disputed under a Grievance or Appeals process. A description of HSCSN s Physician Incentive Plans (PIPs) in accordance with 42 D.F.R., 9 ENROLLEE RIGHTS cont. Section (h)(3). DD. EE. FF. Summaries of any enrollee satisfaction survey in accordance with the requirements found at 42 C.F.R. sec (i)(3)(iv). Receive Family Planning Services and supplies from any Medicaid provider in the District of Columbia. Receive a copy of this Enrollee Handbook and a Provider Directory. It is the enrollee s and family s responsibility to: A. Treat HSCSN staff and providers with the same courtesy and respect that you expect when receiving health care or care coordination services. B. Actively participate with the child s providers and care managers in developing and following plans and instructions for care that they have agreed on with their providers. C. Understand your child s health problems and participate in developing agreed upon treatment goals to the degree possible. D. Notify the child s care manager and PCP if you would like to make a change in the plan of treatment. E. Have the child s Membership Card and shot record available when receiving health care services. F. Keep all health care visits and notify the provider and HSCSN 24 hours in advance (or as soon as possible) when appointments are cancelled. G. Be ready when scheduled transportation arrives to pick up your child for a health care visit. H. Have a grown-up (adult) with enrollees under 18 years old when going to medical office visits. The grown-up has to stay with the enrollee during the ride to the medical appointment and while the enrollee is seeing the provider (doctor, dentist, etc.) I. Be ready to receive your child or youth when the transportation company returns your child from a scheduled health care visit or school activity. J. Ensure there is a responsible adult available to receive the child if you are not able to be there or are detained. 10 ENROLLEE RIGHTS cont. K. Provide HSCSN with appropriate written releases of information (ROI) when requested. L. Notify HSCSN and Income Maintenance Administration (IMA) immediately about changes in name, address, telephone number, emergency contact person, when a enrollee is pregnant or has had a child while enrolled with HSCSN, death of a parent or legal guardian or enrollee, loss of SSI, placed in an institution, incarcerated, death or other information that affects our ability to contact you about your child s health. M. Inform your child s providers and care manager about the child s medical history, answering questions to the best of your knowledge. N. Be an active advocate for your child s best health by informing the HSCSN care manager, the network provider and/or DC Medicaid about your complaints and grievances. O. All clinical trials and experimental medications must be pre-authorized. P. Going to the Emergency Room only if you have a medical emergency Q. Helping your doctor in getting medical records from providers who have treated you in the past. R. Reporting to Income Maintenance Administration (IMA) and HSCSN if you or a family member has other health insurance. S. Know the benefits and services available to your child or youth with special needs under the HSCSN program. T. Not engage in fraud or abuse in dealing with HSCSN, your primary care provider or other providers. 11 PCP Adolescent Medicine Clauser, Janelle MD Adolescent Medicine (202) Privileges: Georgetown University Hagler, Rita NP Adolescent Medicine (202) New Patients: Yes Ages: Privileges: Children s National Reitman, David MD Adolescent Medicine (202) New Patients: Yes Ages: 0-20 Privileges: Children s National Reitman, David MD Adolescent Medicine (202) Privileges: Georgetown University Tuchman, Lisa MD Adolescent Medicine (202) New Patients: No Ages: Privileges: Children s National Upadhya, Krishna MD Adolescent Medicine (202) Privileges: Georgetown University Primary Care Physicians Hawkins, Kirsten MD Adolescent Medicine (202) Privileges: Georgetown University Jarris, Yumi MD Adolesc
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