AvMed Will Be Expanding Medicare Effective January 1, 2023

Published Date: Dec 05, 2022

Effective JANUARY 1, 2022 Therapy Network of Florida (TNFL) will be the mandatory specialty network for Outpatient physical therapy, speech therapy and occupational therapy services provided in a free-standing Facility for AvMed’s expansion counties for Medicare enrolled members.

Medicare Expansion Counties

Palm Beach, Orange, Osceola and Seminole Counties.

Continuation of Care (COC)

Continuation of Care (COC) period is up to 30 days from the date that the member switched to AvMed Medicare from another Medicare Advantage plan. The COC period ends when the old auth expires or when the 30 days ends; whichever comes first. Youarenotrequired toobtainanauthorizationfromTNFLtocontinueprovidingtheseservicesduringtheContinuationof Care Period. If you are NOT a participating provider with TNFL, please refer the member to their Primary Care Physician or ordering Physician so that they may refer the member to a participating therapist. Members may also contact the health plan to locate a participating therapist.

Provider Manual

The TNFL AvMed Provider Manual can be located on our website under provider resources https://mytnfl. com/provider-resources.php

How to Receive Payment For Services Post COC Period

All rendering providers must request a Payment Control Number. You may request a payment control number by submit the following Critical Elements via our Provider Web Portal at mytnfl.com/hs1portal. Fax is available as an emergency backup via TNFL fax at 1-855-410-0121. Forms can be located on our website mytnfl.com.

1. Prescription or Referral Form (N/A for reevaluations)

   • Evaluation;

   • New POC/evaluation must be signed by the treating Therapist;

   • Expired POC from the certification period that just ended must be signed by the treating Therapist and referring provider (Physician/ARNP/P.A./Chiropractor).

2. POC with diagnosis signed/dated by the referring provider (Physician/ARNP/P.A./Chiropractor) and/or Letter of Medical Necessity (LMN)

   • The Plan of Care must include the evaluation and the start and stop dates.

   • The Plan of Care must include the Signature of the referring provider (Physician/ARNP/P.A./Chiropractor) recorded on or after the recorded date of the treating therapist’s signature.

   • The therapist that develops the POC must sign and date the document on the date it is completed. The therapist must sign and date the POC prior to the PCP’s signature and date. The PCP may sign and date the POC on the same date the therapist signs and dates the POC.

3. Assessment Scores clearly denoted

CRITICALLY IMPORTANT: If any of the above elements are missing, TNFL will not be able to issue a payment control number. Provider notification of Payment Control Number Via the Provider Web Portal at https://mytnfl.com/hs1portal

Requesting a Control Number for Multiple Therapy Disciplines

If a patient requires treatment for more than one type of therapy during the same treatment period, such as both Occupational and Speech Therapy, follow the steps outlined below:

1. Request two separate control numbers via the Provider Web Portal at https://mytnfl.com/hs1portal or via fax to TNFL at 1-855-410-0121.

2. All documentation requirements, including the 4 Critical Elements must be included for each discipline with each request.

3. All requests of this kind, for more than one therapy discipline, will be submitted to Clinicians for the review of medical necessity.

TNFL does not issue separate episode levels for symptoms or conditions associated with the main diagnosis. For example, for a therapy of Status Post Total Knee Replacement, TNFL assigns a payment control number level according to the date of surgery. Concurrent therapy for pain, including back pain, gait, instability, muscle weakness, etc; would be considered related to the main diagnosis, and TNFL will not issue a separate payment control number level.

Requesting a Payment Control Number for Custom Hand Splints

All treating providers MUST submit the Patient Splint Form to receive a payment control number. The form is located on the TNFL website www.mytnfl.com under provider resources. Providers must submit the form via fax to TNFL at 1-855-410-0121. Upon receipt of the payment control number request, an TNFL clinician will review the request and issue a level for payment.

Claims Submission

If you were issued an authorization by the member’s previous Health Plan for date of service on or before 12/31/2022, please submit your claims directly to the previous plan for DOS on or before 12/31/2022.

For DOS on or after 1/1/2023, please submit your claims to TNFL at P.O. Box 350590, Fort Lauderdale, FL 33335- 0590; or submit your Electronic Claims (EDI) via Professional Payer ID 65062 or Institutional Payer ID 12k89. Along with your submittal of claims, providers will be required to submit written documentation such as prior existing orders, prior authorizations and treatment plan/plan of care, in order to receive payment on their claim under continuity of care.

Please note: Post COC, if you submit an encounter prior to receiving a payment control number from TNFL, the claim will approve and Pay at Zero with the reason code 2343.

• Reason Code 2343- Services are approved. Please submit via the Provider Web Portal a copy of the Therapy Prescription, Plan of Care and the Evaluation record so proper payment may be issued.

Patient Responsibility

Providers may confirm co-pays, deductibles, co-insurance and MOOP details through Availity’s website at https:// apps.availity.com/availity/web/public.elegant.login or via our Provider Web Portal at https://asp.healthsystemone. com/hs1providers.

For any questions regarding patient responsibilities, please contact AvMed’s Provider Services Department at 1-877-762-3515 or contact TNFL Provider Relations at 1 (888) 550-8800 Option 2.