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Medications to Avoid in the Elderly

View a regularly updated list adapted from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) measure, Use of High-Risk Medications in the Elderly.

EFT and ERA Enrollment Process to support Healthcare Claim Payments and Remittance Advices

CarePlus has updated our process to support the Electronic Funds Transfer (EFT) and Electronic remittance advice (ERA). We have modified our EFT and ERA authorization forms to make the process more simple. To enroll in EFT and/or ERA simply complete the EFT/ERA form and Fax the completed form to: 855-659-7966. You may also mail your completed form to the address below. If at any time you have questions regarding the form call our Provider Operations Department at 866-220-5448 prompt #6 then #4. The provider must contact its financial institution to arrange for the delivery of the CORE required minimum CCD+ data elements needed for reassociation of the payment and the ERA. See Phase III CORE EFT & ERA Reassociation (CCD+/835) rule Version 3.0.0.

CarePlus Health Plans, Inc.
Attention: Provider Ops.
Hector Cuy
11430 NW 20th Street, Suite 300
Miami, FL 33172

Notice of Paper Claim Submission Address Change

CarePlus Health Plans, Inc. (CarePlus) has established a new mailing address for providers to submit paper claims, provider correspondence and written payment inquires. In an effort to better serve our provider community, we expect this change will ensure data integrity, reduce potential fraud risk and improve the overall claims processing time. Please note that any mail sent to the existing claims address will automatically be forwarded to the new address until February 28, 2014.

Effective immediately, providers can begin submitting paper claims and claim related correspondence to the following address:
CarePlus Health Plans, Inc.
Attn: Claims
PO Box 14697
Lexington, KY 40512-4697

Important Information About Sequestration Reductions for Health Care Providers

As sequestration reductions have now been imposed by the Centers for Medicare & Medicaid Services (CMS), CarePlus has implemented the same reductions to network and non-network provider payments. All non-network providers and network providers who are reimbursed using a fee schedule based off 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 same sequestration reduction applied in the same manner as CMS. 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 will receive from CarePlus. On paper remittances, the "sequestration reduction amount" will appear for each line item on all affected claims. Each affected claim will also 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 may be directed to your assigned CarePlus Provider Services Executive (PSE). Additionally, health care providers may refer to the Centers for Medicare & Medicaid Services' Provider e-News (March 8, 2013) for more information.

Requirement for Certain End Stage Renal Disease (ESRD) Drugs

CarePlus Health Plans, Inc. requires a Medicare Part B versus Part D coverage determination for certain medications when used for ESRD.

Addressing Fraud, Waste and Abuse

As part of our efforts to improve the health care system, CarePlus Health Plans, Inc. (CarePlus) has made a commitment to detecting and preventing Medicare fraud, waste and abuse. Success in this effort is essential to maintaining a health care system that is affordable for everyone. CarePlus is undertaking a campaign to get the word out about how physicians, other health care providers, and business partners can help with fraud, waste, and abuse detection, prevention and correction.

Fraud, Waste and Abuse Training and General Compliance Training

CarePlus, and our parent company Humana, have adopted a training document published by the Centers for Medicare & Medicaid Services (CMS) that include this subject matter. For purposes of first tier, downstream and related entities’ (FDRs) relationship with CarePlus, this training, including all references and requirements related to Medicare Part C and Part D, is applicable to all CarePlus lines of business.

CarePlus suggests FDRs use this file to simplify their training process, although they may use another training that is materially similar.

Accessing the CMS Training File

  1. Navigate to
  2. Scroll to the “Downloads” section
  3. Click on “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training”
  4. Select “Open” or “Save”; the training is available in both PDF and PowerPoint formats

For additional information concerning Fraud, Waste and Abuse, please refer to the link below:

Compliance Policy for Health Care Providers and Business Partners

This policy communicates CarePlus’ and our parent company’s, strong and explicit organizational commitment to conducting business ethically, with integrity and in compliance with applicable laws, regulations and requirements. CarePlus and our parent company require its contracted health care providers and business partners to uphold a similar commitment to ethical conduct and assure that they, their employees and downstream entities who support CarePlus comply with the guiding principles outlined within this policy.

Principles of Business Ethics

Here we have posted the Principles of Business Ethics (PBE) for Health Care Providers and Business Partners, which is closely aligned with CarePlus' and our parent company's code of conduct for its employees. We invite health care providers and business partners to review this information as soon as possible.

Special Needs Plans (SNP)

If you are currently a CarePlus provider and have any questions with regards to SNPs, please contact your CarePlus Provider Services Executive or e-mail us at

It is important for Primary Care Providers (PCPs), specialists, and other health care providers to understand SNPs and the responsibilities they have for their CarePlus-covered SNP patients. Please click the link provided below to view Part 1 and Part 2 of the provider's educational presentation.

Telephone Playback Instructions for SNP Education-on-Demand Presentations

If your computer does not have a sound card or is not configured for streaming audio, then you may choose to listen to CarePlus' education-on-demand SNP presentations over the telephone while viewing the slides online. Please click on the link below for details.

Special Needs Plans Model of Care – Full Version

The CarePlus Health Plans Inc. Models of Care (MOC) focuses on delivering and coordinating care management and services for our special needs members. It addresses preventive care as well as acute and chronic disease processes across the continuum of care. This process is member centric and based on an Interdisciplinary Care Team (ICT) approach, which includes participation by members, their families and/or caregivers, Primary Care Provider (PCP), Care Managers, specialty physicians, ancillary providers and/or vendors involved in the treatment of the member. In addition, CarePlus incorporates evidence based care management protocols and nationally recognized care guidelines when applicable. We ask that you please take the time to review both the Dual Eligible and Chronic Care SNP Models of Care, as they contain important information regarding our SNP program goals and processes.

CarePlus Health Plans, Inc.'s Dual Eligible Special Needs Plan (SNP) Benefit Overview

CarePlus Health Plans, Inc. offers two (2) Dual Eligible SNP (HMO) plans for eligible members:

  • CareNeeds (HMO SNP): The beneficiary must be eligible for Medicare and also eligible for full or partial levels of assistance from the state's Medicaid program.
  • CareNeeds PLUS (HMO SNP): The beneficiary must be eligible for Medicare and have QMB or QMB Plus at the time of enrollment to qualify.

It is important that you as a participating provider integrate these program benefits. For your convenience, we have included below our member document, "Dual Eligible Special Needs Plans Overview". This document provides a comparison of the covered benefits offered by the plan and the benefits covered by the state's Medicaid program that will help you become more acquainted with the new plan benefits. We encourage you to review the document below and share it with your employees to ensure services are seamless across all programs.

Dual Eligible Special Needs Plans Overview
English version
Spanish version

The following Agency for Health Care Administration (AHCA), and the Florida Medicaid resources may help you with the understanding and integrating of covered Medicare and Medicaid benefits and services:

CarePlus Health Plans, Inc.'s Chronic Care Special Needs Plans (SNPs)

At CarePlus Health Plans, Inc., we offer the following SNPs to our members with chronic medical conditions:

  • CareDirect (HMO SNP) is available for members with diabetes mellitus (ICD-9-CM codes 250.xx) in Broward, Hillsborough Miami- Dade, Palm Beach, Pasco, Polk, Lake, Marion, Sumter, Orange, Osceola, Seminole and Pinellas counties.
  • CareHeart (HMO SNP) is available for members with cardiovascular disorders and/or chronic heart failure in Broward, Miami-Dade and Palm Beach counties. Please refer to the attachment below to view a complete listing of the CareHeart (HMO SNP) qualifying ICD-9-CM codes.
CareHeart (HMO SNP) List of Qualifying ICD-9-CM Codes

As a reminder, the member's physician or physician's office must confirm the member's qualifying condition either verbally or in writing (Chronic Condition Verification Form) by the last day of the first month of enrollment.

Updates and Educational Resources for Health Care Providers

Delegated Provider Resources

CarePlus Health Plans, Inc. and its parent company (Humana) are committed to informing you about legislative changes as we learn of them. To meet that commitment, we have a process for you to be able to access the new/revised legislation at your convenience.

Simply click on the link below and you will be directed to the "Delegated Provider Resources" Website.

As part of your responsibilities as a delegated health care provider, we encourage you to visit this site regularly and implement any applicable legislative changes. Please note that any legislative changes may become part of the delegation compliance oversight process.

Cultural and Linguistic Competency Resources

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

Clinical Practice Guidelines

These clinical practice guidelines are taken from national organizations generally accepted in their fields as experts, to include 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). Information contained in the guidelines inside the document below is not a substitute for a health care professional's clinical judgment and is not always applicable to an individual. Therefore, the health care professional and patient should work in partnership in the decision-making process regarding the patient's treatment. None of the information in the guidelines is intended to interfere with or prohibit clinical decisions made by a treating health care professional regarding medically available treatment options of patients.

Provider Crisis Contact/Location Information

Please complete the form below if a disaster or other crisis requires evacuation from your geographic area and/or relocation of your provider office(s). This information is needed so that the CarePlus Member Services department will have the most current information to provide to our members who may call for assistance in locating their providers during emergency situations. If you have any questions on when or how to use this form, please contact your assigned CarePlus Provider Services Executive or call the CarePlus Provider Operations Help Line at 1-866-220-5448, Monday through Friday from 8 a.m. to 4 p.m..

Infection Control and Prevention

Wherever patient care is provided, adherence to infection control and prevention guidelines are needed to ensure that all care is safe and provided in a functional and sanitary environment.

All contracted providers are expected to have written policies for infection control and prevention that are readily available, updated annually and enforced. Furthermore, all personnel should be educated and trained on appropriate infection control and prevention policies. The Centers for Disease Control and Prevention (CDC) provide standards and guidelines that are appropriate for most patient encounters. Furthermore, the Occupational Safety and Health Administration (OSHA) require physicians and/or facilities as employers to have processes in place to minimize the risk of their employees from being exposed to bloodborne pathogens or other potentially infectious materials.

Please click on the link below to view additional resources which can assist you or your staff in locating guidelines or "best practices" to reduce the day-to-day risks of transmission in your office/facility setting.

CMS Transmittals and National Coverage Determinations (NCDs)

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 is changed. Furthermore, CMS has developed MLN Matters® which provides Medicare coverage and reimbursement rules in a brief, accurate and easy-to-understand format.

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

To find specific CMS transmittals or MLN Matters® articles, please visit the CMS Website at the following addresses:

From time-to-time CMS makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations. You can access the NCD information by using the link below.

Quality Resources for Healthcare Providers

Increasingly, state and federal governments are moving toward a health care industry driven by quality. Health care providers have likely noticed increased activity among Medicare Advantage payers, regarding quality initiatives.

CarePlus has developed the resources below to help health care providers navigate the new quality landscape. We'll add to this list as additional materials are completed, so we encourage you and your staff to check back often.

Should you have any questions regarding these materials, you may contact your assigned Provider Service Executive or call the CarePlus Provider Operations Help Line at 1-866-220-5448, Monday through Friday from 8:00 a.m. to 4:00 p.m.

Healthcare Effectiveness Data and Information Set (HEDIS) Measures and Codes

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H1019_CPHPEDUMKTG2014REV Approved
Last Updated: 03/06/2014