Provider Manual. Section 11: Definitions
|
|
- Piers Pope
- 5 years ago
- Views:
Transcription
1 Provider Manual
2 Table of Contents SECTION 11: DEFINITIONS... 3 Revised
3 All defined terms in this Section are capitalized throughout this Manual. Capitalized terms that are used in this Manual, but not defined, will have the meanings given to them in your Agreement. Added Choice Point-of-Service (POS): Brand name of Kaiser Permanente s point-of-service product. A point-of-service product is a health benefit plan that allows eligible Members access to different benefit levels based on different provider delivery systems. Advance Directives: Advance Directives are written instructions, such as a living will or Durable Power of Attorney for Health Care, which provides a Member the opportunity to participate in medical decision making and in determining the course of their medical care, in the event the Member becomes unable to make health care decisions on his own. Adverse Determination: Written denial from Kaiser Permanente for coverage of a prospective or retrospective Service. Agreement: Health Care Services Agreement is the contract between Ohio Permanente Medical Group, Kaiser Foundation Hospitals, Kaiser Foundation Health Plan(s), or any combination of the three (Kaiser Permanente), and health care Providers (which include, but are not limited to Physicians, hospitals, skilled nursing facilities, durable medical equipment Providers) to provide, or arrange for the provision of, medical care Services for persons enrolled in a Kaiser Permanente health plan. American Specialty Health Networks, Inc. (ASH Networks): Kaiser Permanente Members have access to discounts through ChooseHealthy. ChooseHealthy, a product of American Specialty Health Networks, Inc. (ASH Networks) and Healthyroads, Inc., provides discounted rates on chiropractic care, acupuncture, massage therapy, and other Services; dietary supplements and other products; and health and fitness equipment, books, and videos. Appeal: Written request for a review of a prospective or retrospective Adverse Determination. Authorization: Kaiser Permanente s approval for the provision of Covered Benefits to Members by persons designated to provide such approval, pursuant to Kaiser Permanente s utilization management programs, and in the manner specified as described in Section 4 of the Provider Manual. Further, Authorization also means the document or electronic documentation indicating Kaiser Permanente s approval, as the context requires. Authorized means provided pursuant to and in compliance with an Authorization. Revised
4 Centers for Medicare & Medicaid Services (CMS): The federal agency responsible for administering Medicare and oversight of states management of Medicaid. Formerly known as Health Care Financing Administration (HCFA). Claim: A request for payment for Services rendered to a Member submitted in accordance with the terms of your Agreement and the Provider Manual. Clean Claim: An itemized Claim that (i) is submitted for payment of Covered Services, (ii) includes each of the data elements specified in Section 5 of the Provider Manual and (iii) complies with applicable Law. Coinsurance: The dollar amount a Member pays for Covered Services after Deductibles have been met. Complaint: Any verbal or written expression of a Member s dissatisfaction with a Plan Provider which is not amenable to prompt resolution at the point of service and requires follow-up and investigation (for example, a Grievance). Concurrent Review Concurrent Review is Utilization Review conducted during a Member s hospital or skilled nursing facility stay, or any other ongoing course of treatment. Coordination of Benefits (COB): Procedure used to prevent duplicate Claim payments when a Member is covered by more than one health plan. Copayment: The dollar amount, if any, the Member must pay at the time of Service for Covered Services that have not been fully prepaid by membership dues. Covered Benefits: The health care Services and benefits that a Member may be entitled to receive under the applicable Membership Agreement, as determined by Kaiser Foundation Health Plan of Ohio (or the applicable Payor). Covered Services: Those Services rendered by Plan Providers to Members that are Covered Benefits, Medically Necessary and Authorized or otherwise approved for payment. Revised
5 Deductible: A fixed amount of health care dollars of which a Member must pay 100 percent before his/her health benefits begin. The dollar amount in Tiers Two and Three of the Kaiser Permanente Added Choice Point-of-Service (POS) plan that must be incurred by an individual or family, per calendar year, before benefits will be paid at the allowed amount. The individual or family is financially responsible for 100 percent of all Deductibles. Direct Access: Specific specialty Services (Ob/Gyn, Optometry and Behavioral Health), where a Member may see a Plan Provider without a Referral from the Member s Primary Care Physician. Eligibility: Status of Member s enrollment with Kaiser Foundation Health Plan of Ohio. Eligibility is based on a number of factors, including age, residence, relationship to the Subscriber, etc. Emerald Health Network, a HealthSmart Company: The preferred provider network Kaiser Permanente contracts with to provide Tier Two Services for Kaiser Permanente Added Choice Point-of-Service (POS) Members. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: Serious jeopardy to the Member s health or, in the case of a pregnant woman, the health of the woman or her unborn child, or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, all as described in the Federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd) and its implementing regulations and any similar State Law (EMTALA). Emergency Services: Covered Services necessary to screen, evaluate and stabilize an Emergency Medical Condition in compliance with the Federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd) (EMTALA) and State Law. Emergency Services do not include post-stabilization Services. Encounter Data: Data relating to Services rendered by a Plan Provider to a Kaiser Permanente Member. Data is generally submitted to Kaiser Permanente via a CMS 1500 or UB04 form, regardless of whether the Provider was reimbursed on a capitated or fee-for-service basis. Revised
6 Evidence of Coverage: The written, legally binding contract between the Subscriber/Member and Kaiser Foundation Health Plan of Ohio, which summarizes the Covered Benefits, exclusions and limitations under a specific insurance plan. Explanation of Payment (EOP): A written statement to a Plan Provider showing action taken on a Claim. Financial Responsibility Form: A form provided by a Plan Provider for execution by a Member, to acknowledge the Member s responsibility to pay for those non-covered Services specifically described on the form. This form shall not be required of a Member prior to his/her receipt of Emergency Services. Formulary: A list of approved prescription medications, both name brand and generic, that are covered under a Member s prescription drug benefit. All Formulary medications have FDA approval. Kaiser Permanente has two Formularies (Commercial and Medicare Part D) which are to be followed by all Plan Providers. The medications included in the Formularies are chosen by a group of Kaiser Permanente Practitioners, pharmacists and nurses known as the Pharmacy and Therapeutics Committee. Grievance: Any Complaint or dispute, other than one involving an Adverse Determination, expressing dissatisfaction with the manner in which Kaiser Permanente or delegated entity provides health care Services, regardless of whether any remedial action can be taken. HEDIS (Healthcare Effectiveness Data and Information Set): The Healthcare Effectiveness Data and Information Set is a tool used by health plans to measure performance on important dimensions of care and Service. HEDIS is designed to assist purchasers and consumers with the information they need to compare the performance of managed health plans. Kaiser Foundation Health Plan of Ohio (KFHP): An Ohio nonprofit corporation which operates health care benefit plans and provides or arranges for the provision of Medically Necessary health care Services to Members. Kaiser Foundation Hospitals (KFH): A California nonprofit public benefit corporation, under which KFH agrees to provide or arrange for certain Medically Necessary hospital or facility Services for Members. Kaiser Permanente: Health Plan, Kaiser Foundation Hospitals, or Ohio Permanente Medical Group (OPMG), or any combination of one or more of them, as applicable. Revised
7 Kaiser Permanente Medicare Plus: The brand name of Kaiser Permanente s Medicare Cost Plan. Law: Local, state or federal Law, regulation or rule, as applicable. Medically Necessary Services or supplies that are proper and needed for the diagnosis or treatment of a Member s medical condition; are used for the diagnosis, direct care and treatment of a Member s medical condition; meet the standards of good medical practice in the local community; are not mainly for the convenience of the Member or a Plan Provider; and, their omission would adversely affect a Member s health. Medical Necessity: Medical Necessity refers to a decision by the Health Plan that a requested treatment, test, or procedure is necessary for a Member s health or to treat a diagnosed medical problem. Medical Record Number (MRN): Unique identification number assigned to each enrolled Member of Kaiser Foundation Health Plan of Ohio. Medicare: The Federal Health Insurance for the Aged and Disabled Act. Medicare is an entitlement program run by the Centers for Medicare and Medicaid Services (CMS) of the federal government through which people age 65 and older or disabled receive health care insurance. Medicare Cost: Kaiser Permanente s Medicare Cost Plan is called Medicare Plus. Medicare Cost is a plan offered by Kaiser Foundation Health Plan of Ohio to Members eligible for Medicare and entitled to benefits under Medicare Part A and enrolled in Medicare Part B, or enrolled in Medicare Part B only. The difference in Kaiser Permanente s plan is that Kaiser Foundation Health Plan of Ohio is a secondary Payor to the Centers for Medicare & Medicaid Services (CMS). If a Member s health care is Authorized by Kaiser Permanente and coordinated by a Plan Provider, then Kaiser Permanente will pay for Deductibles and Coinsurance that CMS does not cover. Medicare Part D (Medicare Prescription Drug Coverage - Part D): The Medicare Modernization Act of 2003 (MMA) expanded Medicare to include outpatient prescription drug coverage to traditional Medicare, Medicare Cost plans and Medicare private fee-for-service plans that do not offer drug coverage. Part D also provides drug coverage for low income beneficiaries and protection for those with the highest annual drug costs. Revised
8 MedImpact Health Care System: Pharmacy benefit management (PBM) company contracted with Kaiser Permanente to administer Eligibility and Claims payment for Plan pharmacies. Member: An individual entitled to Covered Services (at the time such Services are rendered) under a Membership Agreement issued by a Payor or an other arrangement with a Kaiser Payor. Members include the following categories: 1. Medicare Members who include: a. Medicare Advantage Members (formerly known as Medicare + Choice Members) are Medicare Members enrolled under a Medicare Advantage contract between a Kaiser Payor and the Centers for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (DHHS). This definition will apply to Kaiser Foundation Health Plan of Ohio Members if Kaiser Foundation Health Plan of Ohio enters into a Medicare Advantage contract with CMS. b. Medicare Cost Members, who are enrolled under a Medicare Cost contract between Kaiser Foundation Health Plan of Ohio (or an other Kaiser Payor) and CMS. c. Medicare Fee-for-Service (FFS) Members, who are Members i. entitled to coverage under Part A only or Part B only or Parts A and B of Medicare but a. are not enrolled under a Medicare Advantage contract or a Medicare Cost contract between Kaiser Foundation Health Plan of Ohio (or an other Kaiser Payor) and CMS and b. for whom the Medicare program is the primary Payor for Medicare-covered Services under Medicare reimbursement rules, or ii. enrolled under a Medicare Advantage contract and are hospice patients receiving care from Plan Providers for Services unrelated to the hospice patient s terminal condition. 2. Commercial Members, who are Members who are not Medicare Members. Membership Agreement: A description of a plan of health benefits covered, issued, sponsored or underwritten by a Payor. The term Membership Agreement includes the relevant Evidence of Coverage, Statement of Coverage, Certificate of Insurance, or Summary Plan Description issued by an other Payor or other description of Covered Benefits issued to a Member, as amended from time to time. Meritain: The Third Party Administrator contracted with Kaiser Permanente to administer Claims payment for Tiers Two and Three of Kaiser Permanente s Added Choice Point-of- Service (POS) product. Revised
9 National Committee for Quality Assurance (NCQA): A private not for profit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers and the public sector. It is best known for its work in assessing and reporting on the quality of the nation s managed care plans through accreditation and performance measurement programs. To earn accreditation, a health plan must report on its performance in selected areas, including Member satisfaction, quality of care, access and Service. National Provider ID (NPI): NPIs are unique 10 digit numbers required by the Health Insurance Portability and Accountability Act (HIPAA) for all providers across the country. It is the standard system for uniquely identifying all providers of health care services, supplies and equipment. NPIs will be used to identify individual Kaiser Permanente Plan Providers in standard medical Claims and remittance advice transactions. Nonformulary: A prescription medication that is not on Kaiser Permanente's drug Formulary (list of Covered drugs). Ohio Permanente Medical Group, Inc. (OPMG): Kaiser Foundation Health Plan of Ohio has entered into an agreement with OPMG, an Ohio professional medical corporation under which OPMG agrees to provide or arrange for the provision of certain Medically Necessary professional and outpatient Services for Members. Out-of-Area Plan Preferred Provider Organization (PPO) Product: Kaiser Permanente s health plan designed for group employees who are living outside the HMO Service Area. Payment Dispute: If a Plan Provider is dissatisfied with a verbal response to a question or concern regarding the way a particular Claim was processed, the level of Claim payment, or the reason why the Claim was denied (other than Authorization denials), the Plan Provider may file a formal Payment Dispute in writing. Payor: Any entity that falls within either category below: 1. Kaiser Payor, a Kaiser Permanente affiliate having responsibility for the provision or arrangement of health care Services to Members. Without limitation, a Kaiser Payor includes a. a corporation or other organization owned or controlled, either directly or through subsidiary corporations, by Kaiser Foundation Health Plan, Inc. (such as Kaiser Permanente Insurance Company) or under common control with Kaiser Foundation Health Plan, Inc. (such as Kaiser Foundation Hospitals) and Revised
10 b. any regional Permanente Medical Group; and 2. Other Payors, any public or private entity other than a Kaiser Payor that a. sponsors, administers, and/or funds a plan of health benefits coverage or is otherwise responsible for the arrangement for health care Services rendered to Members under a Membership Agreement and b. enters into an administrative and/or management service agreement with a Kaiser administrative services organization, an affiliate that is contracted to perform certain administrative and/or management services on behalf of an Other Payor, and includes a Kaiser Permanente regional health plan, where permitted by Law, and Kaiser Permanente Insurance Company (KPIC). PCP Roster: Monthly report of all Members enrolled with a Kaiser Permanente participating Primary Care Physician. Plan Facility(ies) Facilities owned and operated by Kaiser Permanente or hospitals, skilled nursing facilities, dialysis centers, ambulatory surgery centers, institutions, locations or any other sites (such as medical offices), used by Plan Providers (or any Subcontractor) to provide Covered Services to Members. Plan Physician: A Primary Care Physician or Specialist who works for the Ohio Permanente Medical Group or who is contracted with Kaiser Permanente to provide Covered Services to Members. Plan Provider: A Plan Facility, a Plan pharmacy, and/or Plan Physician. Point-of-Service Product (POS): A health benefit plan that allows enrolled Members the ability to receive care from a Plan Provider, or a preferred provider network physician, or any other licensed physician. Different benefit levels apply based upon which practitioners/providers are seen. The brand name of Kaiser Permanente s point-of-service product is Added Choice Point-of-Service (POS). Post-Service Appeal Requests for payment for Services already received by a Member, including Claims for out-of-plan Emergency Services. Only a Member or appointed representative may file a Post-Service Appeal. Practitioner(s): Health care Practitioners (including Physicians, nurses, physician assistants, nurse practitioners, and physical therapists) who, by way or ownership of, employment by, or Revised
11 contracts with Plan Provider (or any Subcontractor) to provide Covered Services to Members. Precertification: A determination by Kaiser Permanente that an admission, extension of stay or other health care Service has been reviewed and, based on the information provided meets the clinical requirements for Medical Necessity, appropriateness, level of care, or effectiveness under the auspices of the Member s applicable health benefit plan. Precertified means provided pursuant to and in compliance with a Precertification. Pre-Service Appeal Requests that Kaiser Foundation Health Plan of Ohio provide or pay for a Service that a Member has not yet received. If Members receive any of the requested Services before a final determination is issued, the Appeal will become a Post-Service Appeal. Only a Member or appointed representative may file a Post-Service Appeal. Primary Care Physician (PCP): A Doctor of Internal Medicine, Family Practice, or Pediatrics contracted with Ohio Permanente Medical Group, Inc. to provide Medically Necessary health care Services to Kaiser Permanente Members and coordinate Referrals to other Plan Providers as needed. Private Health Care Services Network: The preferred provider network Kaiser Permanente contracts with to provide Tier Two Services outside of Ohio for Kaiser Permanente Added Choice Point-of-Service (POS) Members. Provider Manual: Kaiser Permanente s Manual of policies, procedures and guidelines applicable to Kaiser Permanente s Ohio Region, including billing procedures, Authorization and Referral policies and procedures, utilization management, quality assurance and improvement, Complaints, and other guidelines and criteria for providing health care Services to Members, as updated and supplemented by Kaiser Permanente from time to time. Reconsideration: Preliminary step of the Appeal process; request for review of a prospective or retrospective Adverse Determination. Referral: A prospective, written recommendation by a Plan Provider for medical care, equipment and/or supplies. A Referral is not approved until it is Authorized by Kaiser Permanente. Repatriation: The centralized Kaiser Permanente Repatriation team (Ohio Permanente Medical Group Physicians [OPMG], HUB Coordinator and staff) review Emergency Department and inpatient cases at hospitals for quality and resource stewardship. Kaiser Permanente may transfer stable patients, when appropriate, to Revised
12 Plan Facilities where Kaiser Permanente Inpatient Care Managers and Ohio Permanente Medical Group physicians are on staff and medical records are electronically accessible. Physicians and staff at any facilities are able to talk directly with an OPMG Physician on the centralized Repatriation team 24 hours a day, seven days a week at or to facilitate a safe transfer. If there are any issues around approvals or denials, the facility and Member will be notified. Service Area: A geographic area approved by various regulatory agencies for Kaiser Permanente enrollment. The Ohio non-medicare Service Area includes the following counties: Cuyahoga, Geauga, Lake, Lorain, Medina, Portage, Stark, Summit and Wayne. The Medicare Cost Service Area includes the following counties: Cuyahoga, Geauga, Lake, Lorain, Medina, Portage and Summit. Services: Those Services, supplies and Facilities that Plan Providers or their Subcontractors customarily provide for the delivery of health care Services, including all consults, studies, tests and procedures that are ordinary and necessary for the diagnosis and treatment of their patients. Services also include all administrative Services provided by Plan Providers (or their Subcontractors) pursuant to their Agreement or this Provider Manual. Specialist: A Plan Physician contracted with Ohio Permanente Medical Group, Inc. to provide Medically Necessary health care Services to Kaiser Permanente Members, who by virtue of his/her training, residency and/or board certification concentrates on a particular category of diseases or the diseases of one particular part of the body. Subcontractor: Any person or entity, including a facility, individual practitioner (other than an employee of Plan Provider), practitioner group, or any other individual (including a substitute practitioner), that provides or arranges for Covered Services to Members pursuant to a direct or indirect agreement or other arrangement with a Plan Provider. Subrogation: The legal right to claim or receive compensation damages or other payment for Covered Services received when the action resulting in medical expense was the fault of another person. Subscriber: The person who applied for health care coverage with Kaiser Permanente and agrees to be responsible for payment. Traditional Health Maintenance Organization (HMO): Basic HMO, non-medicare health care plan offered to individuals or employees of contracted employer groups for a fixed prepaid premium. Revised
13 Utilization Review: Utilization Review is a process used to monitor the use of, or evaluate the Medical Necessity, appropriateness, efficacy, or efficiency of health care Services, procedures or settings. Utilization Review exists to assist Members in receiving appropriate Covered Services. Visiting Member: A Member from another Kaiser Permanente Region who is temporarily away from their home Service Area and in the Ohio Service Area for less than 90 days. VSP Vision Care: Kaiser Permanente selected the VSP Advantage Provider network to provide routine optometry Services to Kaiser Permanente of Ohio Members. Revised
2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.
2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc. Welcome from Kaiser Permanente It is our pleasure to welcome you as a contracted provider (Provider) participating under
More informationTransplant Provider Manual Kaiser Permanente Self-Funded Program
Transplant Provider Manual Kaiser Permanente Self-Funded Program Utilization Management Table of Contents 4 SECTION 4: UTILIZATION MANAGEMENT... 3 4.1 OVERVIEW OF UM PROGRAM...3 4.2 MEDICAL APPROPRIATENESS...3
More informationYou recently called the Medicare Rights helpline for assistance with a denial from your Medicare private health plan.
Date: Dear Helpline Caller: The Medicare Rights Center is a national, nonprofit organization. We help older adults and people with disabilities with their Medicare problems. We support caregivers and train
More informationWELCOME to Kaiser Permanente
WELCOME to Kaiser Permanente PPO PLAN RESOURCE GUIDE Colorado kp.org/kpic-colorado Greetings Subscriber name, we re glad to be your partner on this journey, and we look forward to a long and healthy relationship
More information4. Utilization Management (UM) / Resource Management (RM)
4. Utilization Management (UM) / Resource Management (RM) 4.1 Overview of Utilization Management/Resource Management Program KFHP, KFH, and TPMG share responsibility for Utilization Management (UM) and,
More informationINFORMATION ABOUT YOUR OXFORD COVERAGE REIMBURSEMENT PART I OXFORD HEALTH PLANS OXFORD HEALTH PLANS (NJ), INC.
OXFORD HEALTH PLANS (NJ), INC. INFORMATION ABOUT YOUR OXFORD COVERAGE PART I REIMBURSEMENT Overview of Provider Reimbursement Methodologies Generally, Oxford pays Network Providers on a fee-for-service
More informationProtocols and Guidelines for the State of New York
Protocols and Guidelines for the State of New York UnitedHealthcare would like to remind health care professionals in the state of New York of the following protocols and guidelines: Care Provider Responsibilities
More informationProvider Manual Member Rights and Responsibilities
Provider Manual Member Rights and Member Rights and Our Members health is important to us and we strive to meet their health care and wellness needs whatever they may be. This section of the Manual was
More informationPolicy Number: Title: Abstract Purpose: Policy Detail:
- 1 Policy Number: N03402 Title: NHIC-Grievance Resolution Policy and Procedure for Medicare Advantage Plans Abstract Purpose: To define the Network Health Insurance Corporation s grievance process for
More informationA COMPLETE explanation of your plan
A COMPLETE explanation of your plan Legislative changes effective January 1, 2017 are not included in this document. An updated Evidence of Coverage will be available by January 31, 2017. For University
More informationUTILIZATION MANAGEMENT Section 4. Overview The Plan s Utilization Management (UM)
Overview The Plan s Utilization Management (UM) Program is designed to meet contractual requirements and comply with federal regulations while providing members access to high quality, cost effective medically
More informationThese electronic documents must be used as provided, without additions, deletions, or other modifications.
Kaiser Foundation Health Plan, Inc. Electronic Documents Policy This policy document constitutes the explicit, written permission of Kaiser Foundation Health Plan, Inc., (Health Plan) for the Purchaser
More informationKaiser Permanente Senior Advantage (HMO)
Kaiser Permanente Senior Advantage (HMO) Health Maintenance Organization (HMO) Evidence of Coverage for the Medicare Managed Health Care Plan Effective January 1, 2018 Contracted by the CalPERS Board of
More informationOptima Health Provider Manual
Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating
More informationAppeals and Grievances
Appeals and Grievances Community HealthFirst MA Special Needs Plan (HMO SNP) Community HealthFirst MA Plan (HMO) Community HealthFirst Medicare MA Pharmacy Plan (HMO) Community HealthFirst MA Extra Plan
More informationMEMBER HANDBOOK. Health Net HMO for Raytheon members
MEMBER HANDBOOK Health Net HMO for Raytheon members A practical guide to your plan This member handbook contains the key benefit information for Raytheon employees. Refer to your Evidence of Coverage booklet
More informationMEMBER WELCOME GUIDE
2015 Dear Patient; MEMBER WELCOME GUIDE The staff of Scripps Health Plan and its affiliate Plan Medical Groups (PMG), Scripps Clinic Medical Group, Scripps Coastal Medical Center, Mercy Physician Medical
More informationMEMBER INFORMATION...6
Table of Contents Contents Signature Advantage HMO SNP...4 Institutional Special Needs Plan... 4 Model of Care... 4 MEMBER INFORMATION...6 Member Identification & Eligibility... 6 Maximum Out-of-Pocket
More informationKaiser Foundation Health Plan Final Report of Survey of Medical Plan October 24, 2003 TABLE OF CONTENTS PAGE SECTION I. INTRODUCTION...
DEPARTMENT OF MANAGED HEALTH CARE CALIFORNIA HMO HELP CENTER DIVISION OF PLAN SURVEYS ROUTINE MEDICAL SURVEY FINAL REPORT KAISER FOUNDATION HEALTH PLAN ISSUED TO PLAN: OCTOBER 24, 2003 ISSUED TO PUBLIC
More informationPrecertification: Overview
Precertification: Overview Introduction Precertification determines whether medical services are: Medically Necessary or Experimental/Investigational Provided in the appropriate setting or at the appropriate
More informationPassport Advantage Provider Manual Section 5.0 Utilization Management
Passport Advantage Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria 5.3 Prior Authorization Requirements 5.4 Organization Determinations
More informationUpdated March Great Plains Medicare Advantage (HMO SNP) 1
Updated March 2018 Great Plains Medicare Advantage (HMO SNP) 1 Table of Contents Table of Contents Great Plains Medicare Advantage HMO SNP... 4 Institutional Special Needs Plan...4 Model of Care...4 MEMBER
More informationBlue Medicare Private-Fee-For-Service SM (PFFS) 2008 Medicare Advantage Terms and Conditions
Blue Medicare Private-Fee-For-Service SM (PFFS) 2008 Medicare Advantage Terms and Conditions Medicare Advantage Table of Contents Page Plan Highlights...2 Provider Participation The Deeming Process...2
More informationSection VII Provider Dispute/Appeal Procedures; Member Complaints, Grievances, and Fair Hearings
Section VII Provider Dispute/Appeal Procedures; Member Complaints, Grievances, and Fair Hearings Provider Dispute/Appeal Procedures; Member Complaints, Grievances and Fair Hearings 138 Provider Dispute/Appeal
More informationRULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT WORKERS COMPENSATION DIVISION
RULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT WORKERS COMPENSATION DIVISION CHAPTER 0800-02-25 WORKERS COMPENSATION MEDICAL TREATMENT TABLE OF CONTENTS 0800-02-25-.01 Purpose and Scope
More informationMEDICAID CERTIFICATE OF COVERAGE
MEDICAID CERTIFICATE OF COVERAGE Harbor Health Plan 3663 Woodward Ave., Suite 120 Detroit, MI 48201 V01152014MDCH Harbor Health Plan is a licensed health maintenance organization. Harbor Health Plan is
More informationState of New Jersey DEPARTMENT OF BANKING AND INSURANCE INDIVIDUAL HEALTH COVERAGE PROGRAM PO BOX 325 TRENTON, NJ
CHRIS CHRISTIE Governor KIM GUADAGNO Lt. Governor State of New Jersey DEPARTMENT OF BANKING AND INSURANCE INDIVIDUAL HEALTH COVERAGE PROGRAM PO BOX 325 TRENTON, NJ 08625-0325 TEL (609) 633-1882 FAX (609)
More informationAppeals and Grievances
Appeals and Grievances Community HealthFirst MA Special Needs Plan (HMO SNP) As a Community HealthFirst Medicare Advantage Special Needs Plan enrollee, you have the right to voice a complaint if you have
More informationProvider Manual. Utilization Management Care Management
Provider Manual Utilization Management Care Management Utilization Management This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente s Resource Stewardship
More information10.0 Medicare Advantage Programs
10.0 Medicare Advantage Programs This section is intended for providers who participate in Medicare Advantage programs, including Medicare Blue PPO. In addition to every other provision of the Participating
More informationCorCare PPO Provider Manual. Updated 12/19/2016
CorCare PPO Provider Manual 2017 Updated 12/19/2016 TABLE OF CONTENTS TABLE OF CONTENTS 1. Summary of Procedures, Resources, Claims Submissions... 3 2. Claims Completion... 4 3. Prepayment and Balanced
More informationRULES OF DEPARTMENT OF HEALTH DIVISION OF HEALTH CARE FACILITIES CHAPTER STANDARDS FOR QUALITY OF CARE FOR HEALTH MAINTENANCE ORGANIZATIONS
RULES OF DEPARTMENT OF HEALTH DIVISION OF HEALTH CARE FACILITIES CHAPTER 1200-8-33 STANDARDS FOR QUALITY OF CARE FOR HEALTH TABLE OF CONTENTS 1200-8-33-.01 Definitions 1200-8-33-.04 Surveys of Health Maintenance
More informationScripps Health Plan HMO Offered by Scripps Health Plan Services Combined Evidence of Coverage and Disclosure Form Effective January 1, 2017
Scripps Health Plan HMO Offered by Scripps Health Plan Services Combined Evidence of Coverage and Disclosure Form Effective January 1, 2017 Scripps Health Plan 0 Effective January 1, 2017 rev 7 7 2017
More informationSECTION 9 Referrals and Authorizations
SECTION 9 Referrals and Authorizations General Information The PAMF Utilization Management (UM) Program is carried out by the Managed Care department. The UM Program is designed to ensure that all Members
More information(3) The limitations and exclusions listed here are in addition to those described in OAR and in each of the Division chapter 410 OARs.
410-120-1210 Medical Assistance Benefit Packages and Delivery System (1) The services clients are eligible to receive are based upon the benefit package for which they are eligible. Not all packages receive
More informationOASIS HOSPITAL GOVERNANCE POLICY AND PROCEDURE
OASIS HOSPITAL GOVERNANCE POLICY AND PROCEDURE FROM: SUBJECT: OASIS Hospital Board of Directors Financial Assistance Policy - Arizona EFFECTIVE DATE: REVISED: 7/16 REVIEWED WITH NO CHANGES: 7/16 ORIGINAL
More informationOregon Educators Benefit Board (OEBB) Large Group Traditional Plan Evidence of Coverage
Kaiser Foundation Health Plan of the Northwest A nonprofit corporation Portland, Oregon Oregon Educators Benefit Board (OEBB) Large Group Traditional Plan Evidence of Coverage Group Name: Oregon Educators
More informationErrata (Correction Sheet) for 2016 Anthem Blue Cross Medi-Cal Member Handbook/Evidence of Coverage CHANGES EFFECTIVE: January 1, 2017
Errata (Correction Sheet) for 2016 Anthem Blue Cross Medi-Cal Member Handbook/Evidence of Coverage CHANGES EFFECTIVE: January 1, 2017 There are changes to the Anthem Blue Cross Medi-Cal Member Handbook/Evidence
More informationBlue Choice PPO SM Provider Manual - Preauthorization
In this Section Blue Choice PPO SM Provider Manual - The following topics are covered in this section. Topic Page Overview E 3 What Requires E 3 evicore Program E 3 Responsibility for E 3 When to Preauthorize
More informationOregon Educators Benefit Board (OEBB) Large Group Traditional Plan Evidence of Coverage
Kaiser Foundation Health Plan of the Northwest A nonprofit corporation Portland, Oregon Oregon Educators Benefit Board (OEBB) Large Group Traditional Plan Evidence of Coverage Group Name: Oregon Educators
More information2017 SEMI-MONTHLY PREMIUMS. Employee and Spouse $ Employee and Child(ren) $ Family $332.12
2017 BB&T BENEFITS PROGRAM GUIDE SUPPLEMENTAL INFORMATION FOR CALIFORNIA ASSOCIATES PREPARING FOR BENEFITS ENROLLMENT This supplement to the 2017 BB&T Benefits Program Guide contains additional information
More informationEVIDENCE OF COVERAGE Molina Medicare Options Plus HMO SNP
Molina Medicare Options Plus HMO SNP Member Services CALL (800) 665-0898 Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time. Member Services also has free language interpreter services
More informationFidelis Care New York Provider Manual 22B-1 V /12/15
This section of the Fidelis Care Provider Manual provides information for providers serving Fidelis Care at Home (FCAH) members Member Eligibility: Fidelis Care at Home provides managed long term care
More informationEssential Plan Contract
This is Your Essential Plan Contract Issued by WellCare of New York, Inc. One New York Plaza, 15 th Floor New York, NY 10004 BHP_04228E_E3 State Approved 10042017 WellCare 2017 NY8BHPMHB04228E_0000 BHP_04228E_E3
More informationOUTLINE OF MEDICARE SUPPLEMENT COVERAGE
A Medicare Supplement Program Basic, including 100% Part B coinsurance A B C D F F * G Basic, including Basic, including Basic, including Basic, including Basic, including 100% Part B 100% Part B 100%
More informationPatient Financial Services Policy
Patient Financial Services Policy Policy: Purpose: Billing & Collection Policy MaineHealth hospitals and physician practices are the frontline caregivers providing medically necessary care for all people
More informationEVIDENCE OF COVERAGE. January 1 December 31, Your Medicare Health Benefits and Services as a Member of Cigna HealthSpring Advantage (PPO)
January 1 December 31, 2018 EVIDENCE OF COVERAGE Your Medicare Health Benefits and Services as a Member of Cigna HealthSpring Advantage (PPO) This booklet gives you the details about your Medicare health
More information2018 Evidence of Coverage
Los Angeles, Riverside and San Bernardino Counties 2018 Evidence of Coverage SCAN Connections (HMO SNP) Y0057_SCAN_10165_2017F File & Use Accepted DHCS Approved 08232017 08/17 18C-EOC006 January 1 December
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationCalifornia Provider Handbook Supplement to the Magellan National Provider Handbook*
Magellan Healthcare, Inc. * California Provider Handbook Supplement to the Magellan National Provider Handbook* *In California, Magellan does business as Human Affairs International of California, Inc.
More information2009 Evidence of Coverage BlueMedicare SM Polk County HMO. A Medicare Advantage HMO Plan
2009 Evidence of Coverage BlueMedicare SM Polk County HMO A Medicare Advantage HMO Plan Member Services phone number: 1-800-926-6565 TTY/TDD users call: 711 8:00 a.m. - 9:00 p.m. ET, seven days a week
More informationRenee J. Rhem Director Customer Service ( ) 4/03 WELCOMELETTERV003
We would like to thank you for joining Keystone Health Plan East. Carrying a Keystone Identification Card (ID Card) entitles you to access a large network of providers, our friendly service, our value-added
More informationPremera Reference Manual Premera Blue Cross
14 Glossary of Healthcare Terms A Accreditation: Health plan accreditation is a rigorous, comprehensive and transparent evaluation process through which the quality of the systems, processes and results
More informationCARE MANAGEMENT (Utilization, Case Management, and Disease [Condition] Management) PROGRAM DESCRIPTION
Paramount Care, Inc. Paramount Care of Michigan, Inc. Paramount Insurance Company Paramount Advantage CARE MANAGEMENT (Utilization, Case Management, and Disease [Condition] Management) PROGRAM DESCRIPTION
More informationOregon Public Employees Benefit Board (PEBB) Traditional Plan
Kaiser Foundation Health Plan of the Northwest A nonprofit corporation Portland, Oregon Oregon Public Employees Benefit Board (PEBB) Traditional Plan Evidence of Coverage Group Name: Oregon Public Employees
More informationPlan Overview. Health Net Platinum 90 HSP. Benefit description Member(s) responsibility 1,2
PureCare HSP is available through Covered CA in Kings, Madera, Sacramento, and Yolo counties, and parts of El Dorado, Fresno, Nevada, Placer, and Santa Clara counties. Plan Overview Health Net Platinum
More informationProvider Handbook Supplement for Virginia Behavioral Health Service Administrator (BHSA)
Magellan Healthcare of Virginia * Provider Handbook Supplement for Virginia Behavioral Health Service Administrator (BHSA) *In Virginia, Magellan contracts as Magellan Healthcare, Inc., f/k/a Magellan
More informationCape Cod Hospital, Falmouth Hospital Financial Assistance Policy
Introduction This policy applies to Cape Cod Hospital, Falmouth Hospital and any other specific locations and providers as identified in this policy. The hospital is the frontline caregiver providing medically
More informationChiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for SOUTHERN CALIFORNIA IBEW-NECA HEALTH TRUST FUND
EOC #5 - Kaiser Foundation Health Plan, Inc. Southern California Region Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for SOUTHERN CALIFORNIA IBEW-NECA
More informationMolina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)
Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience
More informationFinancial Assistance Policy. TITLE: Financial Assistance Program for Uninsured and Underinsured Hospital Patients
South Nassau Communities Hospital 1 Healthy Way, Oceanside, NY 11572 Financial Assistance Policy TITLE: Financial Assistance Program for Uninsured and Underinsured Hospital Patients I. Purpose/Expected
More informationEssential Plan 1 Plus Subscriber Contract. New York ENY-MHB
Essential Plan 1 Plus Subscriber Contract New York ENY-MHB-0038-17 Essential Plan 1 Plus Subscriber Contract New York ENY-MHB-0038-17 Member rights and responsibilities update We ve added more rights and
More informationMedical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
More informationManaged Care Referrals and Authorizations (Central Region Products)
In this section Page Overview of Referrals and Authorizations 10.1 Referrals 10.1! Referrals: SelectBlue only 10.1! Definition of referrals 10.1! Services not requiring a referral 10.1! Who can issue a
More informationNYACK HOSPITAL POLICY AND PROCEDURE
PP-NH-C104 Last Revision 03/16 Last Review: 08/13 Page 1 of 10 NYACK HOSPITAL POLICY AND PROCEDURE PREPARED BY: CONTACT PERSON: SUBJECT: Administrator of Patient Financial Services Administrator of Patient
More informationA. Utilization Management Delegation and Monitoring
A. Utilization Management Delegation and Monitoring APPLIES TO: A. This policy applies to all IEHP Medi-Cal Members. POLICY: A. IEHP is responsible for the development, implementation, and distribution
More information2016 Open Enrollment Presentation for: University of California Senior Advantage
2016 Open Enrollment Presentation for: University of California Senior Advantage 2 Three ways we make good health easier Quality care. We do what it takes to help you get healthy, and partner with you
More informationUTILIZATION REVIEW DECISIONS ISSUED PRIOR TO JULY 1, 2013 FOR INJURIES OCCURRING PRIOR TO JANUARY 1, 2013
California Utilization Review Plan UTILIZATION REVIEW DECISIONS ISSUED PRIOR TO JULY 1, 2013 FOR INJURIES OCCURRING PRIOR TO JANUARY 1, 2013 GOALS Assure injured workers receive timely and appropriate
More informationCONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT
CONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a provider is deemed to accept Flexi Blue PFFS terms and
More informationDIGNITY HEALTH GOVERNANCE POLICY AND PROCEDURE
DIGNITY HEALTH GOVERNANCE POLICY AND PROCEDURE Dignity Health 9.101 FROM: Dignity Health Board of Directors SUBJECT: EFFECTIVE DATE: January 1, 2017 REVISED: January 1, 2016; (60.4.006) January 17, 2012
More informationProvider Manual Provider Rights and Responsibilities
Provider Manual Provider Rights and Provider Rights and You and your medical team are important to us. We value the care you give our Members and know you, like us, are committed to their good health.
More informationMedica Health Care Plans, Inc. 1 Provider Handbook
MHP Provider Handbook Table of Contents Introduction Your Participating Provider Handbook ------------------------------------------------------------------- -- How to Reach Us & Key Contact Information
More informationProvider Manual Provider Rights and Responsibilities
Provider Manual Provider Rights and Welcome To Kaiser Permanente This section of the Manual was created to help guide you and your staff in understanding your rights and responsibilities as our contracting
More informationNorthwest Utilization Management Policy & Procedure: UR 13a Title: Formulary Exception Process and Excluded Drug Review
Page: 1 of 6 PURPOSE To define the standards, accountabilities, and processes for the Clinician process for Therapeutic Equivalent drugs (TE) and drugs with generic equivalents on the Formularies. To provide
More informationMedicare Plus Blue SM Group PPO
2018 Medicare Plus Blue SM Group PPO Evidence of Coverage Your Medicare Health Benefits and Services as a Member of Medicare Plus Blue SM Group PPO This booklet gives you the details about your Medicare
More informationNorthwest Utilization Management Policy & Procedure: UR 13a Title: Formulary Exception Process and Excluded Drug Review
Page: 1 of 6 PURPOSE To define the standards, accountabilities, and processes for the Clinician process for Therapeutic Equivalent drugs (TE) and drugs with generic equivalents on the Formularies. To provide
More informationEvidence of Coverage
January 1 December 31, 2017 Evidence of Coverage Your Medicare Health Benefits and Services as a Member of Kaiser Permanente Medicare Plus (Cost) This booklet gives you the details about your Medicare
More information2018 IHCP 1 st Quarter Workshop
2018 IHCP 1 st Quarter Workshop MDwise Updates Spring 2018 Exclusively serving Indiana families since 1994. Agenda Meet you Provider Relations Team Quality Review ER Utilization Tips for Claims Adjudication
More informationUTILIZATION MANAGEMENT AND CARE COORDINATION Section 8
Overview The focus of WellCare s Utilization Management (UM) Program is to provide members access to quality care and to monitor the appropriate utilization of services. WellCare s UM Program has five
More informationFOREWORD. This Manual is also designed to be an operational guide to assist providers in participating in the Medical Management Program.
PROVIDER MANUAL FOREWORD This Participating Provider Manual has been prepared to assist Ohio Health Choice (OHC) participating providers and their staff in understanding the Ohio Health Choice Medical
More information17.1 PRODUCT INFORMATION. Fidelis Care s Metal-Level Products
PRODUCT INFORMATION Fidelis s Metal-Level Products Following the implementation of the Patient Protection and Affordable Act, Fidelis offers Metal-Level Products covering Essential Health Benefits as defined
More informationSlide 1 DN1. Emergency Medical Treatment and Active Labor Act Deirdre Newton, 8/24/2012
DN1 Slide 1 DN1 Emergency Medical Treatment and Active Labor Act Deirdre Newton, 8/24/2012 Costs associated with health insurance plans and the increased numbers of uninsured or underinsured persons seeking
More informationMercy Care Advantage (HMO SNP) 2018 Evidence of Coverage Evidencia de Cobertura Visit/Viste
Mercy Care Advantage (HMO SNP) 2018 Evidence of Coverage Evidencia de Cobertura 2018 Visit/Viste www.mercycareadvantage.com AZ-17-07-02 January 1 December 31, 2018 Evidence of Coverage: Your Medicare Health
More informationMedical Management Program
Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina
More informationAMBULATORY SURGERY FACILITY GENERAL INFORMATION
AMBULATORY SURGERY FACILITY GENERAL INFORMATION I. BCBSM s Ambulatory Surgery Facility Programs Traditional BCBSM s Traditional Ambulatory Surgery Facility Program includes all facilities that are licensed
More informationCHAPTER Committee Substitute for House Bill No. 1071
CHAPTER 2013-93 Committee Substitute for House Bill No. 1071 An act relating to health care accrediting organizations; amending ss. 154.11, 394.741, 397.403, 400.925, 400.9935, 402.7306, 408.05, 430.80,
More informationPROFESSIONAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare INPATIENT HOSPITAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare
PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, speech & occupational therapy Flu and pneumonia vaccinations Diagnostic services including
More informationThese electronic documents must be used as provided, without additions, deletions, or other modifications.
Kaiser Foundation Health Plan, Inc. Electronic Documents Policy This policy document constitutes the explicit, written permission of Kaiser Foundation Health Plan, Inc., (Health Plan) for the Purchaser
More informationMEMBER HANDBOOK. A brief guide to your health care coverage. For members of HMO, EPO, PPO and POS plans
MEMBER HANDBOOK A brief guide to your health care coverage For members of HMO, EPO, PPO and POS plans Applicable for 2017 MANAGE YOUR PLAN AT MYTUFTSHEALTHPLAN.COM When you visit mytuftshealthplan.com,
More informationBenefits Handbook CHIP of Pennsylvania. Free or low-cost health coverage through Keystone Health Plan East HMO. Look inside for...
Commonwealth of Pennsylvania chipcoverspakids.com Look inside for... Services covered Services not covered Using your child s insurance How to file a complaint or grievance Seeing a specialist Benefits
More information2018 Medicare Advantage Dual Eligible Special Needs Plan (DSNP) & Model of Care (MOC) Overview
2018 Medicare Advantage Dual Eligible Special Needs Plan (DSNP) & Model of Care (MOC) Overview Medicare Advantage (MA) Program Part C Medicare Advantage Medicare Part A and B benefits are administered
More informationAdministrative Policies and Procedures FINANCIAL ASSISTANCE
Administrative Policies and Procedures FINANCIAL ASSISTANCE POLICY This Financial Assistance Policy is intended to ensure that residents of Washington State who are at or near the federal poverty level
More informationOutpatient Hospital Facilities
Outpatient Hospital Facilities Chapter 6 Chapter Outline Introduce students to 1. Different outpatient facilities 2. Different departments involved in the reimbursement process 3. The Chargemaster 4. Terminology
More informationEMERGENCY HEALTH CARE SERVICES AND URGENT CARE CENTER SERVICES (MARYLAND ONLY)
UnitedHealthcare Community Plan Coverage Determination Guideline EMERGENCY HEALTH CARE SERVICES AND URGENT CARE CENTER SERVICES (MARYLAND ONLY) Guideline Number: CS038.J Effective Date: January 1, 2018
More informationParticipating Provider Manual
Participating Provider Manual Revised November 2012 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER
More informationCHAPTER 3: EXECUTIVE SUMMARY
INDIANA PROVIDER MANUAL EXECUTIVE SUMMARY Indiana Family and Social Services Administration (FSSA) contracts with Anthem Insurance Companies, Inc. (dba Anthem Blue Cross and Blue Shield) for the provision
More informationSummary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this
More informationHow do I get the most from my healthcare benefits? How can I obtain. I file an. appeal? How can. What is an emergency? How do I submit a claim?
How do I know if a certain procedure, surgery or service is covered by my health plan? Where do I find a claim form? am away from home? and coverage when I How do I obtain care Who do I contact about medical
More informationLahey Clinic Hospital, Inc. Financial Assistance Policy
Lahey Clinic Hospital, Inc. Financial Assistance Policy This policy applies to Lahey Clinic Hospital, Inc. DBA Lahey Hospital and Medical Center ( the hospital ) and specific locations and providers as
More informationPrimary Care Provider Orientation. Over 1.4 million people have chosen Molina Healthcare
Primary Care Provider Orientation Over 1.4 million people have chosen Molina Healthcare 2012 Molina Healthcare Mission Statement Our mission is to provide quality health services to financially vulnerable
More information