Southwest Region January 2004

Transcription

1 Southwest Region January 2004

2 POLICY & PROCEDURE MANUAL Copyright Notice As an attachment to the PacifiCare Services Agreement, this Manual is intended for use by PacifiCare contracted providers and practitioners only. This Manual is to be used only by employees or other personnel acting on behalf of PacifiCare or its contracted providers and practitioners who are responsible for administering or authorizing benefits as part of their employment or contract responsibilities. The information contained within this Manual is strictly confidential and proprietary to PacifiCare. The information is not to be copied in whole or part; nor is the information to be distributed without express written consent of PacifiCare.

3 Dear Contracting Provider: Welcome to the PacifiCare Provider Network. We are proud you have chosen to contract with us. We have developed this Provider Manual to assist you in providing service to PacifiCare and Secure Horizons members efficiently. Please take the time to familiarize yourself with its contents. You will find it contains a great deal of useful information organized into practical categories to help answer questions that you and your office staff may have. This tool is designed as a guide; as such, it can not replace individual communication. If at any time there is a conflict between your contract and this provider manual, your provider contract will supercede. If changes are made to the manual, PacifiCare will send you the updates within the required notification period outlines in your PacifiCare Agreement. PacifiCare utilizes the Network Services Fast Facts to communicate any operational changes to providers that are affected by the change. Please ensure your office is aware of this communication which will be received via fax to ensure it is disseminated within your office appropriately. If at any time you have questions concerning PacifiCare, please feel free to call the Provider Relations Team (PRT) at In addition, if you feel you are not receiving these Fast Facts communications, please contact PRT to verify that PacifiCare has your correct fax number listed in our system. Sincerely, Austin Pittman General Manager

4 Introduction History of PacifiCare Introduction Welcome to PacifiCare s Preferred Provider Organization (PPO). PacifiCare Life and Health Insurance Company (PLHIC) or PacifiCare Life Assurance Company (PLAC), cumulatively referred to herein as PacifiCare, underwrite PacifiCare s SignatureOptions (formerly PPO) Plans. This Provider Manual is designed to provide important information about how PacifiCare s SignatureOptions and other PPO plans function. The manual also contains the policies and procedures for these plans and will help answer any questions. PacifiCare contracts with established medical care providers, including physicians, hospitals, outpatient surgery centers, laboratories, diagnostic centers, to create a health care network for its insureds and their covered dependants, cumulatively referred to herein as covered persons. Contracted providers are called Participating Providers. HIPAA Compliance PacifiCare and its Participating Providers must adhere to the Health Insurance Portability and Accountability Act (HIPAA) regulatory requirements relating to the electronic exchange of health information. State and Federal Guidelines All contents in this manual are created to meet all state and federal laws. If at any time a guideline conflicts with any state or federal law, the state or federal law requirements will supercede. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual i

5 Introduction History of PacifiCare, Continued History of PacifiCare From a philosophical perspective, PacifiCare Health Systems (PHS) defines itself as "an organization of dedicated people committed to improving the quality of those lives we touch." In practice, this philosophy is reflected in the company's emphasis on providing members with quality health care and responsive customer service. It also is reflected in the mutually beneficial relationships that PacifiCare establishes with its network of physicians and hospitals. It is PacifiCare's belief that physicians, as well as members, must "win" in order for the organization as a whole to succeed. PacifiCare Health Systems also believes that success should be shared, and is truly committed to "giving back" to the communities it serves. Not only does the company support a broad range of philanthropic organizations on an ongoing basis, but also in 1991, it formed a non-profit foundation of its own. Since that time, the PacifiCare Foundation has made contributions totaling more than seven million to the communities PHS serves. PacifiCare began operations in 1978 as a non-profit health maintenance organization under the sponsorship of the Lutheran Hospital Society of Southern California (now UniHealth America). In 1984, PacifiCare converted from non-profit status to for-profit status. In 1985, PHS was created as a holding company and transferred to a publicly held company. In 1985 PacifiCare was awarded one of the first Medicare risk contracts, now the largest in the nation. By 1989, PacifiCare Health Systems had established managed care organizations in five states, and membership system-wide surpassed the 500,000-member mark. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual ii

6 Introduction History of PacifiCare, Continued PHS' Current Subsidiaries Include: PacifiCare of Arizona (formerly FHP of Arizona) Began operations in 1985 and was acquired in 1997 by PHS. PacifiCare of California Began operations as a federally qualified HMO in Secure Horizons in California was awarded one of the first Medicare risk contracts in the state and began operations in Today, PacifiCare of California is one of the state's largest HMOs. PacifiCare of Colorado (formerly FHP of Colorado) Was acquired in 1997 and began operations as FHP of Colorado in PacifiCare of Nevada (formerly FHP of Nevada) Was established in 1992 PacifiCare of Oklahoma Began operations as a federally qualified HMO in PacifiCare of Oregon Began operations in 1985 and is a health care services plan. PacifiCare of Texas Began operations in San Antonio as a federally qualified HMO in 1986, and expanded into Dallas County in 1994 and Tarrant County in PacifiCare of Washington Began operations in 1986 and is licensed as a health care services contractor. PacifiCare of Asia Pacific Was the first HMO in 1973 to be introduced on the Pacific Island of Guam. PacifiCare Life and Health A life and health insurance company (formerly Columbia General) was acquired in 1986 and is licensed to operate in 37 states and the District of Columbia. The company offers group life and health, supplemental life, and a range of disability insurance products. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual iii

7 Introduction History of PacifiCare, Continued PHS' Current Subsidiaries Include: (continued) PacifiCare Behavioral Health A leading national health care company was established in The company provides a full spectrum of mental health and chemical dependency services including a comprehensive employee assistance program, advanced clinical assessment and referral systems, a national provider network and a quality improvement program. PacifiCare Wellness Company- (formerly Execu-Fit Health Programs) Acquired in 1991 by PacifiCare of California and since June 1, 1994 is owned by PHS. The company is one of the nation's leading providers of work site wellness and health education programs to corporations throughout the United States. Prescription Solutions Offers nationwide pharmacy management services to health maintenance organizations, third-party administrators, self-insured companies and union trusts. The company, which was launched by PacifiCare Health Systems in 1993, manages more than $1 billion worth of prescription drugs annually and currently provides prescription benefits to more than 5 million people nationally. Secure Horizons USA Launched in 1993, this subsidiary focuses on offering the Secure Horizons Health Plan available to Medicare recipients nationwide by forming relationships with other health care organizations. In 1993, Secure Horizons USA formed a partnership with Massachusetts-based Tufts Associated Health Plan, Inc.; in 1997, with Presbyterian Healthcare Services in New Mexico and in 1998 with Queens Health Plan in Hawaii. PacifiCare Dental and Vision (formerly California Dental Health Plan) Acquired by PacifiCare Health Systems in 1993, PacifiCare Dental and Vision is one of the West's largest providers of prepaid dental and vision benefits. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual iv

8 Overview of PacifiCare Products/Plans SignatureValue A select group of physicians PacifiCare s SignatureValue is a Health Maintenance Organization (HMO) product that utilizes a network of contracted providers to provide health care services to members. The member must select a Primary Care Physician (PCP) to manage his/her care. Contracted providers are reimbursed according to the HMO contract. A member s financial responsibility is limited to applicable copayments at the time of service. Balance billing the member is only allowed when services are not covered by the plan. SignaturePOS A choice of physicians and price PacifiCare s SignaturePOS is a Point of Service (POS) product that utilizes both HMO contracted and PPO contracted providers to provide health care services to members. SignaturePOS members can choose HMO in-network benefits directed by their PCP or out-of-network indemnity benefits when they self-refer to a participating provider or self-refer to any licensed non-participating provider. The member s out-of-pocket expenses will vary depending on which level of benefit he or she selects at the time of service. In-network refers to health care services that are provided, arranged or directed by a member s PCP. Contracted providers are reimbursed according to the HMO contract. A member s financial responsibility is limited to applicable copayments at the time of service. Balance billing the member is only allowed when services are not covered by the plan. Out-of-network refers to health care services initiated directly by the member without a PCP referral or health plan prior authorization. PPO contracted providers are reimbursed according to the PPO fee schedule. Depending on the level of benefit chosen, copayments, coinsurance and deductibles may be payable by the member. Balance billing the member is only allowed when services are not covered by the plan. PacifiCare Health Plan Administrators issue indemnity payments. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual 1

9 Overview of PacifiCare Products/Plans, Continued SignatureOptions A choice of physicians and price PacifiCare s SignatureOptions is a Preferred Provider Organization (PPO) product that utilizes a network of contracted providers to provide health care services to members. Contracted providers are reimbursed according to the PPO fee schedule. Copayments, coinsurance and deductibles are payable by the member. Balance billing the member is only allowed when services are not covered by the plan. Specific procedures require prior authorization, which can be obtained by calling the PPO Utilization Review Department. It is the member s responsibility to ensure that prior authorization has been obtained. SignatureFreedom Self-directed physician choice and price PacifiCare s SignatureFreedom is a Self-Directed Health Plan (SDHP) product that utilizes the PPO network of contracted providers to provide health care services to members. It is a combination of a high deductible PPO plan and a Self Directed Account (SDA) that can be used to pay for a select set of services while satisfying the member s PPO deductible and/or coinsurance. Contracted providers are reimbursed according to the PPO fee schedule. Copayments, coinsurance and deductibles are payable by the member directly or through the SDA. Balance billing the member is only allowed when services are not covered by the plan. Specific procedures require prior authorization and can be obtained by calling the PPO Utilization Review Department. It is the member s responsibility to ensure that prior authorization has been obtained. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual 2

10 Overview of PacifiCare Products/Plans, Continued SignatureIndependence An Unlimited Physician Choice PacifiCare s SignatureIndependence is a traditional indemnity product that allows members an unlimited choice of physicians. Should the member choose to see a PPO physician, the PPO fee schedule would apply to payments made to the provider. Secure Horizons PacifiCare offers a health plan called Secure Horizons Medicare + Choice (M+C) that is an alternative to original Medicare. This plan provides more coverage than original Medicare at low monthly premiums and copayments. The Medicare + Choice plan is based on an HMO model utilizing a network of contracted providers that deliver health care services to members. Secure Horizons M+C members must choose a primary care physician from a list of contracted physicians. The member can change primary care physicians within the network at any time. Contracted providers are reimbursed according to the HMO contract. A member s financial responsibility is limited to applicable copayments and/or coinsurance. Balance billing the member is only allowed when services are not covered by the plan. Referrals to contracted specialists are issued at the discretion of the PCP and may fall under the PCP s Medical Group/IPA (UM) guidelines, depending on how the PCP is contracted. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual 3

11 Overview of PacifiCare Products/Plans, Continued Secure Horizons Medicare Supplement Insurance Plans Secure Horizons offers several Medicare Supplement plans to Medicare recipients. HMO benefits and policies DO NOT apply to this product. Members do not need to select a PCP and copayments DO NOT apply. Referrals and prior authorization are not required. Medicare is the primary payer and PacifiCare is secondary. The member is financially responsible for any balance after PacifiCare coordinates benefits. For copayments and coinsurance information, refer to the member's ID card. PacifiCare - Self-Funded PacifiCare Self-Funded plans can be HMO, PPO or SDHP products which are self-funded by the employer group and administered by PacifiCare. HMO, PPO and SDHP benefits and policies apply. Please see previous product descriptions for applicable details. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual 4

12 Section A Eligibility/Benefits/Copayments Table of Contents Enrollment Procedures... A-1 No PCP Selection... A-1 Eligible Member Enrollment Area... A-1 Service Area... A-1 Dependent Description... A-1 Newborn Dependent Coverage... A-1 Adopted Dependent Coverage... A-2 Disabled Dependent Coverage... A-2 Time of Effective Date... A-2 Primary Care Physician Changes... A-2 Accessibility Standards... A-3 Eligibility Confirmation... A-4 How to identify a SignatureValue or Secure Horizons Member... A-5 Sample of SignatureValue HMO ID Cards... A-5 Sample of Secure Horizons ID Card... A-6 Eligibility Options... A-6 On-line Eligibility... A-7 IVR System... A-8 Provider Relations Team... A-8 Eligibility Lists... A-9 Eligibility Verification Guarantee... A-10 Copayment/Coinsurance... A-12 Copayment Collections... A-12 Nonpayment of Copayment... A-13 Annual Copayment Maximum... A-13 Member Communications... A-13 Member Bill of Rights... A-13 Patient Health Information Confidentiality... A-14 Enrollment Form...Figure A-1 How to Register on MyPacifiCare for Providers...Figure A-2 How to Confirm Eligibility On-line...Figure A-3 How to use the IVR System...Figure A-4 Member Bill of Rights...Figure A-5 Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual

13 Authorization to Release Health Related Information...Figure A-6 Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual

14 Section A Eligibility/Benefits/Copayments Enrollment Procedures To enroll for membership in PacifiCare, each subscriber must complete an enrollment form (See Figure A-1 Application for Enrollment) for each individual. PacifiCare may also receive enrollment/eligibility information from employer groups electronically. All members are required to select a Primary Care Physician (PCP) from the PacifiCare Participating Provider PCP listing. Each family member may select a different PCP within the PacifiCare network. PCPs are defined as those in general practice, internal medicine, family practice, geriatrics, and pediatrics. No PCP Selection If a member does not select a PCP during enrollment, PacifiCare will assign the member to the PCP closest to the member s home ZIP code. The member is notified of the assignment and may contact PacifiCare s Customer Service department to make an alternate selection. Eligible Members Enrollment Area Service Area Subscribers and dependents must live or work within the service area unless they are student dependents or enrolled as an out-of-area court ordered dependent, in which case they are covered for urgent and emergent services only. Subscribers and dependents must live or work within the service area unless they are student dependents or enroll as an out-of-area court ordered dependent. Dependent Description Dependents of the subscriber include: Spouse Unmarried children under the limiting age set by employer, including: Stepchildren Legally adopted children Dependents with a physical or mental handicap Domestic partners Children of domestic partners Full-time students Note: PacifiCare requires proof of student status on a periodic basis Newborn Dependent Coverage Coverage of the subscriber s newborn children begins at birth. The subscriber must apply for enrollment within thirty-one (31) days of the date of birth, to continue coverage. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-1

15 Section A Eligibility/Benefits/Copayments, Continued Adopted Dependent Coverage Coverage begins on the first day of physical custody if the subscriber applies for enrollment within thirty-one (31) days of physical custody of the child. Disabled Dependent Coverage Mentally or physically disabled children regardless of age are covered provided: They cannot engage in self-sustaining employment They depend on the subscriber for support Time of Effective Date Coverage begins at 12:01 A.M. Central Time on the effective date. Primary Care Physician Changes A contractual obligation between the PCP and the member is established when a member selects or is assigned a PCP. This physician-patient relationship continues to exist until the member s PCP assignment is changed either at the request of the member, PacifiCare or the current PCP. If a PCP requests termination of the physician-patient relationship, the PCP must follow the Guidelines for Dismissing a member in the Contracting with PacifiCare Section in this manual. The PCP must notify the patient in writing and continue care for 30 days, or until a new PCP is selected or assigned. If a PCP s contract is terminated with PacifiCare, the member will be notified in writing and given the opportunity to select another PCP from the PacifiCare provider network. If the member does not select a new PCP, PacifiCare will reassign the member to a PCP. All PCPs are expected to ensure orderly member transition including transfer of medical records if requested at no cost to the member and/or PacifiCare. Care will only be provided for the remainder of the month or until transfer is completed (not to exceed 30 days). NOTE: Strict adherence to this protocol is necessary to avoid charges of abandonment. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-2

16 Section A Eligibility/Benefits/Copayments, Continued Accessibility Standards All providers must provide covered services during normal business hours. Providers must provide telephone access, on a 24-hour, 7-day a week basis, to advise members for any urgent care services. Providers are responsible for arranging coverage by another contracting provider when the contracting provider is unavailable due to vacation, illness or leave of absence. A physician s after hour line should provide member access to someone who can direct him or her in determining/securing necessary care within a reasonable time (30 minutes). It may be an answering service who pages or contacts the on-call physician, or an answering machine with clear instructions and a second number to call to reach a physician or another person to page the physician. Providers are expected to ensure the following member access standards; Timeliness of preventative care appointment/periodic health evaluation 42 Calendar Days - Periodic health evaluation with absence of clinical symptoms Routine Primary (Symptomatic) Appointments 7 Calendar Days - Health care services provided for the purpose of evaluating the status of urgent symptomatic conditions. Urgent Care Within 24 hours - Services where prompt medical attention is required to prevent serious deterioration of health as a result of an unforeseen illness or injury Emergency Care Immediate - Unforeseen illness or injury; delay in treatment may seriously impact member s health and/or well being. After Hours Response Time 24-hour availability 7 days/week All participating providers must provide timely response (within 30 minutes) to members after hours. The participating providers are responsible for arranging coverage by another contracting provider when contracting providers are unavailable due to vacation, illness or leave of absence. Routine Care for Specialty Within 15 days Services which have been referred to a participating specialist. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-3

17 Section A Eligibility/Benefits/Copayments, Continued Eligibility Confirmation Participating Providers are required to confirm a member s eligibility prior to providing medical services each time the member visits the provider. This is essential for the following reasons: Confirm whether member is eligible under PacifiCare Determine if a member is affiliated with an IPA Employer group may change benefit plans Benefits may change Supplemental benefits may be added Copayment must be determined based on selected plan Fraudulent use of health plan coverage may occur Referral to appropriate network provider when the member s PCP belongs to an IPA Note: Failure to confirm coverage will result in non-payment of services. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-4

18 Section A Eligibility/Benefits/Copayments, Continued How to identify a SignatureValue or Secure Horizons member Each SignatureValue (HMO) and Secure Horizon members and eligible dependent receives a member ID card. The ID card is usually received within ten (10) days of the effective date of coverage. The ID card does not guarantee eligibility. It is for identification purposes only. Eligibility must be confirmed at each visit. Sample of PacifiCare Signature Value Member ID Card SignatureValue ( HMO) TEXAS Continued on next page OKLAHOMA SignaturePOS Back of the ID Card for both States and for both the SignatureValue HMO and POS plans Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-5

19 Section A Eligibility/Benefits/Copayments, Continued Section A Eligibility/Benefits/Copayments, Continued Sample of PacifiCare Secure Horizons Member ID Card Eligibility Options PacifiCare provides three mechanisms to confirm eligibility, benefits, applicable copayments and Primary Care Physician information. On-line (internet) eligibility data Interactive Voice Response (IVR) unit Provider Relations Team Note: The use of any non-pacificare eligibility system may result in a provider obtaining incorrect eligibility information. PacifiCare may provide some thirdparty vendors with eligibility information, however it is not real time data. Providers must use the three approved eligibility mechanisms described in this manual to meet the confirmation eligibility requirements. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-6

20 Section A Eligibility/Benefits/Copayments, Continued On-line (internet) eligibility data On-Line Eligibility service provides easy access to eligibility and minimal benefit and copayment information. You can place up to 10 eligibility requests at a time and receive a printout of the information. Visit the PacifiCare/Secure Horizons on-line eligibility website at: The system provides the most current eligibility information and any coverage. There is no cost to providers however due to the secure site; providers must register to gain a password. Please see: How to Register on MyPacifiCare for Providers Figure A-2 How to Confirm PacifiCare or Secure Horizons Eligibility Figure A-3 Note: Providers should utilize the print option on the internet to capture the eligibility information that was provided. The print out will serve as documentation of eligibility confirmed. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-7

21 Section A Eligibility/Benefits/Copayments, Continued Interactive Voice Response (IVR) unit The Interactive Voice Response Unit provides access to current PacifiCare eligibility information 24 hours a day, 365 days a year, through any touch tone telephone. You can choose to either listen to benefit information on-line or receive the information via your fax machine. This system will allow providers to confirm eligibility for more than one member during one call for past, present and future dates of service. The following information will be verbally communicated or faxed back to you: Member s name Primary Care Physician s (PCP) provider number PCP s name Plan Codes/coverage type Network/Medical Group name Effective date of coverage Copayment Group number Eligibility confirmation number, for your records Access to other benefit information: Hospital Mental Health Optical DME Pharmacy To access the IVR please call the Please See: Figure A-4 How to use the IVR system Provider Relations Team (PRT) Providers can contact the Provider Relations Team at to inquire about a member s eligibility. The Provider Relations Team is available Monday through Friday - 8:00 a.m. to 5:00 p.m. Central Standard Time. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-8

22 Section A Eligibility/Benefits/Copayments, Continued Eligibility Lists PacifiCare sends to each Primary Care Physician an eligibility list of all its assigned members. The list contains: Member ID Name Birthdate Plan code Employer group number HMO effective date Provider effective date Plan effective date Provider name and provider group number Sex (Male or Female) Eligibility status (current eligible, newly eligible) Effective dates of termination s and transfers Benefits and copayments Other insurance indicator (COB) ERISA member Indicator Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-9

23 Section A Eligibility/Benefits/Copayments, Continued Information on this page applies to Texas Providers Only Eligibility Verification Guarantee Note: Texas Physician/Provi ders Only pursuant to TX SB418 guidelines Pursuant to Senate Bill (SB) 418, providers may request a guarantee of payment. Verification is a guarantee of payment. A provider may request verification by telephone or in writing. A guarantee by PacifiCare will ensure payment for proposed medical care or health care services if the services are rendered within the required timeframe to the patient for whom the services are proposed. Provider may request a verification guarantee by: Phone: Writing sending your request to: Provider Correspondence P. O. Box San Antonio, Texas Requests must include the following information: 1. patient name; 2. patient ID number, if included on an identification card issued by the HMO or preferred provider carrier; 3. patient date of birth; 4. name of enrollee or subscriber, if included on an identification card issued by the HMO or preferred provider carrier; 5. patient relationship to enrollee or subscriber; 6. presumptive diagnosis, if known, otherwise presenting symptoms; 7. description of proposed procedure(s) or procedure code(s); 8. place of service code where services will be provided and if place of service is other than provider s office or provider s location, name of hospital or facility where proposed service will be provided; 9. proposed date of service; 10. group number, if included on an identification card issued by the preferred provider carrier; 11. if known to the provider, name and contact information of any other carrier, including the name, address and telephone number, name of enrollee, plan or ID number, group number (if applicable), and group name (if applicable); 12. name of provider providing the proposed services; and 13. Provider s federal tax ID number. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-10

24 Section A Eligibility/Benefits/Copayments, Continued Eligibility Verification Guarantee (continued) On receipt of a request for verification, PacifiCare will issue a verification or declination no later than five days after the date of receipt of the request for verification. If the request is related to a concurrent hospitalization, the response must be sent no later than 24 hours after receiving the request. If the request is related to post-stabilization care or life-threatening condition, the response must be provided no later than one hour after the request is received. A verification or declination may be delivered by telephone or in writing. If the verification or declination is delivered by telephone, a written response will be faxed within three calendar days of providing the verbal response. The response will include: 1. enrollee name; 2. enrollee ID number; 3. requesting provider s name; 4. hospital or other facility name, if applicable; 5. a specific description, including relevant procedure codes, of the services that are verified or declined; 6. if the services are verified, the effective period for the verification, which shall not be less than 30 days from the date of verification; 7. if the services are verified, any applicable deductibles, copayments, or coinsurance for which the enrollee is responsible 8. if the verification is declined, the specific reason for the declination; 9. if the request involved services for which preauthorization is required, a decision as to whether the proposed services are medically necessary and appropriate; 10. a unique verification number; and 11. a statement that the proposed services are being verified or declined pursuant to Title 28 Texas Administrative Code Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-11

25 Section A Eligibility/Benefits/Copayments, Continued Copayments/ Coinsurance A copayment/coinsurance is a fee paid by the member at the time of service. Members are required to pay a copayment/coinsurance for some PacifiCare benefits. PacifiCare members are instructed to pay the copayment/coinsurance amount when services are received. Copayments should be collected when services are rendered. Coinsurance should not be collected at the time of service but rather billed to the member once the coinsurance amount is specified from PacifiCare s Explanation of Payment sent to the provider. Some copayment amounts are listed on the member s identification card. However, all copayment/coinsurance amounts may be confirmed by utilizing one of the confirmation mechanisms. Note: For PacifiCare SignatureValue (HMO) members, only one copayment will be required for covered services performed or furnished on the same date of service by the same provider and shall be the higher of all listed copayments for the same date of service. Copayment Collections It is the responsibility of the participating physician/provider's office to collect any required copayment at the time of the member's visit. If the copayment is not collected from the member, PacifiCare will not reimburse the physician/provider for that copayment amount. Providers should notify PacifiCare of members who routinely do not pay their required copayment. Consistent failure to make required copayments may result in termination of the member's participation in PacifiCare. The copayment is a legal debt owed by the member to the participating physician/provider and can be collected as such. If a provider receives payment from two insurers, and the member has paid a copayment, the copayment must be refunded back to the member so that she/he has no out-of-pocket expenses. Copayments should be collected when professional services are rendered which would generate a charge per office visit. As a point of clarification, professional services would include but are not limited to the following examples: Services rendered by a physician Services rendered by a physician s assistant Services rendered by a nurse practitioner Copayments should not be collected when there is no office visit charge For example: Injections, including allergy Routine immunizations Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-12

26 Section A Eligibility/Benefits/Copayments, Continued Nonpayment of Copayment When a member cannot pay the applicable copayment before the services are provided, Provider has the following options: Reschedule the appointment (unless an urgent/emergent visit). Bill the member. Annual Copayment Maximum PacifiCare provides an Annual Copayment Maximum as stated in the 1973 HMO Act. The Annual Copayment Maximum sets a limit on the total cost in copayments a Member would need to pay during any calendar year. Once a Member has met the copayment maximum, no further copayment is charged for services during the remainder of the calendar year. NOTE: Infertility drugs paid for by the Member at the pharmacy may be covered under the medical benefit, not the pharmacy benefit. Therefore any cost incurred by the Member for infertility drugs, that are included in the medical benefit, counts toward the annual copayment maximum. Member Communications PacifiCare and Secure Horizons is required through the Medicare+Choice contract with Centers for Medicare and Medicaid Services (CMS) and all state and regulatory agencies to ensure that any and all communications from any of PacifiCare s contracted providers to PacifiCare SignatureValue and Secure Horizons members receive approval prior to distribution to any member communication. Contracted provider using the following type of communications include but are not limited to, provider termination notices, provider address changes and information about or invitations to health fairs must be discussed and approved by PacifiCare. Please contact your Network Management Representative or call the Provider Relations Team at before sending massive communications out to PacifiCare members. Member Bill of Rights The purpose of the Member Bill of Rights is to educate members about their rights and responsibilities regarding their health care needs and services they receive through the network. The member enrollment packet includes a copy of the Member Bill of Rights. See Figure A-5 at the end of this section. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-13

27 Section A Eligibility/Benefits/Copayments, Continued Patient Health Information Confidentiality Physician/Providers are responsible for protecting patient/covered Persons confidential medical information. Physician/Providers cannot disclose individual identifiable health information without the written consent of the covered person except when such release is required by law. Physician/Providers must follow these guidelines to ensure protection of Covered Person s health information. Patient unable to give consent - For patients unable to give consent, Physician/Provider must document a process to determine who may authorize any release of information, authorize the patient's care and treatment, and have access to information about that patient. Access to medical records - Physician/Providers must give patients access to their medical records in a timely manner. To help protect our members' privacy and confidentiality rights in all settings, PacifiCare has established policies consistent with state and federal regulatory requirements. Routine Consent - When Covered Persons enroll, they must sign routine consent statements that allow PacifiCare to use identifiable health information needed for treatment, coordination of care, quality assessments, utilization reviews, claims adjustment and management, fraud detection and oversight reviews. Special consent or authorization - When health information (such as psychotherapy notes, genetic testing results) is released outside the scope of routine consent, Covered Persons or their legal representative must sign and date a special consent/authorization form that contains the reason for disclosure of the information and the length of time for which the consent is valid. A copy of this form must be kept in the Covered Person s medical record or case file and a copy must be given to the Covered Person. A copy of the form can be found in Figure A-6. Use of measurement data - PacifiCare does not release information that is explicitly or implicitly Covered Person identifiable beyond that required for routine health care operations. Only aggregated results of measurement activities are made public. Information for employers - PacifiCare does not release Covered Personidentifiable medical information to employers unless authorized by law, special authorization or contract. We take measures to remove all identifiers when reporting medical and other data to employers. We may release information to selffunded when necessary to determine responsibility for payment for health care services rendered to their employees. In such cases, the self-funded employer is required, by contract to have special provisions for protecting the information. Continued on next page Southwest Region SignatureValue (HMO) and Secure Horizons Provider Manual A-14

28 Section A Eligibility/Benefits/Copayments, Continued Section A Eligibility/Benefits/Copayments, Continued Figure A-1 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual A-15

29 M P C for Providers What is the Web site address? Benefits of the Web Site One of the quickest methods to retrieve member WWW eligibility information 1 The following items can be accessed Direct Line Publications 2 PacifiCare routinely used forms Contracting Physician directories Contracting Pharmacy List and Formulary Quality Program Information 3 Registering for MyPacifiCare Step 1: Select Provider under I AM A Step 2: Choose your state Step 3: Click on Click here to Register Step 4: Depending on whether or not you know your PacifiCare Provider ID Select the appropriate option. Register here using your PacifiCare ID# Step 5: Provider enters PacifiCare Provider ID# (DEC# or HCPPN# assigned by PacifiCare) and contact information of the individual requesting the account and clicks on SUBMIT. 4 A provider can register with either their DEC# or HCPPN as their PacifiCare Provider ID#. 5 A DEC# is 6 digits with a dash and 4 digits. Ex A HCCPN# is a Step 6: If all the required fields and information is valid and the system finds the appropriate match the system will respond with Your Account Has Been Created Click Here to register if you do not know your PacifiCare ID Step 5: Step 6: Complete the screen with the contact and Provider information and Click on SUBMIT If all the required fields and information is valid and the system finds the appropriate match the system will respond with Your Account Has Been Created 6 7

30 First Log-In Process 1 Provider enters Provider ID# they used to register and password received from mail and clicks Enter. 2 If Provider ID# and password combination is not recognized, an Invalid Account Information error page will appear containing Try Again. If the Provider attempts to login (with the same Provider ID#) more than 5 times unsuccessfully, an error page will be displayed. 3 If the Provider is recognized, the Provider will be directed to the Change Password Screen. Provider enters old password, new password, and confirmation of new password and clicks Enter. 4 Provider will be taken to a Password Change Accepted Screen. Click on Continue. Provider is directed to the security Questions page where 5 two questions and answers to each question are selected 6 and clicks, Submit. Provider is taken to Validation Screen where the questions and answers selected in step 5 appear. Click Continue if you are satisfied with these. If you wish to change these, use the back button on your browser to return to step 5. 7 If validated, Provider is taken to Provider Portal home page. Providers who experience problems with their passwords or registration process should call CM

31 *Member Eligibility Information is just a click away

32 * just type in 1 Select Provider Under I AM A Choose your appropriate State Click on the Eligibility Click on Check Eligibility 5 Select the type of Verification, Enter up to 5 member IDs, and Information, Click on Submit CM PCMISC

33 ADVANCED SPEECH RECOGNITION Provider Help Fax - TX, OK Welcome to PacifiCare. (Advanced Speech Recognition or Touch-Tone options available) Speech Option Selected Please say one of the following: Eligibility Quickfax Claims Benefits More Options ELIGIBILITY Are you calling about Medical Eligibility? Say: YES Medical Eligibility Information Say: NO Say: Pharmacy Vision QUICKFAX Fax information given in the Medical Eligibility Section. (Available without listening to eligibility information.) CLAIMS Claims Information BENEFITS You can say any of the following to retrieve benefit information: Allergy Testing/Treatment Annual Copayment Maximum Durable Medical Equipment Emergency Services Family Planning Health Assessments Hearing Screening Home Care Immunizations Infertility Services Inpatient Alcohol, Drug or Other Substance Abuse Inpatient Hospice Care Inpatient Hospital Benefits Inpatient Maternity Care Inpatient Newborn Care Inpatient Oral Surgery Services Inpatient Physician Care Inpatient Rehabilitation Care Office Visit Outpatient Alcohol, Drug or Other Substance Abuse Outpatient Lab and X-Ray Outpatient Maternity Care Outpatient Mental Health Services Outpatient Physician Outpatient Rehab Therapy Outpatient Surgery Facility Prescription Drug Skilled Nursing Care HELPFUL HINTS: Speak in a normal conversational tone. (If you are using a headset, don't rest it on your face, it may distort word recognition.) Include any preceeding zeros when supplying the member ID number. In the Medical Eligibility or Benefits options, press the # key to skip the description and continue to the next step. If applicable, you can say "today" instead of the actual date in the Eligibility option. Visit to obtain a copy of this document and for other information. MORE OPTIONS You can say: Billing Address Credentialing Prior Authorization Pharmacy Approval Advanced Speech Recognition and Touch-Tone options are available for the IVR System.

34 Section A Eligibility/Benefits/Copayments, Continued Figure A-5 PacifiCare/Secure Horizons Medicare+Choice (M+C) Plan Member Rights and Responsibilities [Roles] Statement for 2003 As a member of PacifiCare/Secure Horizons M+C Plan you have the right to receive information about, and make recommendations regarding, your rights and responsibilities [roles]. You have the right to: Timely, Quality Care Choose and seek care through a qualified Contracting Primary Care Physician and Contracting Hospital. PacifiCare/Secure Horizons can advise you if a specific contracted Primary Care Physician is not accepting new patients at a particular time. Your Contracting Primary Care Physician will discuss with you the Contracting Hospital that best fits your needs in the event you need hospital services. Timely response to your requests for covered healthcare services; access to your Contracting Primary Care Physician; and referrals to contracted specialists for covered services when Medically Necessary. Receive emergency services when you, as a prudent layperson acting reasonably, believe that an emergency medical condition exists. Payment will not be withheld in cases where you have acted as a prudent layperson with an average knowledge of health and medicine in seeking emergency services. Receive urgently needed services when traveling outside the Plan s service area or in the Plan s service area when unusual or extenuating circumstances prevent you from obtaining care from your Contracting Primary Care Physician. Discuss with your contracting provider the full range of appropriate or Medically Necessary treatment options for your condition, regardless of cost or benefit coverage. Participate actively in decision-making regarding your health with your Contracting Medical Provider. Receive reasonable continuity of care, including information about continuing health care requirements following discharge from inpatient or outpatient facilities. And to know, in advance, the time and location of an appointment, as well as the physician providing care. Receive information about your medications what they are, how to take them and possible side effects. Be advised if a physician proposes to engage in experimental or investigational procedures affecting your care or treatment. You have the right to refuse to participate in such research projects. Continued on next page Southwest Region SignatureValue(HMO) & Secure Horizons A-22

35 Section A Eligibility/Benefits/Copayments, Figure A-5 Continued Treatment with Dignity and Respect Be treated with dignity and respect and have your right to privacy recognized. Exercise these rights regardless of your race, physical or mental disability, ethnicity, gender, sexual orientation, creed, age, religion, national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for your health care. Expect these rights to be upheld by PacifiCare/Secure Horizons and Contracting Medical Providers. Refuse any treatment or leave a medical facility, even against the advice of a physician. Your refusal in no way limits or otherwise precludes you from receiving other Medically Necessary covered services for which you consent. Complete an advance directive, living will or other directive and provide it to your Contracting Primary Care Physician or medical provider to include in your medical record. Treatment decisions are not based on whether or not an individual has executed an advance directive. Information About PacifiCare/Secure Horizons M+C Plan and Their Contracting Medical Providers Receive information about PacifiCare/Secure Horizons M+C Plan and the covered services under your Plan. Receive information about your Contracting Practitioners and Providers involved in your medical treatment, including names and qualifications. Receive information from your Contracting Medical Providers about an illness, the course of treatment and prospects for recovery in language you can understand. This may include information about any proposed treatment or procedures necessary for you to give an informed consent or to refuse a course of treatment. Except in case of an Emergency, this information shall include a description of the procedure or treatment, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who will perform the procedure or treatment. Receive information regarding how medical treatment decisions are made by your Contracting Primary Care Physician, medical group or PacifiCare/Secure Horizons, including payment structure. Receive and examine a billing explanation for non-covered services, regardless of payment source. Request information about PacifiCare/Secure Horizons M+C Plan Quality Improvement Program, its goals, processes and/or outcomes. Continued on next page Southwest Region SignatureValue(HMO) & Secure Horizons A-23

36 Section A Eligibility/Benefits/Copayments, Figure A-5 Continued Timely Problem Resolution Submit complaints and request appeals, without discrimination, about PacifiCare/Secure Horizons or care provided to you. Expect problems to be fairly examined and appropriately addressed within the timeframes set by the Plan. Choose to have a service or treatment decision, if it meets certain criteria, reviewed by a physician or panel of physicians who are not affiliated with PacifiCare/Secure Horizons. This process is referred to as an independent external review. Protection of Privacy in All Settings Know that PacifiCare/Secure Horizons protects the privacy and security of personal health information in all settings from unauthorized or inappropriate use via its policies and procedures and agreements with Contracting Providers. Know that when you or your legal representative sign your application/individual election form, you provide routine consent to PacifiCare/Secure Horizons. Routine consent covers the use of your personal health information needed for Plan operations, such as: treatment, coordination of care, use of measurement and survey data to improve care and service, utilization review, billing or fraud detection. Know that PacifiCare/Secure Horizons does not disclose medical information related to your mental health, genetic testing results and drug and alcohol abuse treatment records, to third parties without your special consent/authorization or as required or permitted by law. Know that if you are unable to give consent, you may extend your rights to any person who has legal responsibility to make decisions on your behalf, regarding your medical care or the release of personal health information. Review your medical records. If you would like to review, correct or copy your medical records, you should contact your Contracting Primary Care Physician or other health care provider who created the medical record directly. Know that PacifiCare/Secure Horizons may accommodate employer requests for information by providing de-identified aggregated data. Only as permitted by law, PacifiCare may release information to self-funded employers where needed to administer the provisions of the plan. If required to supply this information to self-funded employers, they agree to protect the individual s data from internal disclosure that would affect the individual. Your responsibilities [roles] are to: Review information regarding covered services, any exclusions, deductibles or copayments and policies and procedures as stated in your member materials or Evidence of Coverage. Provide PacifiCare/Secure Horizons, your physicians, other health care professionals and Contracting Medical Providers, to the degree possible, the information needed to provide care to you. Continued on next page Southwest Region SignatureValue(HMO) & Secure Horizons A-24

37 Section A Eligibility/Benefits/Copayments, Figure A-5 Continued Follow treatment plans and care instructions as agreed upon with your Contracting Medical Provider. Actively participate, to the degree possible, in understanding and improving your own medical and/or behavioral health condition and, in developing mutually agreed upon treatment goals. Behave in a manner that supports the care provided to other patients and the general functioning of the facility. Accept your financial responsibility for Plan Premiums, any other charges owed, and any copayment or coinsurance associated with services received while under the care of a physician or while a patient in a facility. Ask your Contracting Primary Care Physician or PacifiCare/Secure Horizons questions regarding your care. If you would like information about Contracting Medical Providers or have a suggestion, complaint or payment issue, we recommend you call the PacifiCare/Secure Horizons Customer Service department at or for the hearing impaired TDHI Our Customer Service Associates are available Monday through Friday 8:00 a.m. to 6:30 p.m. Continued on next page Southwest Region SignatureValue(HMO) & Secure Horizons A-25

38 Section A Eligibility/Benefits/Copayments, Continued Figure A-6 - Authorization to Release Health-Related Information Name of Member whose Protected Health Information will be disclosed: Last Name, First Name: Member ID Number: I authorize PacifiCare to release protected health-related information to my designee. Designee s Name Designee's Relationship to Member/Covered Person Designee's Phone Number: Designee s Address: Effective Date: Expiration Date (not to exceed 24 months): This authorization specifically allows PacifiCare to disclose protected information at the request of the member or Personal Representative of the member. The reason for the authorization is (check one). To act on my behalf To have access to my health information Other: This authorization specifically allows PacifiCare to disclose protected information related to (check all that apply): Access to care (e.g., appointment availability) Continuity of Care (e.g., continuation of treatment for a serious medical condition with a terminated provider) Unpaid claims Enrollment Status/Premium Billing Information Balance billing Primary Care Physician change Demographic changes (e.g. address, telephone number, name*) Please attach any relevant documentation (e.g., doctor's bill). PacifiCare understands you may have already sought assistance on the above issue by calling our Customer Service Department and the issue has not been resolved satisfactorily. Southwest Region SignatureValue & Secure Horizons Provider Manual A-26

39 I would like PacifiCare to respond (check one). Directly to my designee with the information requested. Directly to me with the information requested. To both my designee and me with the information requested. This release shall become effective as of my signature date shown below. I also understand this authorization does not allow my designee to make any medical decisions on my behalf. I am aware that PacifiCare may not disclose any medical information or records related to special conditions including, but not limited to, mental health or rehabilitation, alcohol or drug abuse dependency, HIV testing, diagnosis, and treatment and genetic testing results. I am aware that the disclosed health information may no longer be protected by the privacy rule once it is disclosed to the designee. I understand that I have a right to access the information used or disclosed, as part of this request. I am aware that such revocation is not effective to the extent that the person authorized to use and/or disclose this information has acted in reliance upon this authorization. I understand that PacifiCare will not condition treatment, payment, enrollment or eligibility for benefits on my providing or refusing to provide this authorization. I understand that if I refuse to sign this authorization that the Designee may not contact PacifiCare on my behalf. I further understand that the information disclosed by PacifiCare will have no affect on my employment. I agree to release my personally identifiable information as set forth above and am free to decline to be involved or to withdraw at any time without penalty or loss of benefits to which I am otherwise entitled through PacifiCare. To revoke or limit this authorization please provide a written notice to P.O Box San Antonio, TX ATTN: PacifiCare/Secure Horizons Correspondence Team. If you have any questions regarding this authorization, contact PacifiCare Customer Service at or Secure Horizons Customer Service at (Telephone Device for the Hearing-Impaired (TDHI) is available at ). Customer Service is available Monday through Friday from 7:00 a.m. to 9:00 p.m. I further acknowledge, by signing below, that I understand this authorization. Please sign and keep a copy of this form for your records: Signature of Member: Date: If you are a lawful, personal representative acting on the member s behalf, please sign below: Name of Personal Representative: Signature of Personal Representative: Date: Southwest Region SignatureValue & Secure Horizons Provider Manual A-27

40 Section B Claims Process and Submission Table of Contents Introduction... B-1 Time Limits for Filing Claims... B-1 Claims Payment Address by State... B-2 Claims Adjudication... B-2 About Payment... B-3 Claims Reimbursement... B-3 Claims Status and Follow up... B-3 Claim Status On-Line... B-4 Claim Status on the IVR... B-4 Recoupment... B-5 Balance Billing... B-5 Coding Changes... B-6 Billing Remittance Change... B-6 Services Provided to Ineligible Members... B-6 Payment for Eligibility Verification Guarantee... B-7 Level of Care Documentation and Claims Payments... B-8 Level of Specificity - Use of Codes... B-8 Collection of Copayments... B-8 Encounter Submission... B-9 Subrogation/Third Party Liability... B-10 Coordination of Benefits (COB)... B-11 Coordination of Benefits Medicare... B-12 Claim Rework Requests... B-12 Dispute Resolution Procedures for Unresolved Rework Requests... B-14 Workers Compensation... B-14 Benefits of EDI Claims Submission... B-15 Penalty Payments... B-16 ERISA... B-16 Stop Loss... B-16 End Stage Renal Disease... B-16 Clean Claim Information... B-17 Required Elements of a Clean Claim... B-17 Figure B-1 Sample Explanation of Payment... B-18 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

41 Section B Claims Process and Submission Table of Contents Figure B-2 Claim Rework Request Form... B-19 Figure B-3 Sample Accident Questionnaire... B-20 Figure B-4 Notice of Allowance of Lein... B-21 Figure B-5 Notice of Reimbursement Rights... B-22 Figure B-6 Clean Claim elements... B-24 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

42 Section B Claims Process and Submission Introduction PacifiCare/Secure Horizons offers different types of plans and benefit options to their Members. To determine under which plan a member is covered, check the front of their Identification Card. Member Inquiries about claims should be directed to the following Customer Service Departments: Commercial HMO at Secure Horizons at Provider Inquiries about claims should be directed to: Provider Relations Team at Time Limits for Filing Claims All providers are required to submit to PacifiCare clean claims 1 for reimbursement no later than the time specified in the provider s Services Agreement or the timeframe specified in the state guidelines which ever is greater. Accordingly, if a provider fails to submit clean claims to PacifiCare within the foregoing timeframes, PacifiCare reserves the right to deny payment for such claim(s). Claim(s) which are denied for untimely filing cannot be billed to a member. PacifiCare has established internal claims processing procedures to ensure timely claims payment to its providers. PacifiCare is committed to paying claims for which it is financially responsible within the timeframes required by State and Federal law. PacifiCare's timely filing requirements are consistent with industry practices for the submission of claims and enable PacifiCare to manage information pertaining to costs of health care services provided to members. PacifiCare reimburses contracted facilities and facility providers in accordance with the established contract rates. Inpatient stay charges must be submitted once the member has been discharged. Continued on next page 1 A Clean Claim is defined and described in Title 28, Texas Administrative Code, (4) and by the Oklahoma DOH, in 36 O.S Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-1

43 Section B Claims Process and Submission, Continued Claims Payment Address by State SignatureValue (HMO) and Secure Horizons claims must be submitted on industry standard forms (CMS 1500 and/or UB92) using the applicable address below: Oklahoma PacifiCare PO Box San Antonio, Texas PacifiCare's Electronic Payor ID Number is: Texas PacifiCare P. O. Box San Antonio, Texas PacifiCare's Electronic Payor ID Number is: Claims Adjudication PacifiCare reviews and evaluates all claims submissions for medical necessity and the possibility of billing irregularities. The review relies on and complies with the American Medical Association guidelines and the CPT system coding standards. PacifiCare may adjust or decline benefit payments consistent with the evaluation findings. Payments for services will be made based on current CPT codes. PacifiCare s Fee-Schedule utilizes the Medicare Resource-Based Relative Value System (RBRVS) units for most services, and the American Society of Anesthesiologists (ASA) units for anesthesia services. PacifiCare utilizes industry claims adjudication and/or clinical practices, State and Federal guidelines, and/or PacifiCare policies, procedures and data to determine appropriate criteria for payment of claims. To find out more about this information, a request for Fee Disclosure and Payment Guidelines may be submitted to PacifiCare at: PacifiCare Provider Services P. O. Box San Antonio, Texas Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-2

44 Section B Claims Process and Submission, Continued About Payment PacifiCare's payments to its contracted providers will be at the rates set forth in the applicable Services Agreement. Copayments payable by a Member will be deducted from the reimbursement made to a provider. Providers will receive an Explanation of Payment (EOP) detailing how each service was processed within the statutory time limit. Please see Figure B-1 at the end of the section for a sample of an EOP. Claims which have to be reviewed longer than the statutory claims payment period will be processed according to the statutory guidelines. Inquires about payment should be directed to the Provider Relations Team at Claims Reimbursement For each authorized claim submitted in a timely manner for eligible members specified by the contract or statutory guidelines PacifiCare will pay the contracted basis of payment and reimbursement rate due to the provider specified in the Provider Services Agreement. Claim Status and Follow Up If, after submitting a claim within timely filing guidelines a provider has not received an EOP within the timeframes in accordance with State and Federal law, a follow-up call to PacifiCare can be made. To follow-up on the status of a claim, please utilize the PacifiCare web site at or call the Provider Relations Team at Providers may also submit an Electronic Transaction (HIPAA 276/277). Providers should contact their EDI Clearing House for additional information. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-3

45 Section B Claims Process and Submission, Continued Claims Status On-Line Providers can log on to in the provider area and inquire on status of claims. The information provides real-time data and is the quickest method for retrieving claim status information. Claim Status on the IVR PacifiCare s Interactive Voice Response (IVR) system now provides access to claim status information by simply following the prompt instructions over the telephone. The system allows providers to use the touch-tone or speech response method. The IVR system provides a fax back of the claim status detail information that is available for the provider s file. Providers may access the system by calling Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-4

46 Section B Claims Process and Submission, Continued Recoupment When an overpayment is made, PacifiCare will send a letter to the Provider requesting a refund no later than the one hundred eighty (180) days from the date of overpayment. If the Physician/provider disagrees with the request, the Physician/provider must submit in writing the dispute to the following location: PacifiCare Attention: Appeals & Grievance Unit P. O. Box San Antonio, Texas If refund or appeal is not made within forty-five (45) days of PacifiCare's request, PacifiCare shall recoup the amount of overpayment through other means, which may include from future claim payments. Recoupment of claims overpayment will not occur from PacifiCare beyond one hundred eighty (180) days from the date of overpayment or otherwise specified in the physician/provider s Service Agreement. If a provider disputes the refund request the recoupment of claims overpayment will not occur until after physician/provider has exhausted PacifiCare s appeals process. Balance Billing PacifiCare members shall not be subject to balance billing by a provider. Providers may not look to PacifiCare members for payment for covered services beyond the member s copayment. Providers may bill SignatureValue (HMO) and Secure Horizons members only for copayments and non-covered services specifically agreed upon in writing by the member prior to the delivery of the service. In addition, PacifiCare members may not be billed for missed office visit appointments. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-5

47 Section B Claims Process and Submission, Continued Coding Changes PacifiCare reserves the right to review claims for appropriateness in accordance with nationally accepted coding practices and adjust payment and reimburse to the Physician/Provider at the revised allowable. The Provider shall cooperate with PacifiCare s audits of claims and payments by providing access to requested claims information, all supporting documentation and other related data. The nationally recognized coding including but not limited to the revenue and/or DRG, ICD-9, HCPC and CPT-4 codes which could be listed in the Contract Exhibits are PacifiCare s representations of the coding in place at the commencement of the provider agreement for the types of services contracted under their agreement. Such codes are subject to changes or additions as updates are made by the issuing entity. PacifiCare Participating Providers will be expected to utilize industry standards for billing and both parties must coordinate their efforts in good faith to ensure that relevant and current billing codes are utilized. Billing Remittance Change Physician/provider s who need to change the billing remittance address and/or name to be issued on the check must submit the information in writing. In addition, provider must submit a CMS-1500 with boxes 31 & 33 completed or an UB-92 with boxes 1 & 5 completed to the following address: PacifiCare Provider Relations PO Box San Antonio, Texas Fax: or Services Provided to Ineligible Insureds In the event that PacifiCare provides only eligibility confirmation that indicates that a member is eligible at the time the health care services are provided and it is later determined that the patient was not in fact eligible, PacifiCare will not be responsible for payment of services provided to the member. In such event, the physician/provider is entitled to collect the payment directly from the member (to the extent permitted by law) or from any other source of payment. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-6

48 Section B Claims Process and Submission, Continued Payment for Eligibility Verification Guarantee Note: For Texas Providers only pursuant to SB418 Pursuant to Texas Senate Bill (SB) 418, TEXAS physician/providers who request a guarantee of payment through the Verification process outlined in Section A of this manual will be reimbursed according to the contract and the guidelines set in SB418. A guarantee by PacifiCare will ensure payment for proposed medical care or health care services if the services are rendered within the required timeframe to the patient for whom the services are proposed. The payment will be less any co-payments, coinsurance and deductibles. The unique verification number provided by PacifiCare must be included on the claim form submitted to PacifiCare. (Field 23 of CMS 1500 or Field 63 of UB- 93) Verification eligibility guarantee must be requested prior to a service being rendered. If not requested and in the event that PacifiCare provides only eligibility confirmation that indicates that an insured is eligible at the time the health care services are provided and it is later determined that the patient was not in fact eligible, PacifiCare will not be responsible for payment of services provided to the insured. In such event, the physician/provider is entitled to collect the payment directly from the member (to the extent permitted by law) or from any other source of payment. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-7

49 Section B Claims Process and Submission, Continued Level of Care Documentation and Claims Payment PacifiCare processes claims according to the authorized level of care documented in the authorization record, reviewing all claims to determine if the billed level of care matches the authorized Level of care. If the billed level of care is at a higher level than the authorized level of care, PacifiCare will pay only the authorized level of care and the member shall not be billed for any charges relating to the higher level of care. If the billed level of care is at a lower level than authorized, PacifiCare will pay the provider based on the lower level of care, which was determined by provider to be the appropriate level of care for the member. Level of Specificity - Use of Codes In order to track the specific level of care and services provided to its membership, PacifiCare requires the providers to utilize the most current service codes (i.e., ICD9, UB and CPT codes). PacifiCare also requires that the provider ensure the documented bill type is appropriate for the type of service provided. Collection of Copayments Providers are responsible for the collection of applicable copayments in accordance with the applicable member benefits. The member ID card should be checked to verify the copayment. Commercial members and Secure Horizons members may have copayments for emergency room services. Inpatient copayments may also vary depending on plan and service type. Member materials instruct the member to pay their copayments at the time of each visit. Emergency room copayments should be collected at the time of the service, but if the member is admitted, the emergency room copayment may be waived by the provider. Refer to the member s specific benefits for a determination. If not paid at the time of service, members may be billed for copayments. If a provider receives payment from two insurers, and the member has paid a copayment, the copayment must be refunded back to the member so that the member has no out-of-pocket expenses. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-8

50 Section B Claims Process and Submission, Continued Encounter Submission CMS reimburses all Medicare+Choice organizations based on the member s health status. The health status of a member is determined by a specific code that is assigned by CMS. This code is referred to as a Principle In-Patient Diagnostic Cost Group or "PIP-DCG". The PIP-DCG is derived from the principle and all other diagnostic codes coded on the UB92. As a result, PacifiCare is required to send all payable and encounter claims for Secure Horizons members to CMS. These claims and encounters must pass all the edits that CMS applies to its fee-for-service UB92 bills. In order to minimize rejected claims, providers need to process their Secure Horizons claims and encounters in the same manner as their Medicare fee-for-service bills, subject to the specific claims submission and other requirements set forth herein. If the CMS 1500 and UB92 claim data does not pass the CMS edits, CMS will return the claims to PacifiCare. PacifiCare's claims/encounter data staff will then contact the providers billing department to obtain the correct or missing UB92 information for resubmission. Cooperation and quick turnaround time from the provider in obtaining correct information is necessary. CMS may at any time audit the health plan s data submission. The billing and member medical information must be able to be tracked back to the source document; the original CMS 1500 or UB92 submitted by the provider. Only the provider can change or submit new CMS 1500 or UB92 data. Accordingly, compliance on the providers part is needed in order for health plans to submit the correct data. Providers must submit encounter data to payor ID #: Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-9

51 Section B Claims Process and Submission, Continued Subrogation /Third Party Liability Subrogation procedures are used when a member has an illness or injury that is caused by a third party. PacifiCare has the legal right to recover any claim payments from the responsible party or their insurance company. If a member is entitled to payment from a third party, PacifiCare assigns to the Provider for collection, any claims or demands against such third parties for amounts due for the Provider s Services, subject to the following conditions: Provider shall utilize lien forms which are provided by PacifiCare or approved in advance by PacifiCare, to the extent liens are utilized (see Figure B-3 & B-4) Provider is required to notify PacifiCare each time it pursues and each time it obtains a signed lien from a member Provider shall not commence any legal action against a third party without obtaining the written consent of PacifiCare Provider shall make no demand upon PacifiCare for reimbursement until all third party claims have been pursued and it is determined that full payment cannot be obtained within twelve (12) months from the date of the service. PacifiCare may immediately rescind the assignment of any or all claims and demands against third parties by providing written notice of rescission to the provider In the event that a provider receives payment from a third party after receipt of payment from PacifiCare, provider is required to reimburse PacifiCare to the extent that the combined amounts received from all parties exceeds the amounts set forth in the PacifiCare provider contract. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-10

52 Section B Claims Process and Submission, Continued Coordination of Benefits (COB) Coordination of Benefits (COB) is the process of determining if a member has more than one health insurance plan for medically necessary care. If so, PacifiCare will make a determination as to which insurance company has the primary responsibility to provide such care and payment and which company has secondary responsibility, paying only the account balance after the primary s payment. If a member has health benefits coverage through another policy which is primary to PacifiCare or if the member is entitled to payment under a worker s compensation policy or automobile policy, the Provider may pursue payment from the primary payor. As a secondary payor, PacifiCare will reimburse based on the primary payors payment. The overall reimbursement to the provider will not exceed the contract amount as stated in the agreement with PacifiCare. If a member has health benefits coverage through another policy, which is secondary to PacifiCare, the Provider is required to accept payment from PacifiCare for services as payment in full, except for applicable copayments. The member has no obligation for any fees, regardless of whether the secondary insurance is available. If a claim is submitted for covered services or benefits in which coordination of benefits is necessary, the amount paid as a covered claim by the primary plan is considered to be an essential element of a clean claim for purposes of the secondary plan's processing of the claim and CMS 1500, field 29 or UB-92, field 54 must be completed. If a claim is submitted for covered services or benefits in which non-duplication of benefits is an issue, the amounts paid as a covered claim by all other valid coverage is considered to be an essential element of a clean claim and CMS 1500, field 29 or UB-92, field 54 must be completed. If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision the amount paid as a covered claim by all other health insurance coverage s, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is considered to be an essential element of a clean claim and CMS 1500, field 29 or UB-92, field 54 must be completed. The filing deadline for all coordination of benefits is outlined in the Provider Service Agreement or the state guidelines whichever is great of the claims processing date listed on the primary carrier payor's explanation of payment (EOP) or the amount indicated in the agreement. Claims must be accompanied by the primary carrier s EOP. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-11

53 Section B Claims Process and Submission, Continued COB Medicare Under some circumstances, Secure Horizons benefits will be secondary to those medical benefits to which a member is entitled, regardless of the member s enrollment status with Medicare. Should the cost of medical or hospital services exceed other coverage, Secure Horizons benefits will be provided (as secondary coverage) up to Secure Horizons liability. Other coverage is primary over Secure Horizons in the following instances: Aged Employees For members who are entitled to Medicare due to age, Secure Horizons is primary over Medicare if the employer group has 20 or more employees Disabled employees (Large Group Health Plan) For members who are entitled to Medicare due to disability, Secure Horizons is primary to Medicare if the employer group has 100 or more employees. Claim Rework Request PacifiCare providers who question the accuracy of a claims payment/denial must request a reconsideration of the claim by submitting to PacifiCare a Rework Request (a "rework") within one hundred eighty (180) days (or the time period specified in PacifiCare's Services Agreement) of the processing date on the Explanation of Payment (EOP) or the date listed on the letter of denial. Such timeframes are consistent with industry practices and enable PacifiCare to manage information pertaining to costs of health care services provided to members. All rework requests must be submitted with all the applicable documentation described in the following paragraph. If the rework request is not received within the specified timeframe, the provider forfeits the opportunity for the claim to be reviewed. The following information must be submitted with a rework where applicable. Completed Rework Request Form (See Figure B-2) or submit a letter, memo or note stating what claim (identify with claim # or member ID #, DOS and amount) needs to be reviewed and why. A copy of the original claim. A copy of the EOP or denial letter and/or primary carrier EOP (if applicable). Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-12

54 Section B Claims Process and Submission, Continued Claim Rework Request (Continued) A copy of the invoice when appropriate for supplies or operative report for unlisted procedures. Only if these are the codes that need to be reviewed. Electronic submission report or other document showing where the claim was submitted within the required timeline specified in the contract or state guidelines date of service if appealing a timely filing denial. If a Coordination Of Benefits claim, and it was denied for timely filing, a copy of the primary EOP will be used as documentation if received within the required submission of claims guidelines of primary carrier determination. Please submit claim rework requests to: PacifiCare Attn: Claim Rework Resolution P. O. Box San Antonio, Texas Upon final review of rework, PacifiCare will make a determination and reply to the provider within thirty (30) days by one of the following methods: Explanation of Payment will be sent with the appropriate reimbursement or additional denial A letter notifying the provider on the decision to uphold the original denial and the reason for this determination. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-13

55 Section B Claims Process and Submission, Continued Dispute Resolution Procedures for Unresolved Rework Requests The Provider Dispute Resolution process is available to providers who disagree with a claim rework determination. Providers must initiate this process by submitting a written request to the following address within 60 calendar days of the date of the last determination. The last determination would be either an Explanation of Payment or a Denial Letter. PacifiCare Attention: Appeals & Grievance Unit P. O. Box San Antonio, Texas The provider s written appeal must contain the following information: Letter explaining the reason for the appeal Last Denial letter or Explanation of Payment Previous rework documentation Additional supporting documentation including copies of claims, Medical Records if necessary Please see Section G Provider Dispute Resolution for further details on this process. Follow up calls regarding status of appeals can be made by contacting the Provider Relations Team at Workers Compensation Workers Compensation coverage generally provides 100% reimbursement for the expense incurred as a result of work-related injury or illness. On occasion, what appears to be a work incurred injury or illness will later be denied by the Workers Compensation carrier. A copy of the Workers Compensation carrier explanation must be sent to PacifiCare. This explanation gives PacifiCare the basis for the denial by Workers Compensation. PacifiCare will not pay any Workers Compensation claims without a denial letter from Workers Compensation. If the disability was not work related, normal benefits will be paid. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-14

56 Section B Claims Process and Submission, Continued Benefits of EDI Claims Submission PacifiCare accepts EDI transmissions for payable CMS1500 and UB92 claims from hospitals, ancillaries, medical groups or individuals through various Clearinghouses using PacifiCare's electronic Payer ID Using a clearinghouse may help ensure a smooth transition to the forthcoming EDI requirements outlined in the Health Insurance Portability and Accountability Act (HIPAA). The benefits of submitting claims through an electronic data interchange (EDI) have proven to be a significant advantage to both the provider and PacifiCare. Utilization of EDI claim submission can reduce your overall per claim cost. Utilization of the EDI process will improve the speed, accuracy and turnaround time of provider reimbursements. Utilization of the EDI process provides medical practices with an electronic audit trail to help effectively manage account receivables and will provide evidence of accurate and timely claims submissions. You will be required to test your internal claims system with your clearinghouse. This test must be performed and completed between you and your clearinghouse prior to full claims processing implementation with PacifiCare. Once you have successfully completed your test with the clearinghouse, they will notify you of the date on which you may begin submitting live EDI claims. For more detailed information regarding the electronic submission of claims, please contact an EDI clearinghouse. The following list is provided for reference and is not all inclusive: WebMD (800) THIN (972) ProxyMed (888) MedUnite (professional claims only) (800) NDC (hospital claims only) (800) Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-15

57 Section B Claims Process and Submission, Continued Penalty Payments In the event that PacifiCare has failed to pay clean claim within the timeframes set forth in statutory guidelines, PacifiCare shall pay penalty on clean claims in accordance with all State and, if applicable, Federal laws or as specifically set forth in the Provider Services Agreement with PacifiCare. PacifiCare will add the penalty payment owed to the amount due when the clean claim is paid. ERISA PacifiCare is complying with the Employee Retirement Income Security Act (1974) which is a federal statute administered by the Department of Labor (DoL) that requires specific claim processing timeframes. Stop Loss Please refer to your specific Agreement for stop loss provisions. End stage Renal Disease (Secure Horizons only) If a member has (or develops) end stage renal disease (ESRD) while covered under an employer s group plan, they must use the benefits of the plan for the first thirty (30) months after becoming eligible for Medicare based on ESRD. After the 30 months elapse Medicare is then the primary payor. However, if the employer group plan coverage were secondary to Medicare when the member developed ESRD Medicare would be the primary Payor. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-16

58 Section B Claims Process and Submission, Continued Clean Claim Information For each Clean Claim submitted to PacifiCare by a Physician/Provider, PacifiCare would pay the amount due to the provider within the time frames set forth in the Provider Service Agreement. If PacifiCare determines a submitted claim to be deficient, PacifiCare will, within the statutory claims payment period, advise the provider of the basis upon which a claim is not eligible for payment and specify any additional information required for PacifiCare to pay the amount due with respect to the applicable claim. Required Elements of a Clean Claim A provider submits a clean claim by providing the required data elements as specified in this section along with any attachments and additional elements, or revisions to data elements, of which the provider has been properly notified, and any coordination of benefits or non-duplication of benefits information if applicable. Any revisions, additions, and deletions to the required elements of claims submitted to PacifiCare will be communicated to Providers in a timely manner. CMS has developed claim forms, which provide much of the information needed to process claims. Two of these forms are: CMS-1500 UB-92 In addition, the physician/provider will obtain a valid assignment of benefits and a release of records signature. All claims submitted must include a signature assigning benefits, or indicate Assignment on File, otherwise, PacifiCare is obligated to remit payment directly to the Covered Person. Balance forward statements will be returned for itemization of charges. Physicians/Providers can access the prompt payment guidelines specified by each state by logging on to the web sites below. TEXAS OKLAHOMA Please see Figure B-6 for the required elements of a clean claim for paper and electronic claims. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-17

59 Figure B-1 Explanation of Payment (Sample) DATE: 08/13/99 PAGE 1 E X P L A N A T I 0 N O F P A Y M E N T S PO BOX 460 COLORADO SPRING CO P# - MEM1 MEMBER# PATIENT# NAME GROUP# CLAIM NUMBER BEGOAT DIAG1 DIAG2 SVCCOD MD UNT CHARGED ALLOWED DISCNT COP/DED ENODAT LNE EP1 EP2 EP3 EP4 DISALLOW PREPAID WITHOLD COBAMT PAID JOHN G RV A CLAIM.TOTALS: JEFFREY G A CLAIM TOTALS: PROVIDER TOTALS: VENDOR TOTALS: ASSOCIATED CHECK# DATE - 08/13/99 AMOUNT EXPLANATION OF PAYMENT CODES: DEND OF EOB /13/ # two thousand seven hundred sixteen and 20/100 dollars Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-18

60 Figure B-2 Claims Rework Request Claims Rework/Adjustment Request Please submit all claim rework requests by completing one form per claim and submitting to the address listed below. Please note that all claim rework requests must be submitted within 60 days of receipt of PacifiCare s explanation of payment (EOP) or denial letter. If the rework request is not received within specified deadline, the provider forfeits the opportunity for the claim to be reviewed. All rework requests must be submitted with all the applicable documentation listed below. Provider Information Date: Product: Secure Horizons HMO PPO Provider Name: Tax Identification #: Office Contact Name: Phone: Fax: Member Name: Date of Service: Member ID#: Amount of Claim: Reason for Claim Rework Request Here Type of Claim Issue Supporting Documentation Must be Submitted Claim not paid per contract Claim Edit Clinical Issue Length of Stay -all days not paid Miscellaneous Code/Add'l Description Copy of Rate page and signature page from contract Copy of Medical Records to support additional payment Copy of Medical Records Copy of Medical Records Itemized Statement or Invoice Here Type of Claim Issue Additional Information Needed Paid to wrong provider Correct provider is: Incorrect member Correct member is: Other Insurance Policy Name and ID#: Copay Incorrect Should be: Claim Denied no preauthorization Circle one: No Auth needed or Copy of Auth is attached Check Lost/Voided Need to reissue Check number is: Corrected claim or additional charges Corrected HCFA is attached Paid as non-contracted incorrectly Provider Contracted Provider # & Tax ID Benefits paid/denied incorrectly Explanation: Timely Filing Supporting Documentation showing claim filed timely Incomplete payment, Check original HCFA/UB for other Procedures listed Paid # of units incorrectly Other explanation below Please provide a description of problem/issue: Please submit claim rework requests form and supporting documentation to the following appropriate address: SignatureValue (HMO & Secure Horizons SignatureOptions (PPO) PacifiCare PacifiCare Attn: Claim Rework Resolution Attn: Appeal Coordinator P. O. Box P.O. Box 6098 San Antonio, Texas Cypress, CA Fax # Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-19

61 Figure B-3 SAMPLE ACCIDENT QUESTIONNAIRE Date Injured Party Member Number Date of Occurrence Dear: In order to update our records and complete claims processing we are asking that you complete this questionnaire concerning your injuries and return it within 10 days. Enclosed is a postage paid envelope for your convenience. Thank you for assisting our efforts in providing quality service. Briefly describe cause of injury: (e.g., location of accident/how it happened) Name of other Insurance Company (e.g., auto, homeowners, workers comp) Insurance Company Address: Policyholder s Name: Policy No. Claim No. If you have retained an attorney, please provide the following information: Attorney s Name: Address: City: State: Zip: Telephone No: ( ) FAX: ( ) Identity of other parties who may be responsible for the injuries: Name: Telephone No: ( ) Address: City: State: Zip: Name of Insurance Company: Insurance Company Telephone No: ( ) FAX: ( ) Insurance Company Address: City: State: Zip: Policyholder s Name: Adjuster s Name: Date: Member s Signature: Policy No: Claim No: (PLEASE RETURN WITHIN 10 DAYS) Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-20

62 Figure B-4 Notice and Allowance of Lien I, (member name) acknowledge my obligation under the PacifiCare s combined Evidence of Coverage disclosure form to reimburse PacifiCare ( PacifiCare ) for the reasonable value of all benefits provided by PacifiCare as a result of the injuries I sustained on or about (date of accident) in the event that a monetary recovery is made as a result of the injuries. To facilitate PacifiCare in the exercise of this right, I hereby authorize and direct defendants, insurance companies, and my attorney, (attorney name) (if applicable) to pay PacifiCare from the proceeds of any settlement, judgment or award the reasonable value of such additional benefits. I understand that the reasonable value of the benefits provided by PacifiCare to me as a result of the injuries is $ (lien amount). Should PacifiCare provide additional benefits to me because of the injuries, I understand and agree that PacifiCare shall be reimbursed for the reasonable value of such additional benefits. I also agree to compromise or settle any portion of any claim for damages and /or medical expenses brought as a result of the injuries without providing for full reimbursement to PacifiCare from the proceeds of such settlement. We will not compromise or settle any such claim without first obtaining the written consent of PacifiCare right to reimbursement. Date: (member name) I, (attorney name), attorney of record for (member name), agree to comply with the foregoing by withholding from the proceeds of any settlement, judgment or award the sum of $ (lien amount), less attorney s fees and costs to be shared on a pro rata basis by my client, PacifiCare and any other lien claimants, to satisfy PacifiCare lien rights as set forth herein. Date: (attorney name) Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-21

63 Figure B-5 Notice of Reimbursement Rights (Sample Letter - Medical Group/IPA Lien Form) I, (Member name), understand that I have an obligation under the PacifiCare combined Evidence of Coverage disclosure form, to reimburse PacifiCare for the reasonable value of all medical services provided to me by PacifiCare, in relation to my accident on (date) of accident, in the event that a recovery is made from a third party as a result of that accident. I understand that PacifiCare has arranged with (Hospital) to provide me with medical services. The (Hospital) (has/have) provided medical services to me relating to this accident. Pursuant to Secure Horizons agreement with (Hospital), (Hospital) has the right to be reimbursed for the services provided to me by (Hospital) relating to this accident. To facilitate the exercise of this right, I hereby authorize and direct defendants, insurance companies and attorney, (name of attorney), if applicable, to pay (Hospital) from the proceeds of any settlement or judgment made arising out of my (date) of accident for the reasonable value of medical benefits provided to me as a result of that accident. Member Name (Please Print) Parent, or Guardian (Please Print) Member s Signature Signature Date Relationship to Member Date Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-22

64 (Sample letter - Medical Group/IPA Lien Form) Page Two I, (attorney name), attorney for (name of member) agree to comply with the foregoing by remitting from the proceeds of any settlement, judgment or award, the reasonable value of the medical benefits provided by (Hospital) to my client as a result of his/her (date) accident less attorney s fees and costs to be deducted from the settlement, judgment or award on a pro rata basis to satisfy (Hospital s) lien rights as set forth herein. Date Attorney s Name (Please Print) Attorney s Signature Attorney s Address: Telephone Number: ( ) FAX: ( ) cc: Secure Horizons Claims Cost Containment Unit Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-23

65 Required Elements of a Clean Claim Figure B Elements of a Clean Claim for a NON-INSTITUTIONAL PROVIDER. Section B Non-Electronic Claims (1) Required data elements for physicians or noninstitutional providers. The data elements described in this paragraph are required as indicated and must be completed in accordance with the special instructions applicable to the data element for clean claims filed by physicians and noninstitutional providers. A) subscriber's/patient's plan ID number (CMS 1500, field 1a) is required; B) patient's name (CMS 1500, field 2) is required; C) patient's date of birth and gender (CMS 1500, field 3) is required; D) subscriber's name (CMS 1500, field 4) is required, if shown on the patient s ID card; E) patient's address (street or P.O. Box, city, state, zip) (CMS 1500, field 5) is required; F) patient's relationship to subscriber (CMS 1500, field 6) is required; G) subscriber's address (street or P.O. Box, city, state, zip) (CMS 1500, field 7) is required, but physician or provider may enter "same" if the subscriber s address is the same as the patient s address required by subparagraph (E) of this paragraph; H) Other insured's or enrollee's name (CMS 1500, field 9), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; I) Other insured's or enrollee's policy/group number (CMS 1500, field 9a), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; J) (Other insured's or enrollee's date of birth (CMS 1500, field 9b), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; K) Other insured's or enrollee's plan name (employer, school, etc.) (CMS 1500, field 9c), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred 2 Required Elements as defined and described in Title 28, Texas Administrative Code, (4) and by the Oklahoma DOH, in 36 O.S Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-24

66 provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element. If the field is required and the physician or provider is a facility based radiologist, pathologist or anesthesiologist with no direct patient contact, the physician or provider must either enter the information or enter NA (not available) if the information is unknown; L) Other insured's or enrollee's HMO or insurer name (CMS 1500, field 9d), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(Q) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element; M) whether patient's condition is related to employment, auto accident, or other accident (CMS 1500, field 10) is required, but facility based radiologists, pathologists, or anesthesiologists shall enter "N" if the answer is "No" or if the information is not available; N) if the claim is a duplicate claim, a "D" is required, if the claim is a corrected claim, a "C" is required (CMS 1500, field 10d); O) subscriber's policy number (CMS 1500, field 11) is required; P) HMO or insurance company name (CMS 1500, field 11c) is required; Q) disclosure of any other health benefit plans (CMS 1500, field 11d) is required; (i) if respond "yes", then (I) data elements specified in paragraph (1)(H)-(L) of this subsection are required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete the data elements in paragraph (1)(H)-(L) of this subsection; (II) the data element specified in paragraph (1)(II) of this subsection is required when submitting claims to secondary payor HMOs or preferred provider carriers; (ii) if respond "no," the data elements specified in paragraph (1)(H)-(L) of this subsection are not required if the physician or provider has on file a document signed within the past 12 months by the patient or authorized person stating that there is no other health care coverage; although the submission of the signed document is not a required data element, a copy of the signed document shall be provided to the HMO or preferred provider carrier upon request. R) patient's or authorized person's signature or notation that the signature is on file with the physician or provider (CMS 1500, field 12) is required; S) subscriber's or authorized person's signature or notation that the signature is on file with the physician or provider (CMS 1500, field 13) is required; T) date of injury (HCFA 1500, field 14) is required, if due to an accident; U) name of referring physician or other source (CMS 1500, field 17) is required for primary care physicians, specialty physicians and hospitals; however, if there is no referral, the physician or provider shall enter "Self-referral" or "None"; V) I.D. Number of referring physician (CMS 1500, field 17a) is required for primary care physicians, specialty physicians and hospitals; however, if there is no referral, the physician or provider shall enter "Self-referral" or "None"; W) narrative description of procedure (CMS 1500, field 19) is required when a physician or provider uses an unlisted or not classified procedure code or an NDC code for drugs; X) for diagnosis codes or nature of illness or injury (CMS 1500, field 21), up to four diagnosis codes may be entered, but at least one is required (primary diagnosis must be entered first); Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-25

67 Y) verification number (CMS 1500, field 23), is required if services have been verified pursuant to of this title (relating to Verification). If no verification has been provided, a prior authorization number (CMS 1500, field 23), is required when prior authorization is required and granted; Z) date(s) of service (CMS 1500, field 24A) is required; AA) place of service codes (CMS 1500, field 24B) is required; BB) procedure/modifier code (CMS 1500, field 24D) is required; CC) diagnosis code by specific service (CMS 1500, field 24E ) is required with the first code linked to the applicable diagnosis code for that service in field 21; DD) charge for each listed service (CMS 1500, field 24F) is required; EE) number of days or units (CMS 1500, field 24G) is required; FF) physician's or provider's federal tax ID number (CMS 1500, field 25) is required; GG) whether assignment was accepted (CMS 1500, field 27), is required if assignment under Medicare has been accepted; HH) total charge (CMS 1500, field 28) is required; II) amount paid (CMS 1500, field 29), is required if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan in accordance with paragraph (1)(P) of this subsection and as required by JJ) subsection (c) of this section; signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier (CMS 1500, field 31) is required; KK) name and address of facility where services rendered (if other than home or office) (CMS 1500, field 32) is required; and LL) physician's or provider's billing name, address and telephone number is required, and the provider number (CMS 1500, field 33) is required if the HMO or preferred provider carrier required provider numbers and gave notice of that requirement to physicians and providers prior to June 17, Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-26

68 Elements of a Clean Claim for a INSTITUTIONAL PROVIDERS Required data elements for institutional providers. The data elements described in this paragraph are required as indicated and must be completed in accordance with the special instructions applicable to the data elements for clean claims filed by institutional providers. A) provider's name, address and telephone number (UB-92, field 1) is required; B) patient control number (UB-92, field 3) is required; C) type of bill code (UB-92, field 4) is required and shall include a "7" in the third position if the claim is a corrected claim; D) provider's federal tax ID number (UB-92, field 5) is required; E) statement period (beginning and ending date of claim period) (UB-92, field 6) is required; F) covered days (UB-92, field 7), is required if Medicare is a primary or secondary payor; G) noncovered days (UB-92, field 8), is required if Medicare is a primary or secondary payor; H) coinsurance days (UB-92, field 9), is required if Medicare is a primary or secondary payor; I) lifetime reserve days (UB-92, field 10), is required if Medicare is a primary or secondary payor, and the patient was an inpatient; J) patient's name (UB-92, field 12) is required; K) patient's address (UB-92, field 13) is required; L) patient's date of birth (UB-92, field 14) is required; M) patient's gender (UB-92, field 15) is required; N) patient's marital status (UB-92, field 16) is required; O) date of admission (UB-92, field 17) is required for admissions, observation stays, and emergency room care; P) admission hour (UB-92, field 18) is required for admissions, observation stays, and emergency room care; Q) type of admission (e.g., emergency, urgent, elective, newborn) (UB-92, field 19) is required for admissions; R) source of admission code (UB-92, field 20) is required; S) discharge hour (UB-92, field 21), is required for admissions, outpatient surgeries or observation stays; T) patient-status-at-discharge code (UB-92, field 22) is required for admissions, observation stays, and emergency room care; U) condition codes (UB-92, fields 24-30), are required if the CMS UB-92 manual contains a condition code appropriate to the patient's condition; V) occurrence codes and dates (UB-92, fields 32-35), are required if the CMS UB-92 manual contains an occurrence code appropriate to the patient's condition; W) occurrence span code, from and through dates (UB-92, field 36), are required if the CMS UB-92 manual contains an occurrence span code appropriate to the patient's condition; X) value code and amounts (UB-92, fields 39-41) are required for inpatient admissions. If no value codes are applicable to the inpatient admission, the provider may enter value code 01; Y) revenue code (UB-92, field 42) is required; Z) revenue description (UB-92, field 43) is required; AA) HCPCS/Rates (UB-92, field 44), are required if Medicare is a primary or secondary payor; BB) Service date (UB-92, field 45) is required if the claim is for outpatient services; CC) units of service (UB-92, field 46) are required; DD) total charge (UB-92, field 47) is required; EE) HMO or preferred provider carrier name (UB-92, field 50) is required; Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-27

69 FF) provider number (UB-92, field 51), is required if the HMO or preferred provider carrier, prior to June 17, 2003, required provider numbers and gave notice of that requirement to physicians and providers. GG) prior payments-payor and patient (UB-92, field 54), are required if payments have been made to the physician or provider by the patient or another payor or subscriber, on behalf of the patient or subscriber, or by a primary plan as required by subsection (c) of this section; HH) subscriber's name (UB-92, field 58), is required if shown on the patient s ID card; II) JJ) patient's relationship to subscriber (UB-92, field 59) is required; patient's/subscriber's certificate number, health claim number, ID number (UB-92, field 60), is required if shown on the patient s ID card; KK) insurance group number (UB-92, field 62), is required if a group number is shown on the patient s ID card; LL) verification number (UB-92, field 63), is required if services have been verified pursuant to of this title (relating to Verification). If no verification has been provided, treatment authorization codes (UB-92, field 63) are required when authorization is required and granted; MM) principal diagnosis code (UB-92, field 67) is required; NN) diagnoses codes other than principal diagnosis code (UB-92, fields 68-75), are required if there are diagnoses other than the principal diagnosis; OO) admitting diagnosis code (UB-92, field 76) is required; PP) procedure coding methods used (UB-92, field 79), is required if the CMS UB-92 manual indicates a procedural coding method appropriate to the patient's condition; QQ) principal procedure code (UB-92, field 80), is required if the patient has undergone an inpatient or outpatient surgical procedure; RR) other procedure codes (UB-92, field 81), are required as an extension of subparagraph (QQ) of this paragraph if additional surgical procedures were performed; SS) attending physician ID (UB-92, field 82) is required; TT) signature of provider representative, electronic signature or notation that the signature is on file with the HMO or preferred provider carrier (UB-92, field 85) is required; and UU) date bill submitted (UB-92, field 86) is required. Sections C, D, & E Elements if applicable, for any coordination of benefits or non-duplication of benefits information C) Coordination of benefits or non-duplication of benefits. If a claim is submitted for covered services or benefits in which coordination of benefits pursuant to of this title (relating to Group Coordination of Benefits) and (1) of this title (relating to Optional Provisions) is necessary, the amount paid as a covered claim by the primary plan is a required element of a clean claim for purposes of the secondary plan's processing of the claim and CMS 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(ii) and (b)(2)(gg) of this section. If a claim is submitted for covered services or benefits in which non-duplication of benefits pursuant to of this title (relating to Non-duplication of Benefits Provision) is an issue, the amounts paid as a covered claim by all other valid coverage is a required element of a clean claim and CMS 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(ii) and (b)(2)(gg) of this section. If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision as set forth in (a)(4) of this title (relating to Minimum Standards for Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-28

70 Major Medical Expense Coverage) the amount paid as a covered claim by all other health insurance coverages, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is a required element of a clean claim and CMS 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(ii) and (b)(2)(gg) of this section. Notwithstanding these requirements, an HMO or preferred provider carrier may not require a physician or provider to investigate coordination of other health benefit plan coverage. Additional Requirements for Electronic Claims D) A physician or provider submits an electronic clean claim by submitting a claim using the applicable format that complies with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements. E) If a physician or provider submits an electronic clean claim that requires coordination of benefits pursuant to of this title (relating to Group Coordination of Benefits) or (1) of this title (relating to Optional Provisions), the HMO or preferred provider carrier processing the claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider. The primary payor may submit primary payor information electronically to the secondary payor using the ASC X12N 837 format and in compliance with federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual B-29

71 Section C Provider Dispute Process Table of Contents PacifiCare Provider Dispute Resolution... C-1 Appeal vs. Rework... C-1 PacifiCare Appeals Process For All Providers... C-2 Appropriate Document Submission... C-2 Expedited Appeals Process... C-2 Status of Appeals... C-2 Claim Rework Request Form...Figure C-1 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

72 Section C Provider Appeal/Dispute Process PacifiCare Provider Dispute Resolution Providers have the right to submit an oral or written notification regarding dissatisfaction. However, in most cases the notice must be received in writing to initiate a formal process. The definitions of a complaint, appeal or grievance vary based on the regulatory or accrediting agency, so the terms may be used interchangeably. Typically, the term appeal is used to describe the reconsideration of a denial and the terms rework, complaint and grievance are used to describe a non-denial issue. If a member requests a service that you believe is not appropriate or is not a covered benefit, it is the responsibility of the provider to send notification to the PacifiCare Medical Management Department. The Medical Management Department will send out a formal denial letter to the member, which advises them of their appeal rights. Appeal vs. Rework Claims disputes may be handled by two different areas, depending on the issue. Appeals are handled by the Appeals department and claim reworks are handled by the Claims department. A definition of each term is provided below. Appeal written dispute of a denial by PacifiCare that requires comprehensive review of additional documentation (e.g., denial based upon lack of medical necessity or length of stay denial). This term is also used when the provider submits a written dispute of a rework decision. Rework dispute of a denied claim that can easily be resolved with the appropriate documents to support claim payment or corrections (e.g., claim denied for no authorization accompanied by a copy of the authorization or claim denied for untimely filing accompanied by proof of timely filing) or a non-denial dispute such as a payment dispute or claim check edit dispute. A rework may be submitted to PacifiCare by utilizing the Rework Request Form (see Figure C- 1). Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual C-1

73 Section C Provider Appeal/Dispute Process, Continued PacifiCare Appeal Process Submission Requirements Provider appeals must be filed within sixty (60) days from the date of payment/denial (unless otherwise specified in the PacifiCare Provider Agreement or if a provider has been appointed to file an appeal on behalf of a member, which would be handled under the member process). In order to initiate the provider appeal process, the provider must submit a written request to: PacifiCare Appeals Department P.O. Box San Antonio, Texas, Appropriate Document Submission The provider must submit all pertinent documentation that supports their case (i.e., medical records, proof of timely filing, contractual language, eligibility verification etc.). PacifiCare s Response PacifiCare will send a letter of acknowledgment of receipt of the appeal to the provider. The first level of the process can take up to thirty (30) business days. Clinical individuals who were not previously involved in the initial decision will review all clinical cases. A letter will be sent to the provider outlining the outcome of the appeal decision and the basis for the decision. Status of Appeals Follow up calls regarding status of appeals can be made by contacting the Appeals Specialist referenced in the acknowledgement letter. You may also contact the Provider Relations Team at (877) if you have submitted an appeal and have not received a response. Please be sure to review the definitions of a rework and an appeal when contacting the plan to follow up on status to facilitate a prompt response. End of Section Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual C-2

74 Claims Rework/Adjustment Request Please submit all claim rework requests by completing one form per claim and submitting to the address listed below. If the rework request is not received within specified deadline, the hospital and/or ancillary provider forfeits the opportunity for the claim to be reviewed. All rework requests must be submitted with all the applicable documentation listed below. Provider Information Date: Product: Secure Horizons HMO PPO Provider Name: Tax Identification #: Office Contact Name: Phone: Fax: Member Name: Date of Service: Member ID#: Amount of Claim: Reason for Claim Rework Request Here Type of Claim Issue Supporting Documentation Must be Submitted Claim not paid per contract Claim Edit Clinical Issue Length of Stay -all days not paid Miscellaneous Code/Add'l Description Copy of Rate page and signature page from contract Copy of Medical Records to support additional payment Copy of Medical Records Copy of Medical Records Itemized Statement or Invoice Here Type of Claim Issue Additional Information Needed Paid to wrong provider Correct provider is: Incorrect member Correct member is: Other Insurance Policy Name and ID#: Copay Incorrect Should be: Claim Denied no preauthorization Circle one: No Auth needed or Copy of Auth is attached Check Lost/Voided Need to reissue Check number is: Corrected claim or additional charges Corrected claim is attached Paid as non-contracted incorrectly Provider Contracted Provider # & Tax ID Benefits paid/denied incorrectly Explanation: Timely Filing Supporting Documentation showing claim filed timely Incomplete payment, Check original claim form for other Procedures listed Paid # of units incorrectly Other explanation below Please provide a description of problem/issue: Figure C-1 Please submit claim rework requests form and supporting documentation to the following appropriate address: SignatureValue (HMO & Secure Horizons PacifiCare Attn: Claim Rework Resolution P. O. Box San Antonio, Texas Fax # SignatureOptions (PPO) PacifiCare Attn: Appeal Coordinator P.O. Box 6098 Cypress, CA Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual C-3

75 Section D - Preauthorization Table of Contents Introduction... D-1 Delegated Medical Management... D-1 Decision to Render Services... D-2 Criteria for Determining Medical Necessity... D-2 Provider Requirements... D-2 Provider Responsibilities... D-3 Emergency Services or Direct Urgent Hospital Admissions... D-4 Emergency Services... D-4 Medical Observation Status... D-5 Preauthorization Time Requirements... D-5 Preauthorization Protocol... D-6 Medical Management Denials... D-6 Utilization Review Appeals Process Texas Only... D-7 Independent Review Organization... D-8 Appeal of Denials... D-8 Expedited Appeal Process... D-9 Appeal Decision... D-9 Ob/Gyn Services... D-10 Preauthorization Process for Ob/Gyn Services... D-10 Laboratory Services... D-11 Rehabilitation... D-11 Skilled Nursing Facilities (SNF)... D-12 Self Injectable Drugs/Home Infusion... D-12 Contact Numbers/Hours of Operation... D-13 Preauthorization List... Figure D-1 Preauthorization Form... Figure D-2 Ob/Gyn Notification & Assessment Form (TX ONLY)... Figure D-3 Prescription Solutions Injectable Medication Authorization Request... Figure D-4 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

76 Section D - Preauthorization Introduction The purpose of the Preauthorization Medical Management Program is to determine if the medical services proposed or rendered are covered under the PacifiCare benefits and/or medically necessary and are performed at both the appropriate place and level of care. With limited exceptions, providers (physicians, ancillaries, facilities, etc.) will not be reimbursed for services that are not medically necessary or for which correct procedures have not been followed (for example, notification requirements, preauthorization, or verification guarantee process). All Medical Management decision making is based only on appropriateness of care and service and the existence of coverage. PacifiCare does not reward practitioners or other individuals such as review nurses or review physicians conducting utilization review for issuing denials of coverage. There are no financial incentives for Medical Management decision-makers to encourage denials. PacifiCare is not required to pay for services that have not been preauthorized or verification of guarantee has not been obtained except for emergency services. Delegated Medical Management Some Physician Groups have received delegated Medical Management responsibility by PacifiCare. Physicians associated with these delegated IPA/Medical groups must use the group s Medical Management office and protocols for all preauthorizations. Preauthorization for delegated groups processes and forms may differ somewhat from those outlined in this section. Please contact your Provider Relations Representative if you have questions concerning medical management delegation. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-1

77 Section D - Preauthorization, Continued Decision to Render Services Regardless of the Preauthorization Medical Management Program determination, the decision to render medical services lies with the member and the attending physician. If the provider and member decide to go forth with the medical services once preauthorization has been denied, all physician, hospital, and any ancillary services will not be reimbursed by PacifiCare. Criteria for Determining Medical Necessity Nationally utilized Criteria is reviewed to determine medical necessity and appropriate level of care for services whenever possible. PacifiCare will utilize multiple resources & guidelines will be used to determine medical necessity and appropriate level of care. Individual criteria will be provided to you upon request. Provider Requirements Providers are required to participate, cooperate and comply with PacifiCare/Secure Horizons preauthorization procedures. All providers must render covered services at the most appropriate level of service (including levels of acute care as intensive care unit services or regular acute medical and surgical services as determined by the clinical status of the member) which can safely be provided to the member. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-2

78 Section D - Preauthorization, Continued Provider Responsibilities Providers are required to confirm a preauthorization has been approved prior to rendering services for a specified member and to review the amount of services approved. If a preauthorization has not been requested, provider must request prior authorization for services within at least five (5) business days, minimum two (2) business days, prior to providing or ordering the covered service except in the case of emergent or urgent services. Providers may call to confirm a preauthorization has been approved for a particular date of service. PacifiCare must be notified of urgent or emergent cases within a 24 hours of services being rendered or admission. Failure to obtain prior authorization or to notify PacifiCare within the appropriate time frame may result in a denial of payment. NOTE: In no event shall PacifiCare/Secure Horizons or the member be held responsible to reimburse providers for medical services, admissions, inappropriate hospital days, and/or not medically necessary services if prior authorization was not obtained. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-3

79 Section D - Preauthorization, Continued Emergency Services and/or Direct Urgent Hospital Admissions Some admissions cannot be scheduled. The provider is required to contact PacifiCare of admissions as soon as possible on the same day (but no later than 24 hours from admission). The contracted provider must work with the PacifiCare Medical Management Department to obtain authorization. Admission notification can be sent to PacifiCare Medical Management Department at: Fax Number or by phone at hours/day, 7 days/week Notification after hours will be handled by an answering service Eligibility determination should occur before the admission of any after-hours or weekend admission whenever possible. The IVR confirmation eligibility system is available 24 hours a day, 7 days a week. Emergency Services Emergency care is health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in a) placing the patient s health in serious jeopardy: b) serious impairment to bodily functions: c) serious dysfunction of any bodily organ or part: d) serious disfigurement: e) in the case of a pregnant woman, serious jeopardy to the health of the fetus. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-4

80 Section D - Preauthorization, Continued Medical Observation Status Hospital observation status is generally designed to evaluate a patient s medical condition and determine the need for actual admission, or to stabilize a patient s condition (usually 24 hours). Typical cases when observation status is used include rule-out diagnoses and medical conditions that respond quickly to care. Patients admitted under observation status may later be converted to an inpatient admission if medically necessary. For Secure Horizons members, observation status is limited to a maximum of forty-eight (48) hours. For Commercial members, observation status is limited to a maximum of twentythree (23) hours. Services exceeding these time limits as an outpatient will be denied. Observation following an outpatient service is not appropriate unless it exceeds the standard recovery time as established by medical practice. Preauthorization Time Requirements for Elective, Urgent and Emergency Services A minimum notification of three (3) calendar days is required for elective services to complete a thorough clinical analysis prior to a member's proposed elective procedure date. Procedures are not considered scheduled, and should not be communicated to the member as being scheduled, until they have been authorized. An authorization or notification number with the approved date range will be returned by fax to your office within appropriate regulatory guideline requirements. For services that are considered to be urgent care services and are scheduled to be provided within two (2) calendar days, Medical Management will reply by fax within appropriate regulatory guideline requirements, but not to exceed 3 calendar days. Please be sure to identify urgent care services as such to help ensure appropriate priority status. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-5

81 Section D - Preauthorization, Continued Preauthorization Protocol 1. The admitting provider initiates an authorization request by fax at least three (3) calendar days prior to the scheduled date for the services to be provided for any services which require a preauthorization. A list of those services can be found in the provider orientation folder. 2. The provider must complete and submit the appropriate Preauthorization Request Form. See Figure D-2 at the end of this section. Incomplete forms will not be accepted. 3. Medical Management will document the information, respond to the authorization request, and provide a decision within three (3) calendar days. If approved, an authorization number will be issued to the provider. If denied, the reason for denial will be forwarded to the provider. 4. In the case of a denial you will be offered the opportunity to speak with PacifiCare s Medical Director to discuss the case. 5. The authorized provider will deliver care to the member. Documentation of the recommended treatment plan should be shared with the member's Primary Care Physician. 6. The provider will submit a claim with the authorization number in the usual manner to the appropriate address. Medical Management Denials A denial may be issued when there is no apparent medical necessity for a health care service, a non-covered benefit is requested, or when no information or insufficient information is provided. If you disagree with a Medical Management decision to deny requested health care services, you may request an appeal as outlined in the this section. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-6

82 Section D - Preauthorization, Continued Utilization Review Appeals Process TEXAS providers only Submission Requirements TEXAS COMMERCIAL HMO ONLY This section applies to those Texas Commercial provider appeals that are subject to the Texas UR appeal process. This includes any pre-service or concurrent denial based on medical necessity or appropriateness, with the exception of investigational/experimental denials. Note: If a denial is based on contractual reasons (e.g., delay of service or untimely notification, payment of claim or not a covered benefit), then it is not subject to the UR appeals process. UR appeals are not subject to the sixty-day (60) request deadline outlined in section G. In order to initiate the appeal process, the provider may submit their request to: PacifiCare Appeals Department P.O. Box San Antonio, Texas, Telephonic Requests for UR Appeals: Fax Requests for UR Appeals: PacifiCare will send a letter of acknowledgment to the provider within five (5) business days that includes the date of receipt and any documents that need to be submitted. A one-page appeal form will also be included if the appeal was submitted orally. The appeal decision will be made by a physician and the outcome letter will be provided within thirty (30) calendar days of receipt of the appeal. The outcome letter will include the following: Clinical basis for decision The specialty of the physician that reviewed the appeal Notice of the right to review by an Independent Review Organization (IRO) Notice of the right to request a review by specialty provider (that typically manages the medical, dental or specialty condition, procedure, or treatment under discussion). Providers will be given ten business days to present in writing a justified reason for the specialty review. If approved, the specialty review will be completed within fifteen days of the receipt of the request. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-7

83 Section D - Preauthorization, Continued Independent Review Organization (IRO) TEXAS providers only TEXAS COMMERCIAL HMO ONLY If the provider elects to pursue IRO review, the provider must obtain the member s signature on the IRO form and submit it to PacifiCare at the address or fax number listed above. Upon receipt of the IRO forms, PacifiCare will forward the request to the Texas Department of Insurance for the IRO assignment. PacifiCare will forward the appeal file to the IRO within three (3) business days of receipt of the IRO form. The IRO will make their decision and communicate the outcome to the provider no earlier than the 15 th day and no later than the 20 th day after the date the IRO receives all information necessary to make a decision. In a circumstance involving a member s life-threatening condition, the member is entitled to an immediate appeal to an independent review organization and is not required to comply with procedures for PacifiCare s appeal process. Appeal of Denials Upon initiation of an appeal, Medical Management will request from you in writing pertinent information to document the medical necessity of the previously denied health care services. In addition, the Medical Director (or designated medical representative) may contact you to discuss specific circumstances of the case and/or consult a provider practicing in your same specialty. A Medical Director (or designated medical representative), who was not involved in the original denial decision, will review all the information provided and either uphold or reverse the denial. Upon receipt of requested information, a Medical Management designated representative will advise you of the determination within thirty (30) days of the appeal request. An expedited appeal may be requested for a service that is concurrently being rendered or for which delay in the receipt of the requested service would be harmful to the member. Please be sure to notify Medical Management that you are requesting an expedited appeal. In those cases, a Medical Management designated representative will advise you of the determination within one (1) working day of the request. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-8

84 Section D - Preauthorization, Continued Expedited Appeal Process Only pre-service issues are subject to expedited review. If the member is financially responsible for the denial then the provider may appeal on their behalf. Clinical staff will determine if the case is appropriate for expedited review. PacifiCare will follow the most stringent regulatory/accreditation standards for resolving expedited appeals as listed below: State/Product State-Mandated Timeframe NCQA/ Department of Labor Timeframe Centers for Medicare and Medicaid Services Timeframe Oklahoma Commercial 72 Hours 72 Hours N/A Texas Commercial 1 business day for an appeal involving an emergency or discontinuation of an inpatient hospitalization 72 hours N/A Secure Horizons (OK & TX) N/A 72 hours 72 hours Expedited appeals may be submitted to: Telephonic Requests for Expedited Appeals: Fax Requests for Expedited Appeals: Appeal Decision In addition to verbal notification, Medical Management will mail you a written decision, which includes a statement of the basis for the decision to uphold or reverse the original denial. NOTE: Decisions made by Medical Management reflect benefit coverage only and do not determine if health care services should or should not be rendered. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-9

85 Section D - Preauthorization, Continued Ob/Gyn Services PacifiCare provides coverage for an annual routine gynecological examination for all female members performed by either the member s PCP or Obstetrician (OB) or Gynecologist (GYN). The member may also select a family physician, internal medicine physician, or another qualified physician to provide such care. TX ONLY: Under these benefits, all OB and/or GYN services can be accessed through self-referral. That is, the member has the choice of visiting her PCP or participating OB/GYN to perform any service without a referral from her PCP for any of the following reasons: Well woman exams Care related to pregnancy Care for any gynecological condition Any diagnosis, treatment or referral for a condition that is within the scope of practice of the OB/GYN. OK ONLY: Under these benefits, the member may self refer for an annual well woman exam only. That is, the member has the choice of visiting her PCP or participating OB/GYN to perform this service without a referral from her PCP. Preauthorization Process for Ob/Gyn Services Once care is accessed, a provider should complete an OB Notification & Assessment Form. (See Figure D-3) Preauthorization may be required for in-office, inpatient or outpatient services within the scope of the practice of an OB/GYN. Preauthorization can be obtained by completing the Preauthorization Request form and faxing it to the appropriate Medical Management Department. (See Contact Numbers at the end of this section). If a condition outside the scope of practice of the OB/GYN is identified, a referral or preauthorization from the Primary Care Physician must be obtained before services can be rendered. The member s Primary Care Physician and IPA affiliation can be obtained by calling the IVR system at NOTE: Each employer s group benefit structure is different. Services are covered when they are a part of the benefit plan and are medically necessary. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-10

86 Section D - Preauthorization, Continued Laboratory Services When an order is received from the physician requesting outpatient laboratory tests: Determine if the patient has PacifiCare coverage. If the patient has PacifiCare coverage and requires elective testing, direct the patient to the nearest contracted laboratory for the testing or advise them to contact their Primary Care Physician. If there is a STAT lab order, perform the STAT testing ONLY and submit the claim to PacifiCare noting the STAT request. Elective tests can be submitted a contracted laboratory. Rehabilitation Oklahoma Providers Only Oklahoma Providers Only PacifiCare requires preauthorization of all outpatient physical, occupational and speech therapies. When a call is received from the physician ordering therapy: Verify coverage and benefit limitations. For outpatient rehabilitation services ordering physician provides preauthorization number and the number of authorized visits. Document this information on patient record for claim filing. If physician has NOT preauthorized therapy, have him/her contact PacifiCare Medical Management staff to obtain preauthorization and confirmation of benefits prior to providing outpatient rehabilitation services. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-11

87 Section D - Preauthorization, Continued Skilled Nursing Facilities (SNF) Authorization for skilled nursing facility (SNF) services is given in three day to one-week increments depending upon the diagnosis and treatment plan. PacifiCare s Medical Management staff reviews SNF covered person at least weekly (on-site whenever feasible), evaluating the level of care, services being rendered, and the member s progress toward projected goals. A PacifiCare Participating Physician must perform an initial physical exam and written report on patients admitted to a SNF within forty-eight (48) hours of admission. Regulations require that skilled level patients continue to be seen by a physician at least once every thirty (30) days for the first ninety (90) days after admission, and at least once every sixty (60) days thereafter. Self Injectable Drugs/Home Infusion or Injectables at Provider s Office The preauthorization process regarding injectables only applies to those providers who are servicing members whose PCP is NOT affiliated with an IPA that is delegated for Medical Management. Complete Figure D-4 - Injectable Medical Authorization Request Include drug dosage, frequency, route, and time period requested Fax completed form with pertinent clinical information to (800) Non- urgent requests will be processed in 48hrs and authorization faxed back to requesting provider Urgent requests will be processed within 24 hours from the day of receipt STAT and/or Emergent requests will be processed within the same day of receipt Valid for all members being managed by PacifiCare Medical Management. Verification pursuant to SB418(For Texas Providers Only) Requests for verification of services should be phoned to or mailed to : Provider Correspondence P. O. Box San Antonio, Texas See section A for more information regarding requests for Verification. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-12

88 Section D - Preauthorization, Continued Please see subsequent pages for following Figures: Contact Numbers Preauthorization List Procedures requiring Preauthorization Preauthorization Request Form OB Notification & Assessment Form (TX Only) Injectable Medication Authorization Request MEDICAL MANAGEMENT CONTACT NUMBERS Preauthorization Phone: (for URGENT requests) Hours of operations Monday Friday 6:00 am to 6:00 PM Saturday & Sunday 9:00 a.m. to 12:00 After Hours On-Call Nurse: PIN # Preauthorization Fax: (for ROUTINE requests) Medical Management (Inpatient & Observation Admission Notifications) or Fax: Mental Health: Fax: Transplant: Phone: Fax: Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual D-13

89 Figure D-1 SignatureValue(HMO) & Secure Horizons SignatureOptions (PPO) Preauthorization List Please refer to your Provider Orientation Materials Packet for the most up to date Preauthorization List

90 Date Requested: Figure D-2 PHONE ONLY FOR EMERGENT REQUESTS Fax to Phone # Preauthorization Request Form for SignatureValue (HMO) and Secure Horizons ** All Services Must be Provided in Network** ITEMS IN SECTION 3 REQUIRE AUTHORIZATION. ALL OTHER SERVICES DO NOT REQUIRE AUTHORIZATION Type of Service: Outpatient Inpatient DME Therapy Home Health Diagnostic Test Other Type of Request: Urgent/Expedited (based on Medical Need not appt time -1 business day) Routine(2 business days) Requesting Physician Name:(Required - Print) Servicing Provider Name: SECTION 1 PROVIDER DATA Requesting Physician: PCP Specialists PHYSICIAN PHONE: PHYSICIAN SIGNATURE: (REQUIRED) X PHYSICIAN FAX: REASON FOR AUTHORIZATION REQUEST: Is proposed provider an in-network provider? yes no APPT. DATE: PROVIDER PHONE: PROVIDER FAX: CONTRACTED FACILITY (Hospital, Surgery Center, etc. where services will be performed): SECTION 2 PATIENT DATA Product Type: Commercial Secure Horizons Point of Service PATIENT NAME: (REQUIRED) PRIMARY Diagnosis: ICD-9 Code: DATE OF BIRTH: Member ID#: (REQUIRED) PRIMARY Procedure/service: CPT, HCPC code: COMMENTS: (Clinical History, symptoms, tests, previous treatment) SECTION 3 SERVICS THAT REQUIRE AUTHORIZATION SECTION 4 PacifiCare Response In addition to all out-of-network services the following in-network services require authorization from PacifiCare prior to rendering or scheduling services: Inpatient, Institutional, and related Services: Surgical Procedures: Inpatient and/or Outpatient Outpatient, In-Office, and Related Services/Treatment: Elective/Scheduled Medical, Rehab, SNF, Long term Acute Care, Sub-Acute Admissions Referrals for Transplant Evaluations/Services Experimental /Investigational Services Clinical Trials Radiological/Nuclear/Magnetic Resonance Scans: Proton beams Pet Scans Transports: All Air Ambulance Transports Approved Denied If approved, auth # Reason for Denial: Bariatric procedures Cochlear Implants Infertility procedures Orthognathic surgery Pain management procedures Plastic/Reconstructive Surgeries Spinal Surgeries Total Joint Replacements UPPP Appliances/Prosthetics/DME: Orthotics/Prosthetics - L3000 to L3649 & items >$ billed per device DME >$ billed per device Cardiac Rehab Dental Anesthesia EECP Home Health Care DME>$ per device Liquid Oxygen Pulmonary Rehab Sleep Studies Injectible/infusion Medications Therapies(Oklahoma Only) Hyperbaric Oxygen Pain Management Programs Independent From Preauthorization, Notification Is Required For All Inpatient Admissions The Day Of Admission: Urgent/Emergent, Scheduled/Elective Medical/Surgical, OOA, & Ob Services PACIFICARE USE: DO NOT WRITE BELOW Date Range: No. of Visits: This form or authorization does not guarantee or confirm benefits will be paid. Payment of claims is subject to eligibility, benefits, contractual limitations, provisions, and exclusions. Review of medical information, and/or medical records can be requested. To check benefits and eligibility prior to rendering services, please call the VRU at Last updated: August, 2003

91 Figure D-3 PACIFICARE OF TEXAS OB NOTIFICATION & Assessment Form TO BE COMPLETED UPON FIRST VISIT THEN FAXED TO: FAX (800) ATTENTION: PacifiCare Medical Management Department OB/GYN Name: Office Fax: PCP Name: Office Fax: Patient/Coverage Data Patient Name: DOB: ID#: Date of First Visit at weeks Gravida: Para: AB Sp: AB El: Facility: EDC: * Is facility network approved? Yes No * If no, Tax ID# Type of Delivery Anticipated: Normal Vaginal V-BAC C-Section Repeat C-Section Diagnosis: Procedure: ICD-9 code: CPT code: Risk Factors: Risk Category: Routine Risk Moderate Risk High Risk Certification does not guarantee and/or confirm benefits will be paid. Payment of claims is subject to eligibility, contractual limitations, provisions and exclusions. Authorization # Date Range: No. Visits: Medical History Please indicate HISTORY OR PRESENCE of the following conditions: AGE <16 OR >35 SOCIAL/SUPPORT ISSUES CARDIAC DISEASE ASTHMA/PULMONARY DISEASE DIABETES CHRONIC HYPERTENSION SMOKER SUBSTANCE ABUSE: ETOH DRUGS PREGNANCY INDUCED HYPERTENSION GESTATIONAL DIABETES ECLAMPSIA MULTIPLE GESTATION No.- CERVICAL CHANGE (<36 WEEKS GESTATION) PRIOR PREMATURE DELIVERY PRIOR STILLBIRTH HABITUAL ABORTER (2 OR MORE) CONGENITAL ANOMALY UTERINE FIBROIDS UTERINE ANOMALY PLACENTAL ABRUPTION PLACENTA PREVIA INTRAUTERINE GROWTH RETARDATION PREMATURE RUPTURE OF MEMBRANES POLYHYDRAMNIOS OLIGOHYDRAMNIOS OTHER MEDICAL CONDITIONS OR FURTHER EXPLANATION OF ABOVE: Signature/title of person completing form: 5/30/00 Confidential Information

92 INJECTABLE MEDICATION AUTHORIZATION REQUEST Turn Around Times: Plan Type: Standard (48 hours) Urgent (24 hours) Prior Auth Phone: (800) STAT/Emergent (same day) Prior Auth Fax: (800) Figure D-4 Commercial Secure Horizons Patient Name Patient Information Primary Care MD Physician Information Member ID# Prescribing MD Address Specialty City State Address Zip Home Phone City State Zip Sex DOB Age Office Phone # Office Fax # Height/Weight Allergies Contact Person Prescription (one per request form) Medication Strength and Route of Administration Frequency Length of Therapy Qty Refills Date of Initiation Diagnosis ICD: Dispense necessary supplies for infusion therapy Do not substitute Physician Signature DEA# Date: Pertinent Lab Values and Date Lab Performed Clinical History & Physical Findings Medications Tried & Failed Other Pertinent Clinical Information Instructions to Contracted Vendor Delivery to Patient Physician Office Need by THIS PORTION TO BE COMPLETED BY UR ONLY. THIS REFERRAL FORM DOES NOT GUARANTEE ELIGIBILITY PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE. Prescription forwarded to preferred vendor Date: / / Vendor Name Authorized Approval Dates From to Initials Doses/Units Authorized Denied Date Initials Reason Revised 12/17/03 5:01 PM

93 Section E Pharmacy Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual Table of Contents PacifiCare Formulary... E-1 Pharmacy Consultants... E-1 Prescription Solutions... E-2 Medication Coverage... E-2 Exclusions and Limitations... E-3 Pharmacy Network... E-6 Mail Order... E-6 Drug Utilization Review Program... E-6 Preauthorization and Non Formulary Drugs... E-7 Preauthorization Process Flow... E-9 Prior Preauthorization Procedure... E-10 Communication of Information... E-11 Request for Missing/Additional Information Fax Form... E-12 Drugs Specific Form... E-12 Telephone Prior Authorization Procedure... E-12 Fax Prior Authorization Procedure... E-12 Injectable Program... E-13 Purpose of the Drug Program... E-13 Program Applies To... E-13 Who is Exempt from this Program... E-13 How Long will it Take to Get a Decision on Prior Authorization... E-14 Members Needing to Begin an Injectable Program at Time of Discharge... E-14 New Members... E-14 Can Antibiotics like Rocephin be administered in the Physician s Office?... E-14 What Other Medications are Exempt from this Program... E-14 How will Botox be supplied?... E-15 Depo-Provera and Lunelle... E-15 Testosterone Depot... E-15 Caverject... E-15 Lupron Depot... E-15 Zoladex... E-15

94 How does the STAT Process Work?... E-16 How does the After Hours Process Work?... E-16 Who are the Vendors in the Program?... E-16 Injectable Drug Program List... E-16 SECURE HORIZON MEMBERS ONLY Covered Medication List... E-17 Pharmacy Consultants... E-17 Prescription Solutions... E-17 Medication Coverage... E-18 Exclusions and Limitations... E-18 Pharmacy Network... E-20 Mail Order... E-20 Secure Horizons Drug Utilization Review Program... E-21 Preauthorization... E-21 Self-Injectable Program... E-21 Outpatient Self-Injectable Drug Program List... E-22 Medications Excluded from the Prescription Drug Benefit; but covered under the Secure Horizon M+C Medical Benefit...E22 Prescription Solutions Prior Authorization Form...Figure E-1 Request for Missing/Additional Information Form...Figure E-2 Request for Drug Specific Information...Figure E-3 Prior Authorization Telephone Request...Figure E-4 Prior Authorization Fax Request...Figure E-5 Injectable Medication Authorization Request...Figure E-6 STAT Policy & Procedures...Figure E-7 Injectable After Hours Policy & Procedures...Figure E-8 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

95 Section E Pharmacy PacifiCare Formulary The National Pharmacy and Therapeutics Committee defines and revises the Formulary, as well as policies relating to drug usage and coverage. This committee is comprised of physicians and pharmacists, many of which are providers and experts in the diagnosis and treatment of disease. The Pharmacy and Therapeutics Committee meets at least quarterly to evaluate drug requests from physicians, review new drug therapies, routinely review Formulary therapeutic categories, and examine drug utilization and Quality Improvement issues. In addition, the National Pharmacy &Therapeutic Committee is also responsible for making recommendations regarding drugs and/or drug therapies that should be added or deleted from the Formulary based on various criteria including: The drug meets a justifiable need not already met by a drug on the Formulary, or it is recommended to replace a Formulary drug. If the drug is to replace another formulary agent, it is of superior or equal therapeutic value or it displays fewer and/or less severe adverse effects. Indications for use, pharmacology and biopharmaceutics, efficacy as documented by sound clinical evidence and side effects or toxicity. FDA approval rating Cost of therapy, when all of the above criteria are determined to be equal. Pharmacy Consultants A PacifiCare Clinical Pharmacist is available to you as a consultant on any issue relating to the PacifiCare Member's medication needs and drug information. The Clinical Pharmacist can be reached through PacifiCare Pharmacy Services at Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-1

96 Section E Pharmacy, Continued Prescription Solutions Prescription Solutions, is an independent business unit of PacifiCare Health Systems, with the mission of providing comprehensive pharmacy benefit management programs and services nationwide to employer groups and managed care organizations. The programs and services offered are built upon Prescription Solutions' core competency of providing managed pharmacy benefits to the managed care organizations within the PacifiCare family. Prescription Solutions goals include providing clients with the programs and services needed to allow them to successfully meet their cost savings objectives while delivering a cost-effective prescription benefit program without compromising quality pharmaceutical care. Prescription Solutions provides a wide range of cost effective services to ensure PacifiCare members receive the highest quality prescription services available. These services include: Preferred Pharmacy Network Mail Service Pharmacy Center On-line Point of Service Claims Adjudication Toll Free Telephone Number (Retail and Mail Service) Formulary Programs Mandatory Generic Substitution Programs Therapeutic Interchange Programs Prospective, Concurrent, & Retrospective Drug U.R. Clinical Pharmacy Review and Reporting Program Financial and Utilization Reporting Prior Authorization Program For more information about Prescription Solutions call: 800-RxRxRx1 ( ) Medication Coverage The following medications are covered when prescribed by any participating primary care physician or referring specialist: any medicinal substance which state or federal law may dispensed only by prescription unless otherwise excluded; Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-2

97 Section E Pharmacy, Continued Medication Coverage (Continued) Any compound substance that has at least one ingredient, which by Federal or State Law may be dispensed only by prescription; Insulin and insulin syringes; Retin-A when prescribed for acne or other medical conditions; EpiPen and Anakits (each limited to 3 per year) Glucose test strips and lancets. Please refer to the Benefits Manual and Formulary for more detailed information. Generally, members may receive-up to a one- (1) month supply of medications needed to treat an acute illness for the charge of one (1) co-payment. Prescriptions which are to be taken chronically are filled for up to a three (3) month supply for a reduced co-payment through the mail order program. Unless a brand name product is medically necessary as documented in the patient's medical record and approved through the prior authorization process, prescriptions are filled with a FDA approved generic product for any medication available from multiple companies. Exclusions and Limitations The following medications are not covered: Drugs or medications not on the Outpatient Drug Formulary, unless prior authorized; Brand name drugs which have a generic equivalent, unless prior authorized; Drugs or medications purchased and received prior to the Member's effective date or subsequent to the Member's termination; Medications available without a prescription or for which there is a nonprescription equivalent available, even if ordered by a physician; Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-3

98 Section E Pharmacy, Continued Exclusions and Limitations (continued) Therapeutic devices or appliances including; hypodermic needles, syringes, support garments and other non-medicinal substances, penfills, penneedles, insulin pen devices, insulin pumps and related supplies, (except as required by law); Drugs or medicines delivered or administered to the Member by prescriber or prescriber's staff. (Coverage for injectable drugs is a basic medical benefit when administered during the course of a physician's office visit or self-administered pursuant to training by an appropriate health care professional.); All nonprescription contraceptive jellies, ointments, foams and/or devices; *Medications to be taken or administered to the eligible member while he/she is a patient in a hospital, rest home, nursing home, sanitarium, etc. Dietary supplements including vitamins (except prenatal) and fluoride supplements; Medications prescribed for experimental or non-fda approved indications unless prescribed in a manner consistent with a specific indication in Drug Information for the Health Care Professional, published by the United States Pharmacopoeia Convention or in the American Hospital Formulary Sevices edition of Drug Information or any other source which reflects community practice standards; medications limited to investigation use by law; Medications prescribed by dentist and non-contracting physician; Medication for which the cost is recoverable under any Worker's Compensation or Occupational Disease Law or any state or government agency, or medications furnished by any other drug or medical service for which no charge is made to the patients; *Covered under PacifiCare Medical Benefit Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-4

99 Section E Pharmacy, Continued Exclusions and Limitations (continued) Nicotine and smoking cessation products (covered only if enrolled in smoking cessation program). Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance; Saline and medications for irrigation; Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance; *Injectable infertility drugs (Coverage for infertility drugs is a basic medical benefit when pre-authorized by a contracting physician. Refer to Attachment A of the Subscriber Agreement for limitations.); Biological sera, blood or blood plasma, medication prescribed for parenteral use or administration, allergy sera, immunizing agents and injectable drugs (except as required by law); Lost or stolen prescriptions; New procedures, services, supplies, and medications until they are reviewed for safety, efficacy, and cost effectiveness and approved by PacifiCare; *Covered under PacifiCare Medical Benefit Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-5

100 Section E Pharmacy, Continued Pharmacy Network Members can receive prescriptions from any contracted network pharmacy. Members who obtain a prescription from a non-contracted pharmacy will not be eligible for reimbursement of any charges incurred unless the prescription received was not available from a contracted pharmacy site (i.e. urgent or emergent prescriptions after hours or out of the service area). Mail Order Most PacifiCare members with a prescription drug benefit are eligible to use PacifiCare's prescription by mail service. Prescriptions for mail order should be written for a three- (3) month, ninety (90- day) supply for additional refills when appropriate. Only medications that are taken for chronic conditions should be ordered through the mail. Acute prescription needs such as antibiotics and pain medications should be obtained through a network pharmacy site to avoid delay in treatment. Physicians may also elect to discourage members from using the mail service for medications where a large quantity dispensed at one time to the member may pose a problem (e.g., tranquilizers). Members can receive a mail order form by calling PacifiCare Prescription Solutions. Drug Utilization Review Program PacifiCare is dedicated to working with our medical providers to supply information and education needed to effectively manage the growing cost of pharmaceutical care. Our clinical pharmacists can identify and analyze areas where physicians may be able to prescribe products that are considered to be effective as well as economical. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-6

101 Section E Pharmacy, Continued Drug Utilization Review Program (continued) Additionally PacifiCare's pharmacy staff can help identify when a more detailed review of therapy may improve patient care, such as: Overuse of controlled substances Duplicate therapies Drug interactions Polypharmacy Through pharmacist review and information, physicians are given the data needed to better manage the quality of their patient's care while also managing pharmacy program costs. For additional information regarding PacifiCare's Drug Utilization Review Program, contact PacifiCare of Texas or Oklahoma and ask to speak with the clinical pharmacist assigned to you. Preauthoriz ation and Non- Formulary Drugs Certain medications require prior approval by the Plan. Examples of prescriptions which require preauthorization include, but are not limited to: non-formulary medications, drugs prescribed for non-labeled use, all compounded medications, certain high-risk prescriptions The PacifiCare Drug Formulary is designed to meet most prescribing needs. On occasion, situations may arise that require a PacifiCare provider to prescribe non-formulary medications. Non-Formulary drugs, which are not otherwise excluded from coverage, will be pre-authorized in the following instances: No Formulary alternative is appropriate and the drug is medically necessary for patient care. The Member failed an adequate therapeutic trial of the appropriate Formulary alternative(s). (Member s physician may be asked to provide a copy of the medical chart notes specifically stating treatment failure with the Formulary alternative(s). Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-7

102 Section E Pharmacy, Continued Preauthoriz ation and Non- Formulary Drugs (continued) The Member has been under treatment and remains stable on a non- Formulary prescription drug and conversion to a Formulary drug would be medically inappropriate. The Member experiences typical allergic reaction or established adverse effects relating to the pharmacological properties of the Formulary drug which are attributed to formulations or difference in absorption, distribution or elimination. Member s physician provides evidence in the form of documents, records or clinical trials which establishes the use of the requested non-formulary drug over the Formulary drug is Medically Necessary. The request meets the existing Prior-Authorization Guidelines established by the National Pharmacy and Therapeutics Committee. A preauthorization procedure for coverage of non-formulary drugs is outlined in the Formulary, and a Copy of the request form is included at the end of this section of the Provider Manual. See Figure E-1 If preauthorization is denied the Member is responsible for paying the entire cost of the prescription. If preauthorization is approved, the medication will be covered at the highest copayment level. For non-formulary preauthorization information, please call Prescription Solutions at Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-8

103 Section E Pharmacy, Continued Prior Authorization Process Flow Obtain/record member/clinical information for request Phone request to Prescription Solutions Prior Authorization Department Fax request to Prescription Solutions Prior Authorization Department Request routed to appropriate region, if member ID# validated All required information is provided? Request additional/missing information via fax, if original request faxed Qualified request forwarded to designated team Request reviewed against established criteria/guidelines Decision faxed to requestor Decision rendered upon receipt of all information not exceeding 48 hrs Decision mailed to member Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-9

104 Section E Pharmacy, Continued Prior Authorization Procedure Step Action 1 Requestor ensures all relevant member and clinical information is on the fax form or available to the caller before initiating a request for a non-formulary medication (s) and/or prior authorization drugs(s). 2 Requests are phoned-in to Prescription Solutions Prior Authorization Department. Requests may also be faxed or phoned in. 3 Requests are received by Prescription Solutions: If written or fax request has Then it is.. Valid member Id #'s Routed to the appropriate state/regional team Invalid member Id or missing information Note: Additional information may be required at this time. Routed to a representative for assistance in researching a valid ID# and/or returned to sender for correction. Note: This process will cause a delay in obtaining an authorization. 4 Additional/Missing Information: If additional/missing information is Received within 48 hours Not received within 48 hours Then The request is considered a qualified request and will be reviewed for authorization. The request is considered unqualified for reivew and may be denied. 5 Qualified requests are forwarded to the designated state/regional teams. 6 Regional teams of licensed pharmacy technicians review qualified requests, referencing the formulary and clinical guidelines approved and endorsed by the National Pharmacy and Therapeutics Committee as appropriate. Note: When appropriate, qualified requests are reviewed by Prescription Solutions pharmacist. 7 Decisions are rendered immediately pending information provided with resolution of all completed requests not exceeding 48 hours. Note: If complete information is provided in the initial phone call, the decision may be rendered during the call. 8 A written communication of case resolution is faxed to the requestor and mailed to the member in accordance with state regulations. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-10

105 Section E Pharmacy, Continued Communica tion of Information To ensure rapid patient care, effective communication of information between prescribing physicians and Prescription Solutions Prior Authorization Team members is required. As part of your contract with PacifiCare, you are required to provide complete clinical information when requesting prior authorizations. Information required for prior authorization requests includes: Member name, PacifiCare member ID#, and date of birth Patient diagnosis Physician name and specialty, address, phone and FAX number Requested medications with strength and directions for use Name of specific drugs tried and failed Reason for non-formulary medication request - (i.e. list of dates with treatments tried and failed with formulary alternatives; adverse reactions experienced) Patient's pertinent medical test results - (i.e. Lipid panel, BMD, MMSE, etc.) Requests for prior authorization with incomplete or missing information will not be considered qualified requests until all information is provided. Faxed requests with incomplete or missing information will be faxed backed to the requestor with a Request for Missing/Additional Information Fax forms and, if applicable, the Drug Specific Form. Phone requests that cannot be completed during the initial call because of incomplete or missing information will be given a telephone number to call when the information is available, or, if applicable, a fax number to fax requested information. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-11

106 Section E Pharmacy, Continued Request for Missing Additional Information Fax Form The Request for Missing/Additional Information Fax form is a ½ page form that is attached to the bottom half of the faxed request. The type of information not provided on your original fax will be indicated on the form. (A copy of the Request for Missing/Additional Information Fax form is provided as Figure E- 2.) Drug- Specific Form The Drug-Specific form lists additional information required when requesting drugs in one of the six categories listed. The Request for Missing/Additional Information Fax form will indicate which category of questions must be completed. (A copy of the Drug-Specific form is provided as Figure E-3.) To ensure your request is qualified and processed, record missing information on the fax request and/or record additional information on the Drug Specific Form and call or refax to Prescription Solutions Prior Authorization Department using the numbers indicated on the request form. Telephone Prior Authorization Procedure A step by step instruction sheet is provided at the end of this section as Figure E-4. The one page information sheet is available for your office to post when calling Prescription Solutions. Fax Prior Authorization Procedure A step by step instruction sheet is provided at the end of this section as Figure E-5. The one page information sheet is available for your office to post when calling Prescription Solutions. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-12

107 Section E Pharmacy, Continued Injectable Program PacifiCare implemented the injectable program to include certain drugs administered in the physician s office, as well as those administered by the Member at home. Physicians will be required to obtain prior authorization for these injectables through PacifiCare s Pharmacy Benefit Manager, Prescription Solutions at: (phone) or (fax) Please Note: Injectables administered in the physician s office can continue to be provided by a physician through any vendor and billed by the physician to PacifiCare for reimbursement. The Physician can also opt to use PacifiCare vendors if so desired. Current authorization requirements will remain in effect for Specialty physicians, Home Health, or other outpatient services in addition to the injectable. Injectables administered by the Patient at home must be dispensed through PacifiCare s vendors. Purpose of the Drug Program To develop a cohesive infrastructure and delivery mechanism to manage injectable pharmaceuticals (including self-injectables and home infusion) to chronically ill patients. Program Applies This program applies to physicians either directly contracted or part of a nondelegated medical group or medical groups for which PacifiCare manages the injectables. Who is Exempt from this Program? Oncologists and dialysis centers are exempt from this program and would continue to follow their previous process for prior authorization for administration and reimbursement. These providers will continue to follow the Medical Management Preauthorization Process and obtain the necessary Preauthorization prior to rendering service. Epogen, Neupogen and Procrit self-administered at home would require prior authorization through Prescription Solutions. Epogen, Neupogen and Procrit administered at the physician's office would require prior authorization through Medical Management. Note: These claims must be sent to PacifiCare for reimbursement. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-13

108 Section E Pharmacy, Continued How Long Will it Take to Get a Decision on Prior- Authorization? In most cases a decision can be made on the initial call if the physician phones in the prior authorization request. Faxed requests can usually be handled in the same day. Phone requests are handled more quickly. If additional/missing information is provided within 48 hours, the request is considered a qualified request and will be reviewed for prior authorization by Prescription Solutions. Members Needing to Begin an Injectable Program at Time of Discharge PacifiCare concurrent review nurses will review patients discharged from the hospital on injectable medications including but not limited to IV antibiotics and low molecular weight heparin such as Lovenox. Note: Fourteen days should provide for a complete course of therapy. For continuation of therapy after 14 days, PacifiCare s vendors will contact Prescription Solutions prior authorization directly. New Members If a member has a prescription for an injectable drug from a non-contracted physician and is joining PacifiCare with an immediate need for the injectable but can not obtain a new prescription from a contracting physician in a timely manner. The Member must have the non-contracting physician call Prescriptions Solutions at (800) to arrange for 1 month of the medication to be supplied to the member. Can Antibiotics Administered in the Physician's Office? Only IV Antibiotics are part of this program and not IM antibiotics such as Rocephin and IM Penicillin. Physician should continue to provide IM Antibiotics in their office and submit for reimbursement through PacifiCare. Authorization is not required for IM Antibiotics. What Other Medications are Exempt From This Program? Allergy serum, vaccinations, pain management and all epidural injections are not included in this program. No authorization is needed for these injections. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-14

109 Section E Pharmacy, Continued How will Botox be Supplied? Since Botox must be frozen and used immediately the physician may supply the drug and be reimbursed according to the PacifiCare fee schedule. This drug requires prior authorization through Prescription Solutions. Depo- Provera and Lunelle When used for contraception Depo-Provera and Lunelle can be supplied by the physician and be reimbursed according to the PacifiCare fee schedule; or physician has the option to obtain prior authorization and have the drug supplied through the Prescription Solution injectable program? No authorization is needed if the physician supplies the drug. Testosterone Depot Testosterone requires prior authorization due to benefit restrictions. The prior authorization will be handled by Prescription Solutions. The physician has the option to supply in their office or have supplied through the Prescription Solution's delivery system. Caverject Caverject requires prior authorization due to benefit restrictions. The prior authorization will be handled by Prescription Solutions. The physician has the option to supply in their office or have supplied through the Prescription Solution's delivery system. Lupron Depot Lupron Depot is included in this program and requires prior authorization by Prescription Solutions. The physician can supply in their office or Prescription Solutions can provide this through the injectable program. Reimbursement for physician supplied will be based on the physician's contract with PacifiCare. Zoladex Zoladex is included in this program and requires prior authorization by Prescription Solutions. The physician can supply in their office or Prescription Solutions can provide this through the injectable program. Reimbursement for physician supplied will be based on the physician's contract with PacifiCare. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-15

110 Section E Pharmacy, Continued How does the STAT process work? Provider completes Injectable Medication Authorization Request Form (Figure E-6) and either faxes or calls Prescription Solutions. Prescription Solutions processes the request and then calls the local vendor to coordinate delivery of the drug to either the physician's office or the member. See the STAT Policy & Procedure Figure E-7 How does the after hours process work? Provider contacts the PacifiCare vendor directly. Provider can only order the maximum supply amount specified. (See attached documents.) The next business day the provider calls Prescription Solutions for the authorization. See Figure E-8 Who are the vendors in the program? All self-injectables will need to be filled through PacifiCare s selected vendors: Prescriptions Solutions or Fax OptionCare Health Services Oklahoma City (800) Tulsa (918) Houston (800) Dallas (214) San Antonio (210) Accredo Health Services Oklahoma City (800) Houston (800) Dallas/Austin (800) San Antonio (800) Only OptionCare and Accredo participate in the program for delivery of drugs to a patient's home or the physician's office. Injectable Drug Program List The Injectable Drug List can be located in PacifiCare s Provider Orientation Packet. This list is separated by State. Please review the appropriate list for your state and follow those guidelines specified. Drugs used for chemotherapy and immunizations are not included in the current program. Providers may also contact Prescription Solutions to obtain an up to date list by calling Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-16

111 Section E Pharmacy, Continued Covered Medication List Secure Horizons Members Only The Secure Horizons' "Covered Medications List" includes medications that are covered as a pharmacy plan benefit. Any prescription for a medication not listed on the Covered Medications List is the member's financial responsibility. Some medications on the Covered Medications List will require prior authorization by the Plan. Pharmacy Consultants A Secure Horizons Clinical Pharmacist is available to you as a consultant on any issue relating to the Secure Horizons Member's medication needs and drug information. The Clinical Pharmacist can be reached through Secure Horizons Pharmacy Services at Prescription Solutions Prescription Solutions, is an independent business unit of Secure Horizons Health Systems, with the mission of providing comprehensive pharmacy benefit management programs and services nationwide to employer groups and managed care organizations. The programs and services offered are built upon Prescription Solutions' core competency of providing managed pharmacy benefits to the managed care organizations within the Secure Horizons family. Prescription Solutions goals include providing clients with the programs and services needed to allow them to successfully meet their cost savings objectives while delivering a cost-effective prescription benefit program without compromising quality pharmaceutical care. Prescription Solutions provides a wide range of cost effective services to ensure Secure Horizons members receive the highest quality prescription services available. These services include: Preferred Pharmacy Network Mail Service Pharmacy Center On-line Point of Service Claims Adjudication Toll Free Telephone Number (Retail and Mail Service) Formulary Programs Mandatory Generic Substitution Programs Therapeutic Interchange Programs Prospective, Concurrent, & Retrospective Drug U.R. Clinical Pharmacy Review and Reporting Program Financial and Utilization Reporting Prior Authorization Program For more information about Prescription Solutions call: 800-RxRxRx1 ( ) Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-17

112 Section E Pharmacy, Continued Medication Coverage The following medications are covered when prescribed by any participating primary care physician or referring specialist: any medicinal substance which state or federal law may dispensed only by prescription unless otherwise excluded; Please refer to the Secure Horizons Benefits Manual and Secure Horizons Covered Medications List for more detailed information. Generally, members may receive-up to a one- (1) month supply of medications needed to treat an acute illness for the charge of one (1) co-payment. Prescriptions which are to be taken chronically are filled for up to a three (3) month supply for a reduced co-payment through the mail order program. Exclusions and Limitations The following medications are not covered: Drugs or medications not on the Covered Medications List; Drugs or medications purchased and received prior to the Member's effective date or subsequent to the Member's termination; Medications available without a prescription (over-the-counter) or for which there is a nonprescription equivalent available, even if ordered by a physician; Therapeutic devices or appliances including; hypodermic needles, syringes, support garments and other non-medicinal substances, penfills, penneedles, insulin pen devices, insulin pumps and related supplies, (except as required by law); Drugs or medicines delivered or administered to the Member by prescriber or prescriber's staff. (Coverage for injectable drugs is a basic medical benefit when administered during the course of a physician's office visit or selfadministered pursuant to training by an appropriate health care professional.); All nonprescription contraceptive jellies, ointments, foams and/or devices; *Medications to be taken or administered to the eligible member while he/she is a patient in a hospital, rest home, nursing home, sanitarium, etc (Inpatient pharmacy benefits are covered as a basic medical benefit); Dietary supplements including vitamins (except prenatal) and fluoride supplements; *Covered under Secure Horizons Medical Benefit Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-18

113 Section E Pharmacy, Continued Exclusions and Limitations Continued Medications prescribed for experimental or non-fda approved indications unless prescribed in a manner consistent with a specific indication in Drug Information for the Health Care Professional, published by the United States Pharmacopoeia Convention or in the American Hospital Formulary Sevices edition of Drug Information or any other source which reflects community practice standards; medications limited to investigation use by law; Medications prescribed by dentist and non-contracting physician; Medication for which the cost is recoverable under any Worker's Compensation or Occupational Disease Law or any state or government agency, or medications furnished by any other drug or medical service for which no charge is made to the patients; Nicotine and smoking cessation products; Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance; Saline and medications for irrigation; Injectable infertility drugs; Biological sera, blood or blood plasma, medication prescribed for parenteral use or administration, allergy sera, immunizing agents and injectable drugs (except as required by law); Lost or stolen prescriptions; New procedures, services, supplies, and medications until they are reviewed for safety, efficacy, and cost effectiveness and approved by Secure Horizons; Prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence and anorgasmy or hyporgasm. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-19

114 Section E Pharmacy, Continued Pharmacy Network Members can receive prescriptions from any contracted network pharmacy. Members who obtain a prescription from a non-contracted pharmacy will not be eligible for reimbursement of any charges incurred unless the prescription received was not available from a contracted pharmacy site (i.e. urgent or emergent prescriptions after hours or out of the service area). Mail Order All Secure Horizons members with a prescription drug benefit are eligible to use Secure Horizon's prescription by mail service. Prescriptions for mail order should be written for a three- (3) month, ninety (90- day) supply for additional refills when appropriate. Only medications that are taken for chronic conditions should be ordered through the mail. Acute prescription needs such as antibiotics and pain medications should be obtained through a network pharmacy site to avoid delay in treatment. Physicians may also elect to discourage members from using the mail service for medications where a large quantity dispensed at one time to the member may pose a problem (e.g., tranquilizers). Members can receive a mail order form by calling Secure Horizons Prescription Solutions. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-20

115 Section E Pharmacy, Continued Secure Horizons Drug Utilization Review Program Secure Horizons is dedicated to working with our medical providers to supply information and education needed to effectively manage the growing cost of pharmaceutical care. Our clinical pharmacists can identify and analyze areas where physicians may be able to prescribe products that are considered to be effective as well as economical. Additionally Secure Horizons's pharmacy staff can help identify when a more detailed review of therapy may improve patient care, such as: Overuse of controlled substances Duplicate therapies Drug interactions Polypharmacy Through pharmacist review and information, physicians are given the data needed to better manage the quality of their patient's care while also managing pharmacy program costs. For additional information regarding Secure Horizons's Drug Utilization Review Program, contact Secure Horizons of Texas or Oklahoma and ask to speak with the clinical pharmacist assigned to your Provider. Preauthorization Certain medications require preauthorization by the Plan. Examples of prescriptions which require preauthorization include, but are not limited to: Certain high-risk prescriptions. Self- Injectable Program Outpatient Self Injectable Drug coverage is limited to the Secure Horizons M+C Plan outpatient Self-Injectable Drug list and is subject to a 20% co-insurance. All other outpatient self-injectable drugs are excluded from coverage. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-21

116 Section E Pharmacy, Continued Outpatient Self Injectable Medications List Medications on this list are part of the Secure Horizons M+C Plan medical benefits and do not apply toward annual pharmacy benefit maximums. Preauthorization is required and a copayment applies to members who are individually contracted with Secure Horizons M+C Plan. The outpatient self-injectable medications on the list (See Figure E-9 and E10 for your respective state medication list) must be obtained only through a Secure Horizons M+C Plan contracted vendor (home health agency) or contracted medication group's vendor with a written prescription from a Secure Horizons M+C contracted medical provider. Medications on this list require preauthorization prior to obtainment and are subject to a specific copayment for a 30-day supply, course of therapy, or treatment of an acute episode, whichever is shortest. No more than a thirty (30)-day supply will be dispensed at one time. Please refer to the Summary of Benefits for more information. Medications Excluded From the Prescription Drug Benefit; but Covered Under the Secure Horizons M+C Medical Benefit These medications do not apply toward the pharmacy benefit and are coordinated through the Contracting Primary Care Physician. Medications to be administered to the eligible member while he or she is a patient in a hospital, rest home, nursing home, sanitarium, skilled nursing facility, etc., while receiving a skilled level of care; Medications delivered or administered to the member by the Contracting Medical Provider or the Contracting Medical Provider's staff; Immunosuppressive drugs are covered at 80% of the Plan's negotiated rate following a Medicare-approved organ transplant in accordance with Medicare guidelines; Medical covered self-injected medications, Medicare covered oral chemotherapy drugs, certain self-administered anti-emetic medications prescribed for use with Medicare covered oral chemotherapy drugs and inhalant solutions; Injectable drugs for osteoporosis, covered in full for post-menopausal homebound women under a doctor's supervision; Erythropoietin for dialysis patients. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual E-22

117 Figure E-1 Non-Formulary Medications Prior Authorization Request Form DATE: PacifiCare/ of Texas TIME: Managed Formulary Medication Form MOD: III Patients Name: Physician Name: Specialty: Member #: Address: Phone #: ( ) Date of Birth: Phone #: ( ) Male Female FAX #: ( ) Requested Medication: Directions For Use: DIAGNOSIS: Strength: Date Patient Started this Medication: NAME OF SPECIFIC DRUGS TRIED AND FAILED: Reason For Non-Formulary Request. ( Patient chart notes will be requested if further documentation is necessary ) Requesting Physician Signature: Office Use Only Approved Denied Date: Date Received : Date Received : Date Reviewed: Date Reviewed: Approval Dates: to Reason Denied: Signature: PC #: Physician notified : am/pm Signature: Office Use Only Carrier/Acct: Plan Code: Employer Group: Facility ID: 1) To Prescriber- Complete and return to: Prescription Solutions 3515 Harbor Blvd. Costa Mesa, CA Phone # : Fax # : ) Obtain Member s Pharmacy Name and Phone number. 3) Instruct member to call prescriber in three (3) working days of request to check approval. If this request is for an acute medication, please call ) Prescription Solutions will contact prescriber with decision or request for additional information. 5) Once approval is received, prescriber calls in prescription to member s pharmacy 6) Authorization will be granted for up to twelve (12) months unless otherwise noted.

118 Figure E-2 Request for Missing/Additional Information Form Request for Missing/Additional Information Your request for Prior Authorization for the patient listed above is incomplete and cannot be processed as a Prior Authorization request until additional information has been provided. In order to ensure rapid patient care and to expedite appropriate medication consistent with the member s benefit, we need the following pertinent information. Patient name Directions for Use Member # Diagnosis Date Birth Name of specific drugs tried and failed Requested Medication Reason for non-formulary request Requesting physician signature/contact name Additional drug specific information. Complete questions on the following page related to the item number indicated below As part of your contract with PacifiCare, it is important to provide complete clinical information when requesting prior authorization for non-formulary drugs. Please record the requested information in the space provided on the top half of this form, and/or the drug specific information on the next page and then fax back the request to: Or, to expedite the resolution of the requested medication, call Note: If complete information is not returned within 48 hours, a denial will be issued. Once complete information is received, a decision will be rendered.

119 1 2 3 OSTEOPOROSIS DRUGS: Evista Fosamax Miacalcin DRUGS: Aricept Cognex Member Name: Member ID #: Figure E-3 Request for Drug Specific Information 1. Bone Mineral Density/Scan (DEXA or QCT) Date: Result: gm/cc Standard deviation below young adult mean: 2. Is patient currently on ERT? Yes No 3. Does patient have a contraindication for ERT? Yes No If yes, What is the cause? 4. Does patient have a history of vertebral compression fractures? Yes No 5. Does patient have a history of hip or distal radius fractures resulting from minimal trauma? Yes No 6. Is the patient receiving concurrent chronic or expected oral steroid use? Yes No If yes, What dose and for how long? ALZHEIMERS 1. Current Mini-Mental Status Exam (MMSE) Score: Date: 2. If score is 10 or 11, in which of the following categories does the patient exhibit independence? Transferring Feeding Dressing Continence Bathing Going to toilet HYPERLIPIDEMIA 1. Lipid Panel information: Baseline date: Current DRUGS: date: TC TC Lescol TG TG Lipitor Mevacor Pravachol Zocor 4 PPI S DRUGS: Aciphex Prevacid Prilosec LDL LDL HDL HDL Goal of therapy i.e. LDL < 100 Current drug and dose 2. Does patient have any of the following CHD or CAD risk factors? HDL Cholesterol < 35 Diabetes Female > 55 years old Hypertension Smoking Male > 45 years old Female w/ premature menopause and not on ERT 1. Is this initial therapy? Yes No. If no, how long has the patient been on the drug? 2. For continuation of therapy, What are the clinical reasons? 3. Has step down therapy been tried? Yes No If no, list reasons why 4. Has PPI been prescribed by GI consult for long term therapy? Yes No 5. Patient has diagnosis of Zollinger-Ellison Syndrome Barrett s Esophagitis Stomach Cancer Grades III / IV Esophagitis Esophageal Stricture NSAID Gastropathy Other malignancies

120 Figure E-4 Prior Authorization TELEPHONE Request STEP 1 Ensure relevant information is available prior to initiating the call. Member name, PacifiCare/ member ID#, and date of birth Patient diagnosis Physician name and specialty, address, phone and FAX number Requested medications with strength and directions for use Name of specific drugs tried and failed Reason for non-formulary medication request - (i.e. list of dates with treatments tried and failed with formulary alternatives; adverse reactions experienced) Patient's pertinent medical test results - (i.e. Lipid panel, BMD, MMSE, etc.) STEP 2 Call: STEP 3 STEP 4 STEP 5 STEP 6 Listen for the prompt for your area and input the information requested. Stay on the line to be assisted by the next available represent ative. Provide information requested. Record the phone number and name of the representative requesting additional information on your copy of the request, if you are asked to provide information not currently available. STEP 7 Call or fax additional information to the number indicated w/in 48 hours. Decisions may be rendered immediately if complete information is provided during the initial call. Written communication of the decision will be faxed w/in 48 hours. No decision will be made on requests that are incomplete or require additional information.

121 Figure E-5 Prior Authorization FAX Request STEP 1 STEP 2 STEP 3 STEP 4 Record relevant information on fax form. Fax to: (If fax is incomplete or additional information is required, you will receive a return fax.) Locate and record missing and/or additional information on fax form(s) received from Prescription Solutions Prior Authorization Department, if applicable. Call or fax information to Prescription Solutions Prior Authorization Department using the numbers indicated on the Request for Missing/Additional Information form as soon as possible. Decisions are rendered upon receipt of all information and written communication of the decision will be faxed w/in 48 hours. No decision will be made on requests that are incomplete or require additional information.

122 INJECTABLE MEDICATION AUTHORIZATION REQUEST Turn Around Times: Plan Type: Standard (48 hours) Urgent (24 hours) Prior Auth Phone: (800) STAT/Emergent (same day) Prior Auth Fax: (800) Patient Information Physician Information Patient Name Primary Care MD Figure E-6 Commercial Secure Horizons Member ID# Address Prescribing MD Specialty City State Address Zip Home Phone City State Zip Sex DOB Age Office Phone # Office Fax # Height/Weight Allergies Contact Person Prescription (one per request form) Medication Strength and Route of Administration Frequency Length of Therapy Qty Refills Date of Initiation Diagnosis ICD: Dispense necessary supplies for infusion therapy Do not substitute Physician Signature DEA# Date: Clinical History & Physical Findings Pertinent Lab Values and Date Lab Performed Medications Tried & Failed Other Pertinent Clinical Information Instructions to Contracted Vendor Delivery to Patient Physician Office Need by THIS PORTION TO BE COMPLETED BY UR ONLY. THIS REFERRAL FORM DOES NOT GUARANTEE ELIGIBILITY PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE. Prescription forwarded to preferred vendor Date: / / Vendor Name Authorized Approval Dates From to Initials Doses/Units Authorized Denied Date Initials Reason Revised 12/17/03 5:27 PM

123 PacifiCare Southwest Region Figure E-7 STAT Policy & Procedures PacifiCare will cover certain injectable medications through a contracted Vendor, if prior authorization has been obtained. STAT All medications outlined below may be considered STAT and the contracted Vendor will verify the urgency and delivery time requirements with the doctor when the request order is placed. If the Physician notifies the prior authorization staff that the medication is required STAT, prior authorization staff will indicate this STAT need on the decision fax sent to the contracted Vendor. However, if the Physician does not indicate the urgency of the medication, once the contracted Vendor has received an authorization, they will call to verify the urgency with the Physician and process accordingly. Note: Low Molecular Weight Heparins Examples: Fragmin, Lovenox, Innohep and Arixtra are available at retail pharmacies for up to a 14 day supply. STAT Injectable Drug List Name of Injectable Calcimar, Miacalcin & Osteocalcin * Also covered for Secure Horizons DDAVP D.H.E. Epogen & Procrit * Also covered for Secure Horizons Fragmin, Innohep, Lovenox * Also covered for Secure Horizons Interferon-Alpha Products (Alferon-N, Intron-A, Roferon-A, Infergen, PEG Intron) Imitrex IGIV (Gamimune N, Sandoglobulin, Venglobulin-S, Gammagard S/D) Leukine Lupron Lupron Depot Neumega Neupogen Proleukin Sandostatin Sandostatin LAR Vitravene Zemplar Zoladex Prescription Solutions Prior Authorization Hours Monday Friday 8:00 AM to 8:00 PM CST Last Revised 2/11/03

124 PacifiCare Southwest Region Figure E-8 Injectable after Hours Policy & Procedure PacifiCare will cover certain injectable medications at a contracted Vendor if a Prior Authorization has been obtained. When the contracted Vendor receives a prescription for an injectable medication after hours and a prior authorization has not been obtained, the following procedure would apply to ensure prompt and appropriate patient care: After Hours If a Physician needs to obtain an injectable medication from the list below and Prescriptions Solutions is not available: 1. Contact Healix or Gentiva with the prescription for the maximum quantity specified. 2. Healix or Gentiva will contact Prescription Solutions during the next working day for an authorization and to complete the transaction. 3. If the requested injectable is not on the list below, call Prescription Solutions on the next business day. Note: Low Molecular Weight Heparins Examples: Fragmin, Lovenox, Innohep and Arixtra are available at retail pharmacies for up to a 14 day supply. After Hours Injectable Drug List Name of Injectable Calcimar, Miacalcin & Osteocalcin * Also Covered for Secure Horizons DDAVP D.H.E. Epogen & Procrit * Also covered for Secure Horizons Fragmin, Innohep, Lovenox * Also covered for Secure Horizons Interferon-Alpha Products (Alferon-N, Intron-A, Roferon-A, Infergen, PEG Intron) Imitrex IVIG (Gammimune N, Sandoglobulin, Venglobulin-S, Gammagard S/D) Leukine Lupron Lupron Depot Neumega Neupogen Proleukin Sandostatin Sandostatin LAR Vitravene Zemplar Zoladex Maximum supply 5 days 5 days 5 days 5 days 5 days 5 days 2 doses 1 dose 5 days 5 days 1 dose 5 days 5 days 5 days 5 days 1 dose 5 days 5 days 1 dose Prescription Solutions Healix Health Services Gentiva Health Services Prior Authorization Hours After Prescription Solutions Hours After Prescription Solutions Hours Monday Friday Dallas/Austin :00 AM to 8:00 PM CST Houston San Antonio Last Revised 12/11/03 1:16 PM

125 Section F Contracting Table of Contents Contracting with PacifiCare...F-1 Application Request...F-1 Role of the Primary Care Physician...F-1 Primary Care Physician Responsibilities...F-2 Role of the Specialty Care Physician...F-2 Specialty Care Physician Responsibilities...F-2 Specialist as a Primary Care Physician...F-3 Credentialing Program Purpose...F-5 Confidentiality...F-5 Criteria for Practitioner Selection...F-5 Credentials Documentation...F-8 Dismissing a member from a Medical Practice...F-10 Guidelines for Dismissing a Member...F-10 Definition of Minor Disruptive Behavior...F-10 Guidelines for dismissing a member for a Minor Disruptive Behavior...F-11 Definition of Major Disruptive Behavior...F-12 Guidelines for dismissing a member for a Major Disruptive Behavior...F-13 Right to Appeal...F-14 Medical Services Requirement During Dismissal Process...F-14 Recredentialing...F-14 Right to Review...F-14 Termination Request...F-15 Delegated Credentialing...F-15 Delegated Credentialing Program...F-16 Description of the Delegated Credentialing Program...F-16 Credentialing Verification Organization...F-16 Discrimination Prohibited...F-17 Panel Status...F-18 Demographic Changes...F-18 Application Request Form... Figure F-1 Sample of Dismissal Letter... Figure F-2 Provider Update Form... Figure F-3 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

126 Section F Contracting Contracting with PacifiCare PacifiCare selects providers who deliver the highest quality care and service to our members. Once a provider is contracted with PacifiCare, he or she must comply with specific contractual obligations. Application Request Role of the Primary Care Physician Providers who are interested in contracting with PacifiCare must meet the credentialing and contract requirements. To initiate this process the Application Request Form (See FIGURE F-1 in this section) must be completed in its entirety. The completed form must be faxed to the respective Provider Services Department within each market. The number is listed on the form. Once the Application Request Form is reviewed and determination of a credentialing application is required PacifiCare will distribute PacifiCare s credentialing application or the provider may submit the Standardized Credentialing Application specific to your state. Primary Care Physicians are defined as Family Practitioners, General Practitioners, Pediatric, Geriatrics and Internal Medicine physicians. An important component of a successful Medical Management Program is the role of the Primary Care Physician (PCP) as manager of all health services provided to the member. Quality and continuity of care are maintained when the PCP provides a greater range of primary care services. This means that the PCP serves as the single point of contact, reference, resource, and consultation for all health services provided to the member. The PCP is expected to support Medical Management Committee recommendations and discuss them, when needed, with their patients. Nothing contained in this Provider Manual is intended to interfere with the physicianpatient relationship or shall be interpreted to discourage or prohibit participating providers from discussing treatment options or providing other medical advise or treatment deemed appropriate. The member looks to the PCP to provide expertise and direction of their health care needs, and perceives the PCP to be a representative of PacifiCare. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-1

127 Section F Contracting, Continued Primary Care Physician (PCP) Responsibilities Accept and manage the care of those patients who have chosen that physician as their primary care physician. Perform services normally in his or her scope of practice. Coordinate/manage patients care for specialty physicians or other healthcare services. Participate and abide by all decisions regarding member complaints, peer reviews, Quality Assurance and Medical Management. Provide access to medical services 7 days a week/24 hours a day. 1 Provide direction and follow-up care for those members who have received emergency services. Accept and participate in peer review. Obtain pre-certifications as outlined by PacifiCare Medical Management. Role of the Specialty Care Physician The Specialty Care Physician (SCP) is expected to support Medical Management Committee recommendations and discuss them, when needed, with their patients. Nothing contained in this Provider Manual is intended to interfere with the physician-patient relationship or shall be interpreted to discourage or prohibit contracting providers from discussing treatment options or providing other medical advice or treatment deemed appropriate. The participating providers will have the sole responsibility for the Medical care and treatment of members. The member looks to the SCP to provide expertise and direction of their health care needs, and perceives the SCP to be a representative of PacifiCare. Specialty Care Physician (SCP) Responsibilities Perform services normally in his or her scope of practice. Participate and abide by all decisions regarding member complaints, peer reviews, Quality Assurance and Medical Management. Provide access to medical services 7 days a week/24 hours a day. 2 Provide direction and follow-up care for those members who have received emergency services. Accept and participate in peer review. Obtain pre-certifications as outlined by PacifiCare Medical Management. Provide PCP with ongoing feedback regarding patient progress via chart notes, visit reports, etc. Continued on next page 1 All Primary Care Physicians are responsible for arranging to provide access after hours, weekends, and for emergency care. 2 Specialty Care Physicians are responsible for arranging to provide access after hours, weekends, and for emergency care. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-2

128 Section F Contracting, Continued Specialists as a Primary Care Physician (PCP) How to Request PacifiCare members may request to utilize a specialist physician as their primary care physician if the member meets the criteria. The criteria for a member to be a candidate for this is that he/she must have a chronic, disabling, or life threatening disease or illness that requires frequent follow-up and direction from a specialty care practitioner. The request must be done in writing by the member (or individual who may have power of attorney). The request must include the following information: The member s acknowledgement by signature that they wish to be assigned to a specialist as their primary PCP. A letter from the specialist physician indicating the medical need for the member to utilize the nonprimary care physician as the members primary PCP. A statement signed by the specialists physician addressed to PacifiCare indicating that he or she is willing to accept the responsibility for the coordination of all the member s health care needs. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-3

129 Section F Contracting, Continued Specialists as a PCP (continued) All required information above must be sent to: PacifiCare Attn: Specialist as PCP Request P. O. Box San Antonio, Texas Once received by PacifiCare, the request will be forwarded to the Medical Management Department for review. PacifiCare will validate that the request and provider have met the following criteria: Appropriate submission of the request from the member. Specialist letter/agreement to serve as PCP. Validate credentialing status to ensure the practitioner/specialist is properly trained The Specialist is willing to accept the role of Primary Care Physician to include credentialing, contractual, financial and operational guidelines with PacifiCare or Medical Group/IPA by acknowledging this by signature. Medical records if needed to make the determination. The Medical Management Department will provide written notification of approval or denial to the member no later than 30 days after receiving the request. Upon Approval PacifiCare will transfer the member to the new Specialist PCP. PacifiCare will issue new member ID cards to the member. The specialist physician will be added to the list of PCP s receiving the monthly provider directory of contracted specialists and other ancillary providers. Upon Denial PacifiCare will notify member in writing of the denial of the request. Any appeal to the decision to deny must be sent in writing to: PacifiCare Attn: Appeals Department P. O. Box San Antonio, Texas Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-4

130 Section F Contracting, Continued Credentialing Program Purpose PacifiCare has a comprehensive written credentialing program which has been established in accordance with the standards of the National Committee for Quality Assurance (NCQA) and applicable state and federal regulatory requirements are reviewed and revised at least annually. Confidentiality PacifiCare maintains the confidentiality of all information obtained about physicians and other practitioners in the credentialing/recredentialing process as required by law. Criteria for Practitioner Selection All practitioners who fall under the scope of PacifiCare Credentialing Program must meet the following minimum credentials, qualifications and criteria established by PacifiCare, as applicable: 1. For physicians, graduation from a school of medicine or osteopathy that is accredited by the Liaison Committee on Medical Education and completion of a residency and/or fellowship in the requested practice specialty. Graduates of foreign medical schools must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) or must have completed a fifth pathway. For other practitioners, graduation from an appropriate accredited professional school and/or completion of a formal training program. 2. A current valid unrestricted state license to practice his or her specialty in the state in which the applicant will provide services. For categories of practitioners for which licensure is not required by any state board/agency, PacifiCare Credentialing Committee and/or Medical Director will review the education, training and additional criteria to verify practitioner competence. 3. A current valid Drug Enforcement Agency (DEA) certificate, where applicable, and Controlled Dangerous Substance (CDS) certificate in those states that require a state drug certificate. 4. For physicians, board certification by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) in physician s practicing specialty, if the physician states that he or she is board certified on the application; or, for those physician applicants who are not board certified, evidence that the applicant has completed required residency/fellowship programs which meet all ABMS or AOA training prerequisites. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-5

131 Section F Contracting, Continued Criteria for Practitioner Selection (Continued) 5. Current and unrestricted clinical and admitting privileges in good standing at a PacifiCare contracted hospital, or evidence and Medical Director approval that the applicant does not require hospital privileges in order to deliver satisfactory professional services. For PCPs without hospital privileges at a contracted facility, the group or physician must provide a mechanism for continuity of care. Physicians who do not have hospital privileges must have a formal inpatient coverage arrangement through a physician with clinical and admitting privileges at a PacifiCare contracted hospital and who is a PacifiCare Participating Practitioner. 6. Current professional liability insurance that meets or exceeds PacifiCare minimum limits for each type of practitioner (refer to Physician Agreement). 7. A history of fewer than three malpractice claims (including currently open claims and/or closed claims with payment made) in the past five (5) years for initial credentialing or in the most recent review period for recredentialing; no evidence of recurring types of claims and total judgement or settlement in the amount of $200,000 or more. 8. Satisfactory history with respect to licensing actions, malpractice claims, medical staff membership or clinical privileges disciplinary actions, or any other actions reasonably related to applicant's professional qualifications or performance. 9. Satisfactory history with respect to the applicant's cooperation and adherence to the policies and procedures of any hospital medical staff, any third-party payer, any medical group, or any other organization reasonably related to the applicant's professional practice. 10. Absence of history of felony convictions; 11. Absence of a history of sanctions by regulatory agencies, including Medicare/Medicaid sanctions; or for an applicant with such history, evidence that applicant is not currently sanctioned or prevented by a regulatory agency from participating in any federal or state sponsored programs. 12. Adequate physical and mental health status (subject to any necessary reasonable accommodation) and lack of impairment due to chemical dependency/substance abuse Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-6

132 Section F Contracting, Continued Criteria for Practitioner Selection (Continued) 13. Demonstrated ability and willingness to deliver efficient medical care. 14. Adherence to the lawful ethics of the applicant's profession. 15. Demonstrated willingness to participate in and properly discharge PacifiCare responsibilities, including adherence to PacifiCare's peer review, utilization management, and quality assessment programs. 16. Evidence of the capability to provide twenty-four hour coverage as required by PacifiCare. 17. Ability to work cooperatively with others. 18. Appropriate and complete work history for at least the past five- (5) years. 19. Successful completion of an office survey which includes a structured review of the office site and evaluation of the medical record keeping practices. (PCP and OB/GYN and in some cases high volume specialists including behavioral health providers). Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-7

133 Section F Contracting, Continued Credentials Documentation 1. The applicant must provide a completed, signed and dated credentialing application to PacifiCare and any additional information requested by PacifiCare in order to properly verify and evaluate the practitioner s qualifications. If a contracted Medical Group/IPA application is to be used in place of PacifiCare, PacifiCare must approve it prior to use to ensure that it meets PacifiCare and NCQA standards. All questions listed on the application must be answered, and explanations given for all yes answers. The credentialing application requests the following information from the practitioner: a. A valid state professional license number; b. Clinical privileges in good standing at a PacifiCare contracted hospital(s) designated by the practitioner as the primary admitting facility, as applicable or documentation of a formal relationship for inpatient coverage at a network contracted hospital; c. A valid Federal Drug Enforcement Agency (DEA) number or certificate, as applicable, or Controlled Dangerous Substance (CDS) certificate (if required by the state), and whether such certificate (s) have ever been suspended, revoked or limited; d. Graduation from professional school and completion of a formal residency or fellowship training program, as applicable; e. Board certification, if the practitioner states that he or she is board certified on the application (American Board of Medical Specialties or American Osteopathic Association for physicians); f. Work history for at least the past five (5) years. g. Current, adequate malpractice insurance in the minimum amounts required by PacifiCare; Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-8

134 Section F Contracting, Continued Credentials Documentation (Continued) h. Professional liability claims history for, at a minimum, the past five (5) years, with details of any claims/lawsuits that resulted in settlements or judgments paid by or on behalf of the practitioner, as well as the outcome (if the suit or claim has been resolved); i. A statement by the practitioner regarding lack of a physical or mental health condition that would substantially impair the practitioner s ability to competently and safely carry out the scope of his or her duties on behalf of PacifiCare, and a statement by the practitioner regarding lack of impairment due to chemical dependency/substance abuse; j. A statement by the practitioner regarding history of loss or limitation of professional license and/or felony convictions; k. A statement by the practitioner regarding history of loss or limitation of privileges or disciplinary activity. 2. Copies of the following documents must accompany the application: Valid, current and unrestricted professional license Evidence of current malpractice coverage (face sheet) at PacifiCare required limits Evidence of board certification, if applicable, or certificate of completion of a formal residency or fellowship training program Current federal DEA or state CDS certificate if applicable Evidence of eligibility for payment under Medicare Other documents may be required for certain types of practitioners to meet specific license-type requirements. 3. The applicant must submit a signed and dated attestation certifying the correctness and completeness of the information provided on and with the application. This attestation must be signed within 30 days of receipt of application by PacifiCare. 4. A signed and dated consent and release form completed by the applicant authorizing PacifiCare to obtain confidential information for credentialing purposes ( The Release ). Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-9

135 Section F Contracting, Continued Dismissing a Member from a Medical Practice A Provider may dismiss a member from a medical practice, however it must be based upon major or minor disruptive behavior episode(s) on behalf of the member. A provider may not discriminate in the treatment or transfer of a member for reasons of medical condition, source of payment, race, sex, age, religion, or place of residence, or any other protected status. It must be emphasized that a provider member dismissal must not be based on patterns of utilization or diagnosis. Guidelines for Dismissing a Member Providers can dismiss a member from their practice for a minor or major disruptive behavior. Below are the definitions of a minor or major disruptive behavior and the guidelines provider must follow when dismissing a member from a medical practice. Definition of Minor Disruptive Behavior Missed Appointments: Prior to dismissal a provider must document in the patients' chart three (3) missed appointments within six (6) months without twenty-four (24) hour prior notice, or within forty-eight (48) hours following an uncontrollable and reasonable circumstance. All notifications from a provider dismissing a member for this reason must submit all missed appointment dates in the communications to the member and to PacifiCare. Nonpayment of Copayments: Prior to dismissal a provider must document in the patients' chart of three (3) unpaid copayments or the equivalent of $ Patient Non-compliance The refusal to follow physician's recommended treatment or procedures which may result in deterioration of the member's medical condition. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-10

136 Section F Contracting, Continued Guidelines for dismissing a member for a minor disruptive behavior Prior to dismissing a member from a Physician s practice for minor disruptive behavior the following steps must be taken: 1 st Occurrence On the first occurrence of a minor disruptive behavior, the contracting provider must counsel the member and document the counseling session in the patient's medical chart. The counseling session should include: Explanation of potential consequences (dismissal from practice) Expectations of acceptable behavior or office guidelines Notification of the three specific dates of missed appointments or unpaid copays, or the one occurrence of patient non-compliance as outlined in the medical chart. 2 nd Occurrence On the second occurrence, of a minor disruptive behavior as defined above. The contracting provider must send a CERTIFIED DISMISSAL LETTER notifying the member of the need to transfer due to the unacceptable behavior. The letter must include: Explain the reason for dismissal is due to a continued unacceptable behavior Reference to the initial counseling, including the date when it occurred Explanation that care will only be provided until PacifiCare/Secure Horizons processes the transfer which could be up to thirty (30) days. Phone number to contact PacifiCare/Secure Horizons Customer Service Department for assistance with a transfer to a new Primary Care Physician. (A sample of a letter is provided at the end of this section as Figure F- 2 as a guideline) The contracting provider must submit a copy of the letter to the following address: PacifiCare Attn: Customer Service PO Box San Antonio, TX Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-11

137 Section F Contracting, Continued Definition of Major Disruptive Behavior Major disruptive behavior may constitute the immediate dismissal of a member from a practice. Instances of major disruptive behavior are listed below: Fraudulently applying for or obtaining any PacifiCare benefits, including misuse of an identification care or misuse of provider's services or facilities Dangerous behavior exhibited in the course of seeking or receiving care Unruly behavior Use of abusive and/or profane language directed towards provider staff and/or other patients Attempted physical abuse Display of weapon Damage to property Physical or verbal threat of bodily harm towards provider staff and/or other patients or property Chronic demands for unreasonable services Any type of fraud or non-violent criminal behavior, such as, tampering with or stealing provider prescriptions and/or prescription pads CMS defines disruptive behavior as disruptive, unruly, abusive, or uncooperative to the extent that the member s continued enrollment in the plan seriously impairs the Medicare+Choice Plan s ability to furnish services to either the particular member or others enrolled in the plan. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-12

138 Section F Contracting, Continued Guidelines for dismissing a member for a major disruptive behavior Prior to dismissal of a member for a major disruptive behavior, the following steps must be taken: Contracting Provider will document in the patients' file the exact incident of the major disruptive behavior episode(s). The contracting provider must send a CERTIFIED DISMISSAL LETTER notifying the member of the need to transfer due to the unacceptable behavior. The letter must include: Explain the reason for dismissal is due to a continued unacceptable behavior Explanation that care will be provided until PacifiCare/Secure Horizons processes the transfer which could be up to thirty (30) days. Phone number to contact PacifiCare/Secure Horizons Customer Service Department for assistance with a transfer to a new Primary Care Physician. (A sample of a letter is provided at the end of this section as Figure F-2 as a guideline) The contracting provider must submit a copy of the letter to the following address: PacifiCare Attn: Customer Service PO Box San Antonio, TX Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-13

139 Section F Contracting, Continued Right to Appeal Please note any member has the right to appeal any request for dismissal or reported incident. Any appeals by a member should be directed to PacifiCare s Customer Service Department. PacifiCare will investigate all member appeals and providers will be required to cooperate with PacifiCare s investigation. PacifiCare will have the final decision regarding a members dismissal. Medical Services Requirement During Dismissal Process During the thirty (30) day notification period, the PCP of record remains responsible for providing or arranging all care until the effective date of the new PCP selection. The PCP is obligated to provide emergency care services and/or arrange for required services or other continuity of care services for the member until the change is effective. Recredentialing Every three- (3) years, a recredentialing application will be sent to the practitioner. The recredentialing application will request that the practitioner update the same information as was required on the initial credentialing application form. Right to Review Practitioners have the right to review information submitted in support of their credentialing or recredentialing applications. If during the credentialing process, information is received from a third party that varies substantially from information provided to pacificare by the applicant practitioner, pacificare will notify the practitioner via certified mail, Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-14

140 Section F Contracting, Continued Termination Request Participating provider must notify PacifiCare in accordance to their contract, this is typically no less than ninety (90) days prior notification. Participating provider must continue to service members through the notification period. However, PacifiCare may close the practitioner's panel to eliminate any future member assignments. PacifiCare may also reassign the existing members to a new physician within the ninety- (90) day period. All notices required or permitted by the provider contract or agreement shall be in writing and must be sent by registered or certified mail or U.S. Postal Service Express Mail, with postage prepaid, or by Federal Express or other overnight courier that guarantees next day delivery, or by facsimile transmission, and shall be deemed sufficiently given if served in the manner specified in this section. The address below shall be the particular party s address for delivery or mailing of notice purposes: PacifiCare P. O. Box San Antonio, Texas Attention: Provider Services Or Fax to: In addition, a provider must adhere to the continuity of care policy as specified in the contract. Delegated Credentialing PacifiCare may delegate some or all credentialing or recredentialing activities to contracting Medical Groups, which meet PacifiCare's standards and requirements for delegation. In the event of any such delegation to a contracting Medical Group, PacifiCare will monitor and oversee the appropriateness and effectiveness of the Medical Group performance of any delegated credentialing and recredentialing activities. PacifiCare will retain the right to approve or disapprove practitioners to provide health care services to PacifiCare members. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-15

141 Section F Contracting, Continued Delegated Credentialing Program The philosophy of PacifiCare's Delegated Credentialing Program is to promote, manage and continuously monitor the quality of PacifiCare's practitioners. This is accomplished by maintaining oversight of practitioners and Medical Group's credentialing performance. Description of the Delegated Credentialing Program PacifiCare's Delegated Credentialing Program is designed to delegate to established Medical Groups key credentialing components, as appropriate, when these components are in place and conform to PacifiCare's credentialing requirements. While the components which will be delegated are negotiable, the requirements and the objectives of the delegated credentialing program are not since they are essential to meet the objectives of the provision of quality network practitioners that render care to PacifiCare members. PacifiCare will be a resource to the Medical Group to improve its credentialing program to ensure compliance with PacifiCare's credentialing program as well as regulatory agencies and the National Committee of Quality Assurance (NCQA). The Credentialing and recredentialing of PacifiCare's health care practitioners may be delegated, at PacifiCare's sole discretion, to a Medical Group that meets all the requirements set forth in the Delegated Credentialing Program. Delegation of credentialing by PacifiCare to the Medical Group shall be pursuant to a written agreement, which may be part of PacifiCare's provider agreement with the Medical Group, or a separate letter of agreement, or another written document signed by both PacifiCare and the Medical Group (the "Delegation Agreement"). Credentialing Verification Organization PacifiCare or the Medical Group may contract with a credentialing verification organization (CVO) for the purpose of collection of credentials and performing primary source verification for initial credentialing and recredentialing of practitioners. The credentialing department will audit the CVO annually, or more frequently if deemed necessary for elements not NCQA certified. The audit is to ensure that information is appropriately verified, and in accordance with PacifiCare criteria and standards. The CVO shall guarantee access for audit purposes to outside regulatory and/or accreditation organizations, upon request by PacifiCare. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-16

142 Section F Contracting, Continued Discrimination Prohibited A provider may not discriminate in the treatment or transfer of an Insured for reasons of medical condition, source of payment, race, sex, age, religion, or place of residence, or any other protected status. It must be emphasized that a provider Insured dismissal must not be based on patterns of utilization or diagnosis. Panel Status PCPs, may elect to change his/her panel status at any time, however a ninety- (90) day written notice (or appropriate timeframe specified in a provider s contract) is required. Included at the end of this section as Figure F-3 is a Provider Update Form which can be completed and faxed or mailed to the address below: PacifiCare Provider Services P. O. Box San Antonio, Texas Attention: Provider Services OR Fax to: or The request will be reviewed and, if there are no contractual conflicts, the information will be used to update our provider database. Primary Care Physicians may elect to change their panel status with PacifiCare to one of the defined categories below: Open Panel Status PCP is accepting new PacifiCare Commercial and/or Secure Horizons members. Existing Only Panel Status PCP is accepting PacifiCare Commercial and/or Secure Horizons members that are existing members of a provider s practice. This would apply to those members who change insurers but would like to remain with the same PCP. This option will allow providers the flexibility to continue to accept family members of existing members without being required to accept all new members. In addition, this panel status will allow current patients who may be involved in treatment to change insurance carriers and continue to utilize the same Primary Care Physician. If it is questionable whether the member is currently existing, PacifiCare will contact the provider for approval or verification that an existing relationship prior to assigning the member. NOTE: The ninety- (90) day written notice allows PacifiCare the time to update all physician directories that are distributed to members. The updates in printed materials may not always reflect the accurate information depending on the timing of the printing and the change being made by a PCP. PacifiCare s IVR system is updated on a timely basis and members will be appropriately assigned based on the category type identified in our system. The IVR is available 24 hours / 7 days a week. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-17

143 Section F Contracting, Continued Demographic Changes The following supporting documentation is required for the specific type of demographic change listed below. Please provide the supporting documents in the method listed to PacifiCare Provider Relations P. O. Box San Antonio, Texas78229 Fax: or Type of Change Supporting Documentation Required Phone/Fax Number Accepted verbally Physical Address Written request required with information and effective date Billing Address Written request required with information Completed W-9 Form Sample CMS or UB Form with Boxes 31 & 33 completed Billing Name Written request with effective date Completed W-9 Form Tax ID Written request with effective date Completed W-9 Form Termination Written request with the appropriate notice requirements outlined in the Provider Service Agreement Panel Status Request Written request with the appropriate notice requirements outlined in the Provider Service Agreement Age Restrictions Written request with limiting age and information Name Change (marriage/divorce) Hospital Privileges Specialty Change New Medical License Completed W-9 Form Notify Credentialing Contract Change Written request with hospital name and type of privilege Written request with specialty change and appropriate credentials for the requested specialty Note: This type of change must go through PacifiCare s credentialing process for approval prior to processing Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual F-18

144 Figure F-1 APPLICATION REQUEST FORM Both pages of this form must be filled out completely to ensure processing of your application. SECTION A PHYSICIAN INFORMATION Name Degree Group Name Specialty Practice Limitations Subspecialty Tax ID Are you Board Certified? Yes No If yes, by which boards: If eligible, when did you complete your residency? Name of Professional Liability Carrier: Limits: Occurrence Aggregate Do you file claims electronically? Yes No Vendor: Current Hospital Affiliations Privilege Type/Association Percent of Admissions Do you use a Hospitalist? Yes No If yes, who? If no, would you consider it? Which products are you applying for? PacifiCare Commercial Secure Horizons (Medicare +Choice) Contracting Contact Phone: Fax: I am requesting an application for appointment to the PacifiCare Network: X Date: Physician Name (print) PLEASE COMPLETE SECTIONS A and B INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED

145 APPLICATION REQUEST FORM Both pages of this form must be filled out completely to ensure processing of your application. SECTION B OFFICE LOCATIONS PRIMARY OFFICE ADDRESS: Office Mgr: City State County Zip Phone Fax **Hours you are at this office:** Mon Tue Wed Thur Fri Sat Sun SECONDARY OFFICE ADDRESS Office Mgr: City State County Zip Phone Fax **Hours you are at this office:** Mon Tue Wed Thur Fri Sat Sun BILLING OFFICE ADDRESS Phone Fax Office Mgr: City State County Zip **Hours of Operation:** Mon Tue Wed Thur Fri Sat Sun Please list all the physicians in your practice: Please List your Call Coverage Physician(s) by name of physician (only): NOTE: Any provider who covers call for your practice will need to be credentialed by PacifiCare prior to treating your PacifiCare members.

146 APPLICATION REQUEST FORM Both pages of this form must be filled out completely to ensure processing of your application. SECTION C FOR PACIFICARE USE ONLY Physican Name Date Application Rec d Group Name: Date Reviewed: Recommendation: yes no By (print name) DEC# Type of Contract Type of Response PCP SCP PEDI Offer Demographic need Hospital Privileges CO Terms: Chiropractic Service Area SH Terms: Other: Comments: Network Manager signature Date Contract Generation Process Date ARF entered in database Response/Contracts sent on Credentialing App sent on Review Response entered in database Contracts Rec d Entered in DB Contract Generation Name

147 Figure F-2 - Sample Dismissal Letter Date CERTIFIED MAIL Member Name Member Address City, State Zip Member Name: Member ID #: Dear Member: This office has observed a pattern of inappropriate conduct towards myself and/or my staff within this clinic. This letter serves as your notice that this office will no longer continue to be your Primary Care Physician as we feel we can not establish a beneficial physician/patient relationship due to this behavior. (PMG/IPA/PCP) is requesting PacifiCare to reassign you to a new Primary Care Physician where your needs can be met. We do understand, and agree that (PMG/IPA/PCP) is obligated to provide and/or arrange medical care until PacifiCare and/or the member arranges for a new Primary Care Physician up to thirty (30) calendar days. Please feel free to contact PacifiCare Customer Service at should you have any questions with regards to this issue. Sincerely, Physician Name Provider Medical Group/IPA cc: [PacifiCare/Secure Horizons] Attn: Customer Service Manager PO Box San Antonio, TX

148 Provider Update Form Today's Date: North Texas San Antonio Austin Houston Tulsa Oklahoma City To ensure your Provider Profile in PacifiCare's system is updated correctly, please complete the following update form. This information will be utilized for claims payment, provider directory information and communications between PacifiCare and its physician/providers. Please make any necessary updates/changes on this form and return it by fax to (800) If you are unable to fax your information please return to the address on the bottom of this form. Please note that all contractual requirements must be met prior to change. If this information/change pertains to more than one physician/provider, please attach a list of all names. Please Check the Type of Change and Submit the Required Documentation where required Specialty Change Panel Status /Age Limit Tax ID# (Please submit a completed W-9 form) Change of IPA Affiliation Address/Phone # Billing Address/Phone # (Submit a HCFA sample) Adding Hospital Affiliation Other (Please specify) Effective Date of the change: Do you want to be listed in the directory? yes no Physician/Provider Name: Office Manager/Contact Name: Primary Specialty: Sub Specialty: Primary Office Address Street: City: State/Zip: Telephone: Fax: Tax ID Number: Secondary Office Address Street: City: State/Zip: Telephone: Fax: Tax ID Number: Billing Address Street: City: State/Zip: Telephone: Fax: Tax ID Number: Mailing Address Street: City: State/Zip: Telephone: Fax: Tax ID Number: I have reviewed and updated the information above. Product Panel Status/Age Limitation Commercial HMO Members: Secure Horizons Members: Hospital Affiliations Primary Admitting Hospital: Secondary Hospital Affiliation: Additional Hospital Affiliations: Patient Status Open or existing only Age Lo Hi By: (printed name) Signature: Thank you for your cooperation. Should you have any questions, please contact the Provider Relations Team at Provider Relations Correspondence PacifiCare P.O. Box San Antonio, TX Fax #

149 Section G Quality Improvement Program Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual Table of Contents Quality Improvement Program...G-1 Access Standards...G-1 Beneficiary Protections...G-2 Emergency Medical Conditions...G-2 Post Stabilization Care...G-2 Direct Access to Women Health Services...G-3 Cultural Competency...G-3 Member Satisfaction...G-3 Continuity and Coordination of Care...G-3 Health Management Programs...G-4 Preventive Health & Clinical Practice Guidelines...G-5 Clinical Practice Guidelines...G-5 Quality Improvement Initiatives...G-6 Physician/Provider & Member Complaints...G-7 Potential Quality of Care Monitoring...G-8 Medical Record Documentation...G-9 Disease Management (Vendor) Programs Overview... Figure G-1 Program Referral Fax Form... Figure G-2 Preventive Health Recommendations... Figure G-3 HEDIS Update... Figure G-4 Alere Congestive Heart Failure Program... Figure G-5 AirLogix COPD Management Program... Figure G-6 Renaissance ESRD Program... Figure G-7 QMed CAD/Stroke Program... Figure G-8 Provider 800# Meter Request Program... Figure G-9 Outpatient Management of Congestive Heart Failure... Figure G-10 Outpatient Management of Coronary Artery Disease... Figure G-11 Hypertension... Figure G-12 Diabetes Management Guidelines... Figure G-13 Diagnosis and Treatment of Asthma... Figure G-14 Treatment of Major Depressive Disorder... Figure G-15

150 Outpt. Mngmt. of Chronic Obstructive Pulmonary Disease (COPD)... Figure G-16 Appointment Audit Process... Figure G-17 Access Appointment Audit Corrective Action Process... Figure G-18 Access Appointment Audit Sanction Process... Figure G-19 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual

151 Section G Quality Improvement Program Quality Improvement Program PacifiCare Health Plan is committed to providing quality health care to its members. To that end, PacifiCare has implemented a comprehensive Quality Improvement Program (QI Program) that is built on the concepts of continuous quality improvement and incorporates clinical care and service activities. The QI Program is developed with practitioner, provider, purchaser, and member input to address the specific needs and demographics of the enrolled population. PacifiCare requires contracting providers to participate and cooperate in the plan s quality improvement plan emphasizing change through education. Active involvement includes, but is not limited to, participating on committees, collecting data and providing access to medical records, identifying barriers when opportunities for improvement are identified, and implementing targeted interventions. Access Standards PacifiCare has adopted the following standards for access: Periodic Health Exam Within 42 calendar days Routine Primary Care (Symptomatic Exam) Within 7 calendar days Routine Care for Specialty Within 15 working days Urgent Exam Within 24 hours Emergent Exam Immediately After Hours 24 hours, 7 days per week to a live person A Physician after hour line should provide member access to someone within 30 minutes who can direct him or her in determining/securing necessary care. It may be an answering service who pages or contact the on-call physician, or an answering machine with clear instructions and a second number to call to reach a physician or another person to page the physician. Compliance with these standards is measured annually at a minimum. These assessments are made through one or more of the following methods: Member complaints for access-related issues and primary care provider transfers; Quality of care issues related to access; On-site and/or telephonic audits; and Member satisfaction surveys. Please see Figures G- 17,18 & 19 for the process flows for Appointment Audit Process, Access Appointment Audit Corrective Action Process and Access Appointment Audit Sanction Process. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-1

152 Section G Quality Improvement Program, Continued Beneficiary Protections PacifiCare, regulated by the Texas Department of Insurance (TDI), the Oklahoma Department of Insurance and Department of Health and Secure Horizons compliance with CMS standards, has a number of measures that govern beneficiaries access to health care. A review of recently enacted changes is provided below. Emergency Medical Condition Retrospective denial of services for what appears to the prudent layperson to be an emergency is prohibited. If a physician or other representative affiliated with the organization instructs the enrollee to seek emergency services, the organization is responsible for payment for medically necessary emergency services regardless of the prudent layperson standard. The complete definition of an Emergency Medical Condition is as follows: 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 1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman the health of the woman or her unborn child; 2) Serious impairments to bodily functions; or 3) Serious dysfunction of any bodily organ or part. Post Stabilization Care This care is medically necessary, non-emergency services needed to ensure the enrollee remains stabilized from the time the treating hospital requests authorization from the Plan until; the enrollee is: 1) Discharged; 2) A plan physician arrives and assumes responsibility for the enrollee s care; or 3) The treating physician and the organization agree to another arrangement. The Plan is responsible for the cost of post-stabilization services provided outside the plan if it was pre-approved or if the organization did not respond within one hour to the request for post-stabilization care, or the Plan could not be contacted for pre-approval. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-2

153 Section G Quality Improvement Program, Continued Direct Access to Women Health Services Cultural Competency OKLAHOMA: Female members may self-refer to a contracted OB/GYN one time each year for a pap smear, pelvic, and breast exam. TEXAS: Plans must provide direct access to women health specialists within their selected network for routine and preventive health care services, to include screening pap smears and pelvic examinations. All female enrollees must be able to directly access contracted gynecologists, certified nurse midwives and other qualified health care providers for the provision of routine and preventative women health services. Services must be provided in a culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities. Member Satisfaction PacifiCare uses several mechanisms to measure member satisfaction with the plan, providers, care and service. Member Satisfaction Surveys PacifiCare contracts with an NCQA certified vendor to conduct an annual assessment using the CAHPS. Members rate their satisfaction in multiple areas including: their perceptions of the health plan, health care, providers, access, referral process, specialty care, benefits, and customer service. Member Complaints PacifiCare codes all complaints received from members, both written and verbal, and enters the information into a centralized system to identify trends and opportunities for improvement related to care and service. Evaluation of the reason members request to change primary care providers is also conducted on a routine basis. Continuity and Coordination of Care Every member is assigned a primary care physician at the time of enrollment. The primary care physician is designated as having primary responsibility for coordinating the member s overall health care, including behavioral health care, and the appropriate use of pharmaceutical medications. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-3

154 Section G Quality Improvement Program, Continued Health Management Programs PacifiCare knows the importance of providing easily accessible Health Improvement Programs to our members. It is so important, that our services are being integrated more effectively into our core products so that they are available to all members. The Programs have been developed to support the Quality Initiatives. In addition to providing our members with better tools to help them manage their lifestyles and health risks, we are assisting our providers with more information and programs to make their jobs easier. Pregnancy to Preschool Program - Pregnancy to Preschool is an educational program via the web site. It includes general information from pregnancy to preschool. Encourages early prenatal care, improve birth outcomes and assists with childhood development. Taking Charge of Diabetes : Tools to Help You Succeed - A self-directed intervention program that addresses self-care and lifestyle issues. The major components consist of interactive member mailings, as well as smoking cessation referral process for those members who smoke. Participants are encouraged to improve nutrition and exercise habits, practice self-care, and seek appropriate prevention services. Provider reports are available to identify members participation in the program. All members with diabetes have access to free glucose meters. Taking Charge of Your Heart Health : Tools to Help You Succeed - A self-directed, lifestyle management program focusing on behavior modification with diet, exercise, stress, tobacco use and self-care. The main components of this non-clinical program are interactive member materials and a smoking cessation referral process. The program is designed to be utilized in conjunction with a clinically based cardiovascular disease management program offered by the providers. Provider reports are available to identify members participating in the program. Taking Charge of Depression A program to improve member compliance with antidepressant medication and increase communication between members and their providers about the nature of their treatment. Enrolled members receive a kit of educational materials and six months of telephone lifestyle coaching with PacifiCare Behavioral Health care consultants. Free and Clear Stop Smoking Program For PacifiCare Commercial members only. A self-directed, self-paced program which includes telephonic counseling. The program is designed to be customized to each individual s needs and readiness to quit. The components of the intervention build the participant s self-confidence in their ability to quit smoking through goal oriented lifestyle modification. Secure Horizons members may use the American Cancer Society Tobacco Quit Line (877-YES-QUIT/ ). Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-4

155 Section G Quality Improvement Program, Continued Health Management Programs Continued 24 Hour Health Information - program is available to all Commercial and Secure Horizons members through the PacifiCare and Secure Horizons Web sites. The Internet-based information helps to educate members about a variety of conditions and health-related topics and encourage their participation in making health care decisions. The program consists of On-line health information, including "live chat" feature, 24-hour Nurse Line and Audio Library, which members can call to hear prerecorded information on hundreds of health topics. Preventive Health and Clinical Practice Guidelines The PacifiCare Health Systems (PHS) corporate Medical Management Guideline Committee is responsible for the review, adoption and approval of guidelines. The process of review includes the development and dissemination of draft guidelines adopted from nationally recognized sources with solicitation for comments from PacifiCare medical directors and contracted practitioners. PacifiCare engages in an active process of choosing guidelines appropriate to its membership and uses these guidelines as the standard to measure performance. PacifiCare recognizes that the benefits of promoting guidelines for use by contracting provider network include decreasing variations in practice patterns; increasing appropriateness of care; and improving health outcomes and health status. See Figure C-3 for guidelines. Preventive Health Guidelines are based on the U.S. Preventive Healthcare Screening Task Force and the American Academy of Pediatrics recommendations. The guidelines are communicated to our members on an annual basis through member communication as well as to practitioners through our provider newsletter, Direct Line. PacifiCare uses these guidelines as the standard to measure performance across the network through our annual Quality Improvement activities related to preventive health. Clinical Practice Guidelines These are evidence-based guidelines promulgated to help practitioners and members make decisions about specific clinical situations. Nationally recognized guidelines and standards are utilized as major sources in the development of PacifiCare Clinical Practice Guidelines. These sources include: the American Diabetes Association, the American College of Obstetrics and Gynecology, the American College of Cardiology and the Agency for Health Care Policy and Research. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-5

156 Section G Quality Improvement Program, Continued Quality Improvement Initiatives PacifiCare s Quality Initiatives address the health care needs of our entire member population, from newborns to the elderly, and target common medical conditions that occur frequently among our membership. They also involve collaboration with academic and professional experts in quality of care and improvement. The main goal of these initiatives is to demonstrate improvement in the quality of care that our members receive. A collaborative work effort with our providers, throughout all phases of our Quality Improvement Program, is required to accomplish this goal. The initiatives address four areas of health care: Women s and Children s Health This initiative focuses on maternal and child health, including childhood and adolescent immunizations, and cancer screening. Diabetes Management This initiative focuses on the outpatient treatment of diabetes emphasizing the early detection and prevention of complications. Cardiovascular Health This initiative focuses on the outpatient treatment of Coronary Artery Disease and congestive heart failure. Depression This initiative focuses on early diagnosis, appropriate treatment and referral of members with depression. Coordination of care between the Primary Care Provider and the Behavioral Health Provider is also emphasized. COPD This initiative focuses on the outpatient treatment of Chronic Obstructive Pulmonary Disease for all members 40 years of age or older. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-6

157 Section G Quality Improvement Program, Continued Physician/ Provider and Member Complaints PacifiCare maintains a centralized system of logging, tracking and analyzing issues received from members and providers to measure and improve member and provider satisfaction. This system operates to assist PacifiCare to fulfill the requirements and expectations of our customers and our contracted physicians. In addition, PacifiCare supports compliance with the Centers for Medicare and Medicaid, the National Committee for Quality Assurance, JCAHO Network Accreditation, Oklahoma State Department of Health, and other accrediting regulatory requirements. Physician/Provider and Member complaints are a vital and necessary component of the re-credentialing process to ensure that PacifiCare attracts and retains quality providers, employer groups and members. All written complaints will be acknowledged and then entered into the complaint database. If a potential quality of care issue is identified within the complaint (using pre-established triggers), the case is forwarded to the PHS Grievance/Quality of Care Department to investigate the care elements. Complaints received are tracked and trended by physician/provider and the information is utilized at the time of physician/provider s recredentialing. An annual analysis of the complaint data is performed to identify opportunities for improvement. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-7

158 Section G Quality Improvement Program, Continued Potential Quality of Care Monitoring The potential quality of care monitoring process provides a system which facilitates the use of quality data in the participating physician/provider s recredentialing process; to identify opportunities for improvement in clinical areas; to identify participating physician/provider issues that may impact the care provided to members; and to comply with regulatory requirements. This process is managed within the PHS Grievance/Quality of Care Department and is supported by PacifiCare s Southwest Peer Review Committee. The quality of care indicators are: 1. Documentation 2. Medication 3. Practice 4. Access (one time issues/provider specific) 5. Access Systemic (greater than 2 cases within 6 months period for the same issue) 6. Communication 7. Lack of Member Education 8. Service 9. Referrals 10. Member Potential Quality of Care issues are reviewed and investigated by Quality Management Clinical Staff. Cases are assigned a quality of care level ranging from Level 0, no quality of care issue, to Level III, a serious quality of care issue. Generally a Level III case is a serious departure from the Standard of Care with a high likelihood of a potential serious adverse outcome. All potential Level II and III cases are reviewed by a PacifiCare Medical Director. A response from the provider/practitioner will be solicited for all potential Level II and III cases. Based upon the response the case may be presented at the Peer Review Committee for further discussion and corrective action as appropriate. If a practitioner/provider does not respond within the required period, a notation of non-compliance with the Quality Improvement Process will be documented in the practitioner/provider's file in the peer review database. This may impact the physician/provider at the time of recredentialing. Quality of care cases are monitored and evaluated for trends and opportunities to improve the quality and safety of clinical care and service to members. Practitioners with <5 Level IIs or <2 Level IIIs in a three year period are subject to more in depth review. Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-8

159 Section G Quality Improvement Program, Continued Medical Record Documentation Medical records are the data source that documents the services provided to our members and verify the quality of the healthcare provided by participating practitioners. PacifiCare and regulatory review entities frequently use this documentation to assess quality of care. Medical record documentation is used in the resolution of member grievances and appeals related to their healthcare. The medical record is a legal document subject to discovery during litigation. All medical records and books pertaining to PacifiCare members will need to be kept for a minimum of six (6) years. Medical Record Confidentiality - PacifiCare recognizes that the information contained in medical records is highly confidential. All providers must have policies and procedures to ensure the confidentiality of member information. Employees with access to medical record information must have confidentiality statements on file. Medical records are to be stored in a location secure from public access. Any request to release medical records requires patient consent before release to any source. Medical Record Availability - In addition to assuring that medical records be maintained in a confidential manner, member s medical records must also be available at the time of an appointment. Medical Record documentation facilitates communication, coordination, and continuity of care to promote the most efficient and effective treatment of the member. On a periodic basis, PacifiCare staff will require access to member medical records for the purpose of quality improvement and peer review. On at least an annual basis, PacifiCare will require the assistance of provider staff in collecting medical record information for HEDIS reporting 1. HEDIS reporting is required by selected purchasers and regulatory and accrediting agencies. Continued on next page 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-9

160 Section G Quality Improvement Program, Continued Medical Record Documentation (continued) PacifiCare has medical record standards that apply to all contracted Primary Care Physicians (PCPs). Consistent and complete documentation in the medical record is an essential component of quality patient care. At the time of recredentialing, PacifiCare conducts medical record reviews at Primary Care Physician sites with 50 or more total members. The performance goal is 85%. The documentation standards are listed below. 1. Chart contents are organized and secure. 2. There is documentation to support that the member is appraised of Advance Directives. (Required for all members 65 years and older). 3. *Significant illnesses and medical conditions are indicated on the problem list. 4. *Medication allergies and adverse reactions are prominently in/on the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record. 5. *Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (eighteen (18) years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses. 6. *Working diagnoses are consistent with findings. 7. *Treatment plans are consistent with diagnoses. 8. *There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure. 9. Continuity and Coordination of Care between primary care physician and specialty practitioners and providers is evidenced by documentation in the primary care medical record: Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-10

161 Section G Quality Improvement Program, Continued Medical Record Documentation (continued) A. CONSULTATIONS: If a consultation is requested, there is a note/report from the Consultant, ancillary or service provider in the PCP medical record. B. HOSPITALIZATIONS: If a member is hospitalized while under the care of his PCP, there is a hospital discharge summary in the PCP medical record. If the member is seen in the Emergency Room, there is an ER report. C. HOME HEALTH AGENCIES: If a member has a referral to a Home Health Agency, there is a summary or status documentation in the PCP medical record. D. SKILLED NURSING FACILITY: If a member is admitted to a Skilled Nursing Facility (SNF), there is a summary or status documentation in the PCP medical record. E. FREE -STANDING SURGICAL CENTER If a member is admitted to a Free-Standing Surgical Center, there is a summary or status documentation in the PCP medical record. F. BEHAVIORAL HEALTH CARE SPECIALIST: If a member is referred to a Behavioral Health Care Specialist, there is evidence of communication with the PCP. 10. Each page in the record contains the patient s name or ID number. 11. Personal/biographical data to include employer home and work telephone numbers, address, DOB, marital status, and emergency contact. For pediatric patients, at least one parent s employer should be documented. (To receive a yes, chart may not miss more than 1 element.) 12. All entries in the medical record contain author identification, verified by signature, stamp or initials and tittle. Review as appropriate for electronic medical records. 13. The record is legible to someone other than the writer. A second surveyor will examine any record judged to be illegible by one surveyor. Entries in the record are reviewed for the past two years. 14. Mammogram within the last two years (Females years). 15. Cervical Cancer Screening within the last three years or appropriate documentation of a hysterectomy without residual cervix. (Females years. Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-11 Continued on next page

162 Section G Quality Improvement Program, Continued Medical Record Documentation (continued) 16. Lipid Screening (Total cholesterol) every 5 years (Males years and Females years). 17. For Diabetic patients: Hemoglobin A1C is documented at least annually Diabetic retinal eye exam annually for member s years of age. 19. Immunizations are administered and documented according to PacifiCare s recommendations. (In accordance with NCQA HEDIS guidelines). A. CHILDHOOD IMMUNIZATIONS 4 DTP, DTaP, or DT on or before the 2 nd birthday 3 OPV or IPV on or before the 2 nd birthday 1 MMR or one measles and one rubella on or between the 1 st and 2 nd birthday 3 HIB (Haemophilus B) 3 Hepatitis B 1 VZV or documented history of chickenpox B. ADOLESCENT IMMUNIZATIONS - Ages 13 to 21 years 1 MMR or one measles and 1 mumps and 1 rubella 3 Hepatitis B 1 VZV or history of chicken pox C. ADULT IMMUNIZATIONS Ages 21 to 65 years Current tetanus immunization (every 10 years) Influenza annually (adults over 50 years) D. SENIOR IMMUNIZATIONS Ages 65 years and older Current tetanus immunization (every 10 years) Influenza annually Pneumococcal (as indicated for immunocompetent) Continued on next page Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-12

163 Section G Quality Improvement Program, Continued Please see Quality Improvement programs and Clinical Practice Guidelines in this section as listed below Disease Management (Vendor) Programs Overview... Figure G-1 Program Referral Fax Form... Figure G-2 Preventive Health Recommendations... Figure G-3 HEDIS Update... Figure G-4 Alere Congestive Heart Failure Program... Figure G-5 AirLogix COPD Management Program... Figure G-6 Renaissance ESRD Program... Figure G-7 QMed CAD/Stroke Program... Figure G-8 Provider 800# Meter Request Program... Figure G-9 Outpatient Management of Congestive Heart Failure... Figure G-10 Outpatient Management of Coronary Artery Disease... Figure G-11 Hypertension... Figure G-12 Diabetes Management Guidelines... Figure G-13 Diagnosis and Treatment of Asthma... Figure G-14 Treatment of Major Depressive Disorder... Figure G-15 Outpt. Mngmt. of Chronic Obstructive Pulmonary Disease (COPD)... Figure G-16 Appointment Audit Process... Figure G-17 Access Appointment Audit Corrective Action Process... Figure G-18 Access Appointment Audit Sanction Process... Figure G-19 Southwest Region SignatureValue (HMO) & Secure Horizons Provider Manual G-13

164 PacifiCare of Texas Disease Management (Vendor) Programs Overview Figure G-1 PROGRAM DESCRIPTION GOAL ADVANTAGES FOR THE MEDICAL GROUP/PCP Alere Heart Health Program for CHF IHMC ohms cvd Program for CAD & Stroke The AlereNet Heart Health Program is NOT a UM/Case Management/Disease Management program. It combines a customized education plan, with the use of its DayLink monitor (a precision electronic scale, speaker and communications device) and staff of nurses to monitor patient s weight and physical symptoms and notify the patient s physician about clinical changes the patient is experiencing. The DayLink monitor is shipped directly to the patient. The patient is asked to step on the scale and answer questions twice a day. The monitor then transmits the information over the patient s phone line. Alere s nurses review the data reported daily. If there is a weight or symptom change, the Alere nurse telephones the patient to verify the information and then notifies the designated health care providers by fax. The OHMS/CVD Program is NOT a UM/Case Management/Disease Management program. Patients are identified as being at-risk and then approved for the program by their PCP. Patients are asked to wear an unobtrusive silent ischemia monitor for 24 hours. Individual patient demographics, medical history and results of the ischemia evaluation are transferred to a data processing center, analyzed and compared to national guidelines. Cardiologists, with the aid of the database, review results with the PCP and a patient specific treatment plan is jointly developed with the PCP. Once the patient specific treatment plan is completed, the PCP provides intervention (optimization of medical therapies such as ambulant ischemia, lipid and blood pressure management), via office visits or phone, as recommended by the cardiologist. The goal of the AlereNet system is to identify problems early in NYHA Class III IV patients and alert the patient s own clinician. Facilitating timely intervention at the PCP s direction and avoiding unnecessary hospitalizations. The goal of the ohms cvd Program is to aid PCPs in modifying their current approach of acute & episodic intervention for the treatment of CAD and stroke towards a focus on preventive therapy. It is designed to incorporate systematic modifications of cardiovascular risk factors in high-risk patients, and amplify the benefits of modern medical therapy. FINANCIAL: PacifiCare of Texas pays for the cost of the program. - CHF admissions historically have been reduced by 86%. - Reduction in the number of ambulatory office visits QUALITY OF CARE: Survey monitor of compliance with evidence-based pharmaceutical recommendations. PCP SATISFACTION: The monitoring program is perceived as an adjunct to care and assistance in managing difficult patients. PATIENT SATISFACTION: The patient perceives an improved quality of care and experiences a reduction in anxiety due to having their personal nurse watching over them. FINANCIAL: PacifiCare of Texas pays for the cost of the program. - CAD admissions and invasive procedures are reduced. - Reduction in the number of ambulatory office visits PCP is reimbursed $25 for each medical record review to determine appropriateness for enrollment in OHMS/CAD PCP is reimbursed $50 for following those members who are tested and following the recommended treatment plan. QUALITY OF CARE: Survey monitor of compliance with evidence-based pharmaceutical recommendations. PCP SATISFACTION: The monitoring/treatment plan program is perceived as a free cardiology consultative service and an adjunct to care and management of high-risk patients. PATIENT SATISFACTION: The patient perceives an improved quality of care and quality of life. Healthcare Quality, PacifiCare of Texas 1 30 April, 2002 (last updated)

165 AirLogix Inc. Program for COPD Renaissance Health Care Inc. Program for ESRD The AirLogix COPD Program is NOT a UM/Case Management/Disease Management program. Following the guidelines of the American Thoracic Society, AirLogix establishes a partnership to coordinate care for COPD patients. Symptoms and lung measurement function are assessed. Patients are educated to avoid and control respiratory triggers. An ActionPath TM (treatment plan) is established, and follow-up care is provided. All identified members are contacted for an initial telephone assessment of symptoms and quality of life related information. Based on this assessment, members are enrolled in one of three programs educational materials, telephonic visit, or in-home visit. In conjunction with the member s treating physician(s), respiratory therapists determine interventions based on a member s symptoms, compliance and preferences. Members may move between programs as necessary. Renaissance Health Care provides disease management services for members with end stage renal disease (ESRD), which include a comprehensive assessment, care plan recommendations and appropriate interventions. Program excludes pediatric patients. Patients are assigned a nurse case manager who assesses the member s needs and develops an individual care plan. The case manager acts as a liaison to assure that communication and coordination of care is maintained with the nephrologist and other specialty providers. The case manager follows each patient when hospitalized and is actively involved in discharge planning and facilitation of early discharge. The goal of the AirLogix COPD Program is to educate and encourage patients to selfmanage their chronic disease. Respiratory care practitioners from AirLogix partner with PacifiCare /Secure Horizons, physicians, and identified members to improve quality of life and to decrease healthcare utilization. Goals for members include promoting independence, enhancing quality of life, improved outcomes, minimized hospitalizations and preventing emergency room visits. FINANCIAL: PacifiCare of Texas pays for the cost of the program. - Reduced COPD hospitalizations. - Reduction in the number of ambulatory office visits QUALITY OF CARE: Survey monitor of compliance with evidence-based pharmaceutical recommendations. PCP SATISFACTION: The assessment/treatment plan program is perceived as a consultative service and an adjunct to care and management of difficult patients. PATIENT SATISFACTION: The patient perceives an improved quality of care and experiences a reduction in anxiety due to having their personal nurse watching over them FINANCIAL: PacifiCare of Texas pays for the cost of the program. - Reduced ESRD hospitalizations. - Reduction in the number of ambulatory office visits. QUALITY OF CARE: Case Management interventions to improve compliance with evidence-based pharmaceutical recommendations. PCP SATISFACTION: The program is perceived as a consultative service and an adjunct to care and management of difficult patients. PATIENT SATISFACTION: The patient perceives an improved quality of care and experiences a reduction in anxiety due to having their personal nurse watching over them Healthcare Quality, PacifiCare of Texas 2 30 April, 2002 (last updated)

166 PacifiCare of Texas Health Management Programs* Overview PROGRAM DESCRIPTION GOAL PROCESS Taking Charge of Improve the care of members with diabetes. Diabetes Increase self-management skills and selfefficacy in managing their condition. program Taking Charge of Your Heart Health program (For CAD and CHF) StopSmoking SM program (PacifiCare Commercial Members Only) Asthma Education Program Taking Charge of Depression SM program PREGNANCY TO PRESCHOOL PROGRAM FORMERLY: Healthy Pregnancy SM Taking Charge of Your Health The Taking Charge of Diabetes program addresses both self-care and lifestyle areas. The major components of this nonclinical program are interactive member materials and provider reporting. Taking Charge of Your Heart Health is a self-directed intervention program that addresses both self-care and lifestyle areas. The major component of this nonclinical program is the interactive member materials. The StopSmoking SM program is a selfpaced smoking cessation program designed to meet individual needs. The program includes telephonic support and interactive member materials. Smoking cessation aids can also be used. Childhood asthma education kits are available, along with peak flow meters and spacers. (Peak flow meters and spacers are available for adult members as well.) The Taking Charge of Depression SM program assists members diagnosed with depression who have been prescribed an anti-depressant medication. Members receive information on topics, including medications and improving communication with their PCP. Pregnancy to Preschoolis an educational program via the website. It includes general information from pregnancy to preschool. Health and wellness information available on-line. Improve the care of members with congestive heart failure or who have had a heart attack or heart-related procedure. Increase the member s self-management skills and self-efficacy in managing their heart disease. Help members quit smoking and remain smokefree. Educate the member on triggers for asthma, ways to control those triggers, how to better manage their asthma, and the importance of their medications. Improve anti-depressant medication compliance and member communication with their health care provider. Encourage early prenatal care, improve birth outcomes and assist with childhood development. Provide a reliable resource for health and wellness information. Members are sent basic information about diabetes and will receive additional mailings each year. Each mailing will focus on an aspect of diabetes education and preventive care. Physicians receive reports identifying patients participating in the program and those delinquent with preventive exams. Members are sent basic information about congestive heart failure or heart disease, and will receive additional mailings each year. Each mailing will focus on an aspect of self-care and preventive care. Educational materials are mailed and a smoking cessation specialist makes 5-6 support calls over a oneyear period. If the member is enrolled, Nicoderm CQ or Zyban TM are covered a prescription is needed. Materials are sent directly to the member s home. Members are accepted into the program via PCP referral or approval only. Members receive the Taking Charge of Depression kit containing a manual, workbook, resource list, pill dispenser, and audiotape. Telephonic support may also be available. Member will be mailed an intro letter with instructions on how to access the website along with a free gift. This interactive component is accessed via the Internet at the PacifiCare web-site ( *All PacifiCare of Texas Disease Management and Health Management Programs are offered at no cost to the member or PCP. Healthcare Quality, PacifiCare of Texas 3 30 April, 2002 (last updated)

167 PacifiCare of Texas & Oklahoma Health Services P R O G R A M R E F E R R A L F A X F O R M Referral Date: To: PACIFICARE OF TEXAS & OKLAHOMA Fax: Figure G-2 Dept:Healthcare Quality Health Management Team Phone: Information below is REQUIRED to process the referral in a timely manner From (Referral Source): Address: Company & Department: Title: Fax: ( ) Phone: ( ) Member Name: Member Phone: ( ) Member Address: PCP Name: MG/IPA Name: Member ID: Member DOB: PCP Phone: ( ) Plan: (circle one) PacifiCare CO Retiree Secure Horizons Gender: Male Female PCP Fax: ( ) Language Preference: Please indicate program selection(s) by checking the appropriate box(es) and providing required information Population Management Programs Health Management Programs Congestive Heart Failure (excludes ESRD, pediatrics or organ transplants) Referral request from: Patient / M.D (circle one) Date of most recent hospitalization / / Chronic Obstructive Pulmonary Disease (excludes members under 40 or with ESRD) Referral request from: Patient / M.D (circle one) Date of most recent hospitalization / / Coronary Artery Disease / Stroke (available in selected locations only) Check all condition(s) reported by M.D. MI Angina CABG Stroke PTCA TIA Date of most recent hospitalization / / End Stage Renal Disease (excludes pediatrics or organ transplants) Receiving hemodialysis / peritoneal dialysis (circle one) Dialysis provider Provider phone Type of access Cancer (Commercial members only) (excludes ESRD, pediatrics, carcinoma in situ, and basal or squamous cell skin cancer) Cancer Dx confirmed? Yes No Patient aware of cancer Dx? Yes No ICD-9 code Rx Referral Known metastatic sites Most recent admission date / / Oncologist: Taking Charge of Your Heart Health Education Kit CAD or CHF Taking Charge of Diabetes Education Kit SPANISH Members may call for a free Accu-Chek Advantage Glucose Taking Charge of Depression SM Program Referred member must be diagnosed with depression and prescribed an anti-depressant. Free & Clear StopSmoking SM Program SPANISH (PacifiCare TX/OK Commercial Members only) Members may call (800) to self-enroll If member was recently hospitalized, please provide date of most recent hospitalization / / Secure Horizons members can be referred to the ACS Tobacco Quit Line (877) and Tulsa county members can also be referred to the Pitch-Em Program at (866) Asthma Education Childhood Asthma Kit Adult/Pedi Peak Flow Meter Adult/Pedi Asthma Spacer Pregnancy to Preschool Members may call Customer Service to self-enroll Case Management Referrals To refer into Case Management provide your name, phone and members name and ID# above. Then indicate the referral reason below. End of Life Care Management Frail Member ER Frequent Utilizer General Case Management Case Management - ph: , fax:

168 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/ ASSESSMENT 0 10 years years years 65+ years Blood Pressure Clinical assessment during Clinical assessment during Periodic screening 2 Periodic screening 2 office visit from age 3 years 1 office visit 1,2 Breast Cancer Screening Cervical Cancer Screening Chlamydia Infection Screening Colorectal Cancer Screening Depression Screening Remain alert for possible signs and symptoms of depression 7 Figure G-3 At least every 3 years for women who are or have been sexually active or beginning at age 21; interval as recommended by physician based on risk factors 4 Screening mammography, with or without clinical breast exam, every 1 to 2 years for women age 40 and older 3 Inform of potential benefits, limitations, and possible harms of mammography in making decisions about when to begin screening 3 At least every 3 years for women who have a cervix; interval as recommended by physician based on risk factors 4 Routine for sexually active females 5 Routine for sexually active females age 25 and younger 5 Routine screening for adults 7 Remain alert for possible signs and symptoms of depression in younger patients 7 Routine for other asymptomatic females at increased risk for infection 5 Routine screening beginning at age 50 for men and women at average risk with interval determined by method. Potential screening options include home Fecal Occult Blood Test (FOBT), flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and doublecontrast barium enema 6 PHG 016 Screening mammography, with or without clinical breast exam, every 1 to 2 years for women age 40 and older 3 Inform of potential benefits, limitations, and possible harms of mammography in making decisions about when to begin screening 3 May discontinue regular testing after age 65 in women who have had adequate recent screenings in which test results have been normal and who are otherwise not at risk 4 Routine for asymptomatic females at increased risk for infection 5 Routine screening with interval determined by method. Potential screening options include home Fecal Occult Blood Test (FOBT), flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and doublecontrast barium enema 6 Routine screening for adults 7 Routine screening for adults 7

169 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 ASSESSMENT 0 10 years years years 65+ years Diabetes-Type 2 Screening of adults with Screening of adults with hypertension or hyperlipidemia 8 hypertension or hyperlipidemia 8 Hearing Height and Weight At physician discretion 9 Growth chart plotted during office visit from birth on 10 Periodically10 Periodically 10 Periodically 10 Lead Testing Screening for elevated levels of lead in the blood at age 12 months for all children at increased risk of lead exposure 11 Lipid Disorder Screening Routine screening beginning at age 20 if other risk factors for coronary heart disease exist 12 Routine screening for males age 35 and older and females age 45 and older 12 Routine screening for younger adults if other risk factors for coronary heart disease exist 12 Osteoporosis Routine screening beginning Screening 13 at age 60 for women at increased risk of osteoporotic fracture 13 Prostate Cancer Screening Discuss risks and benefits of screening with medical professional 14 Routine screening Routine screening for women 13 Discuss risks and benefits of screening with medical professional 14 Tuberculosis All persons at increased risk Screening All persons at increased risk All persons at increased risk All persons at increased risk of developing tuberculosis 15 of developing tuberculosis 15 of developing tuberculosis 15 of developing tuberculosis 15 Vision Screening Screening for amblyopia and Refer high risk individuals for Refer high risk individuals for Refer high risk individuals for strabismus between ages 3 and 4 16 evaluation by eye specialist; frequency at physician discretion 16 evaluation by eye specialist; frequency at physician discretion 16 evaluation by eye specialist; frequency at physician discretion 16 2

170 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 COUNSELING Dental Health 17 Regular dental care Floss, brush with fluoride toothpaste daily Daily fluoride drops or tablets for children living in areas with inadequate fluoridation 0 10 years years years 65+ years Recommended Topic: Recommended Topic: Recommended Topic: Recommended Topic: Regular dental care Regular dental care Regular dental care Floss, brush with fluoride Floss, brush with fluoride Floss, brush with fluoride toothpaste daily toothpaste daily toothpaste daily Daily fluoride drops or tablets for children living in areas with inadequate fluoridation Diet and Exercise 18 Encourage breastfeeding of infants; diet of iron-enriched formula and foods Over age 2, limit fat and cholesterol, maintain caloric balance and emphasize fruits, vegetables, and grain products containing fiber Regular physical activity Hormone Replacement Therapy Injury Prevention/Patient Safety 20 Federally approved child safety seats appropriate for the child s age and size Safety belts when not covered by state child safety seat laws 21 Safety helmet for high speed activities Smoke detectors Flame retardant sleepwear Place infants on their backs to sleep Hot water heater temperature < F Window/stair guards, pool fence Restrict access to drugs, toxic Limit fat and cholesterol, maintain caloric balance and emphasize fruits, vegetables, and grain products containing fiber Adequate calcium intake (women) Regular physical activity Safety belts 21 Safety helmet for high speed activities Smoke detectors Restrict unauthorized access to firearms CPR training for caretakers of high risk individuals Water safety Limit fat and cholesterol, maintain caloric balance and emphasize fruits, vegetables, and grain products containing fiber Adequate calcium intake (women) Regular physical activity Counsel women approaching menopause regarding alternatives to prevent chronic disease 19 Safety belts 21 Safety helmet for high speed activities Smoke detectors Restrict unauthorized access to firearms CPR training for caretakers of high risk individuals Water safety Limit fat and cholesterol, maintain caloric balance and emphasize fruits, vegetables, and grain products containing fiber Adequate calcium intake (women) Regular physical activity Safety belts 21 Safety helmet for high speed activities Smoke detectors Restrict unauthorized access to firearms Hot water heater < F CPR training for caretakers of high risk individuals Measures to reduce risk of falling Water safety 3

171 COUNSELING PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/ years years years 65+ years Recommended Topic: Recommended Topic: Recommended Topic: Recommended Topic: substances, firearms and matches Syrup of Ipecac on hand Poison control phone number CPR training for caretakers of high-risk individuals Water Safety Prenatal Care Pregnant women should be advised to seek their first pre-natal visit in the first trimester or as soon as pregnancy is known 22 To reduce the risk of neural tube defects in newborns, all women not planning but still capable of pregnancy should take a multivitamin containing 0.4mg of folic acid daily 23 Sexual Behavior 24 Sexually Transmitted Disease: All adolescent and adults advised of risk factors and counseled about effective measures to prevent infection Unintended pregnancy: Contraception Substance Use and Substance Abuse 25 Effects of passive smoking Anti-tobacco message Regular screening for tobacco-use status and problem drinking Strongly advise tobaccousers to quit Avoid underage drinking and illicit drug use Avoid alcohol/drug use while driving 21, swimming, boating, etc. Pregnant women should be advised to seek their first prenatal visit in the first trimester or as soon as pregnancy is known 22 To reduce the risk of neural tube defects in newborns, all women not planning but still capable of pregnancy should take a multivitamin containing 0.4mg of folic acid daily 23 Sexually Transmitted Disease: All adults advised of risk factors and counseled about effective measures to prevent infection Unintended pregnancy: Contraception Regular screening for tobacco-use status and problem drinking Strongly advise tobaccousers to quit Avoid alcohol/drug use while driving 21, swimming, boating, etc. Sexually Transmitted Disease: All adults advised of risk factors and counseled about effective measures to prevent infection Regular screening for tobacco-use status and problem drinking Strongly advise tobaccousers to quit Avoid alcohol/drug use while driving 21, swimming, boating, etc. 4

172 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 IMMUNIZATIONS years years years 65+ years Note: The 2003 ACIP recommendations include a catch-up schedule for children and adolescents who start late or who are >1 month behind. Refer to for additional information. Diphtheria, Tetanus, 2, 4, 6, months and 4 acellular Pertussis 6 years 27 Tetanus Diphtheria Once at years; then Booster every 10 years 28 Booster every 10 years 28 every 10 years 28 Haemophilus 2, 4, 6 and months 29 Influenza type B Hepatitis A For children > age 2 years living in areas with rates that are at least twice the national average, 2 doses: 2 nd dose 6 18 months after 1 st dose 30 consult your physician Hepatitis B 1 st dose soon after birth and before discharge; 2 nd dose 1 month after 1 st dose; 3 rd dose 4 months after 1 st dose and at least 2 months after the 2 nd dose, but not before 6 months of age 31 Influenza For children > 6 months with increased risk of complication or transmission to high risk persons, annually in fall or winter 34 Healthy children 6-23 Measles, Mumps, Rubella All children and adolescents through age 18 living in areas with rates that are twice the national average, 2 doses: 2 nd dose 6 18 months after 1 st dose; adults at increased risk: 2 doses 30 consult your physician years if not previously immunized 32 All adults with medical, behavioral, occupational or other high risk indications 33 All children and adults at increased risk for complications or transmission to high risk persons, annually in fall or winter 34 months, if feasible months and 4 6 If second dose not years 35 completed: then 2 nd dose at years old 35 Meningococcal Education about disease and benefits of vaccination for incoming or current college freshmen, particularly those living in dormitories 37 All adults at increased risk, 2 doses: 2 nd dose 6 18 months after 1 st dose 30 consult your physician All adults with medical, behavioral, occupational or other high risk indications 33 All adults beginning at age 50 and others at increased risk for complications or transmission to high risk persons, annually in fall or winter 34 Based on vaccine history 36 All adults at increased risk, 2 doses: 2 nd dose 6 18 months after 1 st dose 30 consult your physician All adults with medical, behavioral, occupational or other high risk indications 33 Annually, in fall or winter 34 Consider for adults with Consider for adults with medical indications 37 medical indications 37 5

173 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 IMMUNIZATIONS years years years 65+ years Inactivated Polio 2, 4, 6 18 months and 4 6 Vaccine years 38 Pneumococcal All children > 2 years at increased risk for pneumococcal disease 39 All children and adults at increased risk for pneumococcal disease 39 Rubella All women of childbearing age should be screened for rubella susceptibility or, if nonpregnant, may be offered vaccination without screening 40 Varicella months 40 Susceptible persons >13 years at risk for exposure or transmission: 2 doses 4 Pneumococcal conjugate vaccine (PCV7) 42 <6 months 3 doses, 2 months apart beginning at age 2 months; 1 dose at months; For unvaccinated children: 2 6 months 3 doses, 2 months apart beginning at age 2 months and 1 dose at months; 7 11 months 2 doses, 2 months apart; 1 dose at months; months 2 doses, 2 months apart; months with SCD, asplenia, HIV infection, chronic illness or immunocompromising condition 2 doses, 2 months apart 42 weeks apart 41 All adults at increased risk All persons > 65 years; for pneumococcal disease 39 second dose if initial vaccination was > 5 years previously and <65 years 39 All women of childbearing age should be screened for rubella susceptibility or, if nonpregnant, may be offered vaccination without screening 40 Susceptible persons at risk for exposure or transmission: 2 doses 4 weeks apart 41 Susceptible persons at risk for exposure or transmission: 2 doses 4 weeks apart 41 6

174 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 These recommendations are not to be confused with the benefits covered by PacifiCare/Secure Horizons as defined in the member s Evidence of Coverage/Disclosure Form. Nothing in these guidelines should be construed to establish a new benefit under PacifiCare or indicate a change in federal or state required benefits. The PacifiCare/Secure Horizons member s Evidence of Coverage/Disclosure Form should be consulted for the specific coverage and limitations of benefits. References: American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF). Unless otherwise specified, please note that the designations for each recommendation reflect the evidence rating assigned by the USPSTF. Designations: (A) strongly recommends the service based on good evidence; (B) recommends the service based on fair evidence; (C) makes no recommendation for or against the service based on fair evidence but concludes the balance of benefits and harms is too close to justify a general recommendation; (D) recommends against the service in asymptomatic patients based on at least fair evidence that the service is ineffective or that harms outweigh benefits; (I) insufficient evidence for or against the service based on evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined. 1 The AAP recommends a clinical assessment of blood pressure during office visits from age 3. The USPSTF recommends blood pressure screening during office visits for children and adolescents (B). 2 The USPSTF recommends periodic screening for hypertension for all persons age 21 and older (A). 3 The USPSTF recommends screening mammography, with or without clinical breast examination, every 1 to 2 years for women age 40 and older B). The USPSTF further recommends women be informed of potential benefits, limitations, and possible harms of mammography in making decisions about when to begin screening. 4 The USPSTF strongly recommends cervical cancer screening for all women who are or have been sexually active and who have a cervix (A). Direct evidence to determine the optimal starting and stopping age and interval for screening is limited. Indirect evidence suggests most of the benefit can be obtained by screening within 3 years of onset of sexual activity or age 21 (which ever comes first) and screening at least every 3 years. The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer. (D) The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease. (D) The USPSTF concluded that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. (I) 5 The USPSTF strongly recommends routinely screening all sexually active women age 25 and younger and other asymptomatic women at increased risk for infection, for chlamydial infection (A). 6 The USPSTF strongly recommends that clinicians screen men and women 50 years of age and older for colorectal cancer (A). Potential screening options include home FOBT, flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema. Each option has advantages and disadvantages that may vary for individual patients and practice settings. The choice of specific screening strategy should be based on patient preferences, medical contraindications, patient adherence, and available resources for testing and follow-up. Clinicians should talk to patients about the benefits and potential harms associated with each option before selecting a screening strategy. The optimal interval for screening depends on the test. Annual FOBT offers greater reductions in mortality rates than biennial screening but produces more false-positive results. A 10-year interval has been recommended for colonoscopy on the basis of evidence regarding the natural history of adenomatous polyps. Shorter intervals (5 years) have been recommended for flexible sigmoidoscopy and double-contrast barium enema because of their lower sensitivity, but there is no direct evidence with which to determine the optimal interval for tests other than FOBT. 7 The USPSTF recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow-up (B). Many formal screening tools are available. Asking two simple questions about mood and anhedonia ( Over the past 2 weeks, have you felt down, depressed or hopeless? and Over the past 2 weeks, have you felt little interest or pleasure in doing things? ) may be as effective as using longer instruments. All positive tests should trigger full diagnostic interviews that use standard diagnostic criteria to determine the 7

175 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 presence or absence of specific depressive disorders. The optimal interval for screening is unknown. The USPSTF concluded evidence is insufficient to recommend for or against routine screening of children or adolescents for depression (I) 8 The USPTF recommends screening for type 2 diabetes in adults with hypertension or hyperlipidemia. (B) 9 The USPSTF concluded there is insufficient evidence to recommend for or against routine screening of newborns for hearing loss during the postpartum hospitalization (I). The USPSTF recommends screening older adults for hearing impairment by periodically questioning them about their hearing, counseling them about the availability of hearing aid devices and making referrals for abnormalities when appropriate. The optimal frequency of such screening has not been determined and is left for clinical discretion. (B). 10 The APA and USPSTF recommend periodic height and weight measurements plotted on growth chart (B). 11 The USPSTF recommends screening for elevated lead levels by measuring blood lead at least once age 12 months for all children at increased risk for lead exposure (B). 12 The USPSTF strongly recommends routinely screening men age 35 and older and women age 45 and older for lipid disorders and treating abnormal lipids in people who are at increased risk of coronary heart disease (A). The USPSTF recommends routinely screening younger adults for lipid disorders if they have other risk factors for coronary heart disease (B). 13 The USPSTF recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk of osteoporotic fractures (B). The exact risk factors that should trigger screening in this age group are difficult to specify based on evidence. Lower body weight (weight <70kg) is the single best predictor of low bone mineral density. There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65. At any given age, African-American women on average have higher bone mineral density (BMD) than white women and are thus less likely to benefit from screening. Among different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites. Other technologies for measuring peripheral sites include quantitative ultrasonography (QUS), radiographic absorptiometry, single energy x-ray absorptiometry, peripheral dual energy x-ray absorptiometry, and peripheral quantitative computed tomography. Recent data suggest that peripheral bone density testing in the primary care setting can also identify postmenopausal women who have a higher risk of fracture over the short term (1-year). Further research is needed to determine the accuracy of peripheral bone density testing in comparison with DXA. The optimal interval for repeated screening is unknown. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD; however, longer intervals may be adequate. 14 The USPSTF does not recommend routine screening for prostate cancer. Patients who request screening should be given objective information about the potential benefits and harms of early detection and treatment. Despite the absence of firm evidence of effectiveness, some clinicians may opt to perform prostate screening for other reasons. Clinicians should not order the PSA test without first discussing the potential, but uncertain, benefits and possible harms. 15 The USPSTF recommends screening by tuberculin skin testing for all persons at increased risk of developing tuberculosis (A). 16 The USPSTF recommends vision screening for amblyopia and strabismus once before entering school (preferably between age 3 4 years) (B). There is insufficient evidence to recommend for or against routine screening by primary care practitioners for elevated intraocular pressure or early glaucoma (C). Recommendations to refer high-risk patients for evaluation by eye specialist may be based on the substantial prevalence of unrecognized glaucoma in these populations, the progressive nature of untreated disease, and expert consensus that reducing intraocular pressure may slow the rate of visual loss in patients with early glaucoma or severe intraocular hypertension. Populations in whom the prevalence is >1% include blacks over age 40 and whites over age 65. Patients with family history of glaucoma, patients with diabetes, and patients with severe myopia are also at increased risk. The optimal frequency for glaucoma screening has not been determined and is left to clinical discretion. 17 Counseling patients to visit a dental care provider on a regular basis is recommended by the USPSTF based on evidence for risk reduction from such visits when combined with personal oral hygiene (B). The AAP recommends regular dental care beginning at 3 years. Clinicians caring for children 8

176 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 should ascertain the fluoride concentration of their water supply. For children living in an area with inadequate water fluoridation (<0.06 ppm), the prescription of daily fluoride drops or tablets is recommended (A). 18 The USPSTF recommends counseling to promote regular physical activity for all children and adults to prevent coronary heart disease, hypertension, obesity, and diabetes (A). Adults and children over age 2 should limit dietary intake of fat (A) and cholesterol (B), maintain caloric balance in their diet (B), and emphasize fruits, vegetables, and grain products containing fiber (B). Parents should be encouraged to offer breastfeeding to their infants (A) and to include iron-enriched foods in their diet (B). Clinicians who lack the time or skill to perform a complete dietary history, to address potential barriers to changes in eating habits, and to offer specific guidance on meal planning and food selection and preparation, should either have patients seen by other trained providers in the office or clinic or should refer patients to a registered dietician or qualified nutritionist for further counseling. 19 The USPSTF recommends against the routine use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women (D). The USPSTF concludes that the evidence is insufficient to recommend for or against the use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy (I).Clinicians should develop a shared decision-making approach to preventing chronic diseases in perimenopausal and postmenopausal women. This approach should consider individual risk factors and preferences in selecting effective interventions for reducing the risks of fracture, heart disease, and cancer. Clinicians should discuss with patients other effective strategies for preventing osteoporosis and fractures. 20 Injury prevention is addressed under USPSTF recommendation for periodic counseling. (B). 21 The CDC Task Force on Community Preventive Services strongly recommends interventions to increase use of child safety seats, increase safety belt use and reduce alcohol-impaired driving. 22 The American College of Obstetricians and Gynecologists (ACOG) recommends prenatal care beginning early in pregnancy and continuing through the postpartum period. 23 The USPSTF recommends that to reduce the risk of neural tube defects in newborns, all women not planning but still capable of pregnancy should take a multivitamin containing 0.4mg of folic acid daily (B) 24 The USPSTF recommends that all adolescent and adult patients be advised about risk factors for sexually transmitted disease and counseled appropriately about effective measures to reduce risk of infection (B). Periodic counseling about effective contraceptive methods is recommended for all women and men at risk for unintended pregnancy (B). 25 The USPSTF recommends pregnant women and parents with children living at home also should be counseled on the potentially harmful effects of smoking on fetal and child health (A). Screening to detect problem drinking and hazardous drinking is recommended for all adults and adolescents (B). All adolescents and adults who use alcohol or other drugs should be advised to avoid engaging in potentially dangerous activities while intoxicated (B). The US Public Health Service recommends all patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Evidence has shown that this significantly increases rates of clinician intervention (A). All physicians strongly advise every patient who smokes to quit because evidence shows that physician advise to quit smoking increases abstinence rates (A). All clinicians should strongly advise patients who use tobacco to quit (B). 26 The ACIP Schedule (Jan Dec 2003), updated annually by the CDC s Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), and the AAP, is recommended. The schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines. Combination vaccines may be used whenever the combination is licensed for use for any components of the combination that are indicated and its other components are not contraindicated. Providers should consult the manufacturers package inserts for detailed recommendations. Information on vaccine supply and statements on specific vaccines can be found at 27 DTaP is the preferred vaccine for all doses, including completion of a series begun with whole cell DTP according to ACIP guidelines. The fourth dose may be administered as early as 12 months, provided 6 months have elapsed since the 3 rd dose and if the child is unlikely to return at age months. The ACIP recommends that, whenever feasible, the same brand of DTaP vaccine be used for all doses in the vaccine series. When unknown or not available, any of the licensed vaccines can be used. 9

177 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 28 The ACIP recommends Td vaccination at years of age if at least 5 years have elapsed since the last dose of DTP, DtaP or DT. Subsequent Td boosters are recommended every 10 years thereafter. Tetanus prophylaxis in routine wound management if other than clean or minor wound and >5 years since last dose. 29 The ACIP recommends only FDA-approved combination products for primary Haemophilus influenza type B (HiB) vaccination in infants 2, 4 or 6 months. 30 The ACIP recommends Hepatitis A vaccination for persons, >2 years, who are at increased risk for infection (travelers, men who have sex with men, illegal-drug users, occupational risk, clotting-factor disorder, chronic liver disease consult ACIP) and any person wishing to obtain immunity. Children, > 2 years, living in areas where rates of hepatitis A are at least twice (>20 cases per 100,000 population) the national average, should be routinely vaccinated. Vaccination should be considered for children living in areas where rates of hepatitis A are at (>10 <20 cases per 100,000 population) the national average. The schedule is determined based on vaccine formulation and age. Contact local public health authority for current recommendations. 31 The ACIP recommends all infants receive the 1 st dose of hepatitis B vaccine soon after birth and before hospital discharge; the 1 st dose may also be given by age 2 months if the infant is born to a hepatitis B surface antigen (HbsAg)-negative mother. The 2 nd dose should be at least 1 month after the 1 st dose. The 3 rd dose should be administered at least 4 months after the 1 st does and at least 2 months after the 2 nd does, but not before 6 months of age. Infants born to HBS-Ag-positive mothers should receive hepatitis B vaccine and 0.5 ml hepatitis B immune globulin (HBIG) within 12 hours of birth at separate sites. The 2 nd dose is recommended at 1 month of age and the 3 rd dose at 6 months of age. Infants born to mothers whose HbsAG status is unknown should receive hepatitis B vaccine within 12 hours of birth. Maternal blood should be drawn at the time of delivery to determine the mother s Hasbro status; if the Hasbro test is positive, the infant should receive HBIG as soon as possible (no later than 1 week of age). 32 The ACIP recommends all children and adolescents who have not been immunized against Hepatitis B should be begin the Hepatitis B vaccination series during any visit (refer to Catch-up Schedule). Immunization status should be routinely evaluated during preadolescents (age years). 33 The ACIP recommends administering 3 doses of Hepatitis B for persons with medical (hemodialysis patients and patients who receive clottingfactor concentrates), behavioral (injecting drug users, persons with more than 1 sex partner in 6 months, persons with a recently acquired STD, clients in STD clinics and men who have sex with men), occupational (health-care and public-safety workers who have exposure to blood), or other indications (household contacts and sex partners of persons with chronic Hepatitis B infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic Hepatitis B infection for more than 6 months, inmates of correctional facilities). The 2 nd dose should be administered 1-2 months after the 1 st does and the 3 rd dose should be administered 4-6 months after the 1 st dose. 34 The ACIP recommends influenza vaccination for any person >6 months, who because of age or underlying medical condition, is at increased risk for complications of influenza. Groups at increased risk include: residents of nursing home or other chronic care facilities; adults or children who have chronic disorders of pulmonary or cardiovascular systems or who have required regular medical follow-up or hospitalization because of chronic metabolic disease (including diabetes), renal dysfunction, hemoglobinopathies, or immunosuppression; children or adolescents receiving long-term aspirin therapy; and women who will be in the 2 nd or 3 rd trimester of pregnancy during the influenza season. Care givers to persons at high risk, persons in institutional settings, providing essential community services and other persons who wish to reduce the likelihood of becoming ill with influenza, should be considered for vaccination. Healthy children age 6-23 months are encouraged to receive influenza vaccine if feasible because children in this age group are at substantially increased risk for influenza-related hospitalizations. 35 The ACIP recommends the 2 nd MMR vaccination at 4 6 years of age but vaccine may be administered during any visit provided at least 4 weeks have elapsed since receipt of the 1 st dose and that both does are administered beginning at or after 12 months of age. Those who have not previously received the 2 nd dose should complete the schedule by the years old visit. 36 The ACIP recommends, for the measles component, 2 doses of MMR for adults with one or more of the following conditions and without vaccination history: adults born after 1956, persons vaccinated with killed measles virus vaccine , students in post-secondary education 10

178 PREVENTIVE HEALTH RECOMMENDATIONS FOR 2003 PHG 016 DEVELOPED BASED ON SCIENTIFIC EVIDENCE ADOPTED BY PHP TECHNOLOGY ASSESSMENT AND GUIDELINE COMMITTEE 2/13/03 institutions, health care workers, susceptible international travelers to measles endemic countries. For the mumps component, 1 dose of MMR should be adequate protection. See Rubella recommendations. 37 The ACIP recommends that providers of medical care to incoming and current college freshmen, particularly those who plan to or already live in dormitories and residence halls, should, during routine medical care, inform these students and their parents about meningococcal disease and the benefits of vaccination. ACIP does not recommend that the level of increased risk among freshman warrants any specific changes in living situations for freshman. College freshman who want to reduce their risk for meningococcal disease should be administered vaccine. The ACIP recommends considering vaccination for persons with medical (adults with terminal complement component deficiencies, with anatomic or functional asplenia) or other indications (travelers to countries in which disease in hyperendemic or epidemic. Revaccination at 3-5 years may be indicated in persons at high risk for infection. 38 The ACIP recommends an all-inactivated poliovirus (IPV) vaccination at 2, 4, 6 18 months and at 4 6 years. For children who have already received oral polio vaccine (OPV) but have not completed the series, the additional doses should be IPV. If accelerated protection is needed, the minimum interval between doses is 4 weeks, although the preferred interval between the 2 nd and 3 rd doses is 2 months. All children who received three doses of IPV before age 4 years should receive a 4 th dose before or at school entry. The 4 th dose is not needed if the 3 rd dose is administered on or after the 4 th birthday. 39 The ACIP recommends pneumococcal vaccine for all immunocompetent persons who are 65 years and older with 2 nd dose if vaccine was administered under age 65 years and more than 5 years previously (A). Additionally vaccination is recommended, for persons age 2 64 years with chronic cardiovascular disease, chronic pulmonary disease, diabetes, or functional/anatomic asplenia (A). For persons > 10 years with asplenia, single revaccination > 5 years after previous dose. For persons < 10 years with asplenia, consider revaccination 3 years after previous dose (A). 40 The USPSTF recommends screening for rubella susceptibility by history of vaccination or by serology for all women of childbearing age (B). Alternatively, all susceptible nonpregnant women of childbearing age should be offered vaccination against rubella without screening (B). 41 The ACIP recommends vaccination at any visit on or after the first birthday for susceptible children, i.e. those who lack a reliable history of chickenpox (as judged by a health care provider) and have who have not been immunized. Susceptible persons age >13 years at high risk for exposure or transmission should receive 2 doses, given at least 4 weeks apart. 42 The ACIP recommends all children age <23 months should be vaccinated with PCV7. Infant vaccination provides the earliest possible protection, age 2 6 months and age 7 23 months (B). Children age months should receive PCV7 vaccination if they are at high risk for pneumococcal infection caused by an underlying medical condition. This recommendation applies to the following groups: children with sickle cell disease and other sickle cell hemoglobinopathies, including hemoglobin SS, hemoglobin S-C, or hemoglobin s-β-thalassemia, or children who are functionally or anatomically asplenic (B); children with HIV infection (B); children who have chronic disease, including chronic cardiac and pulmonary disease (excluding asthma), diabetes mellitus, or CSF leak; and children with immunocompromising conditions including a) malignancies, b) chronic renal failure or nephrotic syndrome; c) those children receiving immunosuppressive chemotherapy, including long-term systemic corticosteroids; and d) those children who have received a solid organ transplant (C). The ACIP further recommends that PCV7 vaccination (1 dose) be considered for all other unvaccinated children age months with priority given to children age months, children of Alaska Native, American Indian or African-American descent, and children who attend group day care centers (B). Modified recommendations apply during periods of shortage. See MMWR 12/21/02. Return to Table of Contents 11

179 PacifiCare s TIPS for IMPROVING DOCUMENTATION FOR HEDIS 2004 The following table is provided to inform Physicians and office staff of the HEDIS 2004 Measures. Medical Record Reviews for HEDIS 2004 will begin in late February Please make copies of this document and share with your staff. Measure Result Description Medical Record Documentation Standard Childhood Immunization Status % of children who turned 2 years old in 2003 who had all of the specified immunizations 4 DTPs 3 OPV/IPVs 1 MMR 3 HIBs 3 Hepatitis Bs 1 VZV IMMUNIZATION MEASURES 1. Documentation must include the specific dates and names of the vaccines for all immunizations: 2. OR Date of contraindications (per vaccine) 3. OR Date of disease CLAIM/ ENCOUNTER CODES ( approved by NCQA for HEDIS ) Vaccine CPT Codes ICD-9- CM Codes DtaP 90700,90701, 90720, 90721, Diphtheria and tetanus Diphtheria V02.4*, 032*, Tetanus *, Pertussis 033*, OPV IPV 90713, V12.02*, 045*, MMR 90707, Measles 90705, Mumps 90704, Rubella 90706, HIB 90645, 90646, 90647, 90648, 90720, 90721, *, *, 320.0*, 482.2* Hepatitis B 90723, 90740, 90744, 90747, VZV 90710, *, 053* * Indicates evidence of the disease.

180 IMMUNIZATION MEASURES (continued) Measure Result Description Medical Record Documentation Standard Adolescent Immunization Status % of children who turned 13 years old in 2003 who had all of the specified immunizations 1. Specific date and name of the following immunizations: 2 MMRs 3 Hepatitis Bs 1 VZV 2. OR Date of contraindications per vaccine 3. OR Date of disease CLAIM /ENCOUNTER CODES Vaccine CPT Codes ICD-9- CM Codes MMR 90707, Measles 90705, *, Mumps 90704, *, Rubella 90706, 90708, *, Hepatitis B 90723, 90740, 90743**, 90744, 90747, V02.61*, 070.2*, 070.3* Chicken Pox (VZV) 90710, *, 053* * Indicates evidence of the disease. ** This CPT code identifies the 2-dose regimen for Hep B Controlling High Blood Pressure % of members years in 2003 with dx of HTN who have documented confirmation of controlled BP (below 140/90 by the end of 2003) CARDIAC MEASURES 1. Documented Dx of HTN on or before 6/30/2003 AND Last B/P in 2003 is below (140/90) Medical Record Review ONLY Cholesterol Mgmt. after an Acute Cardiovascular Events CABG PTCA AMI Members years in 2003 who were discharged alive with one of 3 cardiac events. % screened for LDL-C between 60 and 365 days after discharge AND % with an LDL-C level <130mg/dl % with an LDL-C level <100mg/dl 1. Date of LDL-C test between 60 and 365 days after members discharge for cardiac event 2. Numeric result of LDL-C between 60 and 365 days of members d/c for the cardiac event. Codes to identify LDL-C Screening 80061, 83715, 83716, 83721

181 Measure Result Description Medical Record Documentation Standard CLAIM / ENCOUNTER CODES Beta Blocker Treatment After a Heart Attack Comprehensive Diabetes Care % of Members 35 years and older who were hospitalized and discharged alive with an AMI and received an ambulatory Rx for a beta blocker upon discharge or within 7 days of discharge Members age years with a dx of diabetes (type 1 or type 2) who had specified screenings. % w/ HbA1c testing %w/ LDL-C screening % w/ LDL-C controlled (<130mg/dl) % w/retinal eye exam % w/nephropathy monitoring CHANGES FOR 2004 % w/ poorly controlled HbA1c control (>9.0%) (changed from >9.5%) 1. Medical record documentation of a beta blocker on discharge summary or within 7 days of discharge for AMI OR 2. Documentation of a contraindication for beta blockers. DIABETES MANAGEMENT MEASURES 1. Date and result of at least one HbA1c tests in The last result in 2003 will be counted for control measure. 2. Date and result of a retinal eye exam for diabetic retinal disease in 2003 performed by an eye care professional (optometrists or ophthalmologists). The result MUST ADDRESS RETINOPATHY. Ensure that retinal eye reports from Optometrists or Ophthalmologists are filed in the member s medical record. 3. Date and result of LDL-C screening in Pharmacy claims for Beta Blocker Medications Description CPT Codes ICD-9 CM Codes Retinal Eye Exam 67101, 67105, , 67110, 67141, 67145, 67208, 67210, 67218, 67227, 67228, 92002, 92004, 92012, 92104, 92018, 92019, 92225, 92226, 92230, 92235, 92250, 92260, 92287, 99204, 99205, 99214, 99215, , 14.9, , 95.11, 95.12, % w/ldl-c controlled (<100mg/dl) ADDITIONAL MEASURE 4. Screening for nephropathy including microalbumuria / macroalbuminuria tests, or documentation of existing renal condition

182 NEW for 2004 Measure Result Description Medical Record Documentation Standard Colorectal Cancer Screening % of adults years of age who had appropriate screening for colorectal cancer (CRC). Appropriate screenings are defined by any one of the four criteria below: Fecal occult blood test (FOBT) during the measurement year (2003) Flexible sigmoidoscopy during the measurement year or the 4 years prior ( ) Double contrast barium enema (DCBE) during the measurement year or the 4 years prior ( ) Colonoscopy during the measurement year or the 9 years prior ( ). A note in the medical record indicating the DATE the CRC was performed and the RESULT or FINDING EXCEPTION: Members with a dx of colorectal cancer CLAIMS / ENCOUNTER CODES ( approved by NCQA for HEDIS ) Description CPT Codes ICD-9-CM Codes Fecal occult blood test (FOBT) 82270, Flexible sigmoidoscopy Double contrast barim enema (DCBE) 45330, 45331, 45335, 45333, 45334, 45335, 45337, 45338, 45339, , Colonoscopy 44.88, 44389, 44390, 44391, 44392, 44393, 44394, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, , 45.23, 45.24, 45.42

183 Breast Cancer Screening % of women age years in 2003 who had a mammogram within the past 2 years (2002 or 2003) Cervical Cancer Screening % of women age years. in 2003 Documentation of a pap test within the past 3 years ( 2000, 2001, or 2002) Women s Health Measures 1. Date and result / finding of mammogram (normal / abnormal) within the last 2 years (2002 or 2003) 2. OR date of bilateral mastectomy 1. Date and result or findings of pap smear (normal or abnormal) within last 3 years ( 2000, 2001, or 2003) OR 2. Exclusion: Documentation with the following: Date of hysterectomy with no residual cervix i.e, vaginal hysterectomy, TAH, TVH, complete hysterectomy CPT Codes , 88147, 88148, 88150, , , Breast Cancer Screening Codes Cervical Cancer Screening Codes ICD-9-CM Codes V Codes: V76.2 UB-92 Rev Codes 923 Prenatal and Postpartum Care % of women who delivered a live birth between 11/6/02 and 11/5/03 who have evidence of prenatal care in the first trimester and postpartum care on or between days after delivery. NOTE: A notation of hysterectomy only does not met NCQA s criteria for exclusion. FOR APPLICABLE PHYSICIANS The Health Plan reviews the OB/GYN record for this measure: 1. Evidence of Prenatal Care within the FIRST TRIMESTER includes any of the following: Date of OB physical Date of OB screening test (examples include: OB panel, TORCH) 4. Date of Postpartum Visit between (21 56) days after delivery include any of the following: a pelvic exam a notation of postpartum care an evaluation of weight, B/P, breasts AND abdomen

184 Breast Cancer Screening % of women age years in 2003 who had a mammogram within the past 2 years (2002 or 2003) Women s Health Measures 3. Date and result / finding of mammogram (normal / abnormal) within the last 2 years (2002 or 2003) 2. OR date of bilateral mastectomy Breast Cancer Screening Codes

185 Figure G-5 ALERE CONGESTIVE HEART FAILURE PROGRAM PacifiCare of Texas is pleased to announce that we have partnered with Alere Medical to provide physicians an innovative tool to improve outcomes for our PacifiCare/Secure Horizons members with high-risk heart failure. The Alere program is a technologybased, physician-directed program that provides clinicians with timely objective information about changes in their patient s heart failure symptoms. The Alere program: Provides a daily link between the patient at home and experienced cardiac nurses. Delivers objective monitoring of patient s weight as well as information on key symptom changes. Relies on alert parameters set for each patient. When the patient's weight and/or symptoms exceed these parameters, the physician is notified. Is available in both English and Spanish. Alere's outcomes show a 50-86% reduction in heart failure hospitalizations in high-risk patients, compared to an estimated average of two hospitalizations per patient per year. PacifiCare is committed to providing physicians with effective health improvement programs like Alere. We appreciate your support in our ongoing efforts to improve outcomes for our members, and look forward to working with you to bring this program to your patients. If you would like to enroll a PacifiCare/Secure Horizons member in the Alere program, or if you would like further information about the heart failure program, please contact Alere at

186 Figure G-6 Dear Healthcare Provider PacifiCare /Secure Horizons is pleased to introduce the AirLogix COPD Management Program - a program sponsored by PacifiCare/Secure Horizons. This program is designed to assist your members with COPD who are 40 years old or older in managing their breathing successfully and is being provided at no additional cost to you or your patients. As part of this program, AirLogix will send the patients self-administered test materials and/or an educational booklet. If necessary, they may also arrange for a licensed Respiratory Therapist to visit in the privacy and convenience of the patients own home to: Evaluate breathing Teach how to take medications appropriately and effectively Educate about issues such as seasonal changes, lifestyle, exercise, and breathing techniques Help find triggers in the home that could irritate breathing The AirLogix Respiratory Therapist will send all the information gathered at the initial visit to the patient s doctor with any recommendations to their treatment plan based on the findings. All of AirLogix education efforts and other actions, including explaining medications, providing advice for symptoms and doing follow-up visits, will be based on this plan. The AirLogix Respiratory Therapist will arrange a follow-up visit with the patient lasting about 45 to 60 minutes in order to: Explain the daily medication treatment plan and the treatment plan for exacerbation Schedule another home visit, if needed, and perform periodic follow-up calls If you have any questions about the COPD program, please contact Chuck Alvarado, PacifiCare, State Manager, Health Improvement at or AirLogix at their toll-free number: 1 (800) We appreciate your support of our efforts to improve the health of the members we serve. Sincerely, Naim Munir, MD Vice President, Health Services/Chief Medical Officer PacifiCare of Texas

187 Figure G-7 Dear Health Care Provider: PacifiCare of Texas is pleased to announce a new service to benefit your patients with End Stage Renal Disease (ESRD). This new service is offered to patients free of charge and was available as of June 1, We are working with Renaissance Health Care a disease management company which focuses exclusively on patients with renal failure. Renaissance supports the care currently being provided by you and the patient s dialysis unit with a locally-based case manager. The Renaissance case manager is a renal nurse who understands the unique needs of these patients and is available to augment your efforts through coordination among PacifiCare of California, the dialysis unit, the hospital, yourself, and most importantly the patient. In addition, this program recognizes the important role of the nephrologist as the primary physician for patients with ESRD. To this end, Renaissance provides the resources for clinical and administrative support through a dedicated renal nurse case manager. In this way, we can work as a team to enhance the clinical outcomes for our patients in a cost-effective manner. The Renaissance case manager is available to answer any questions you may have about this new service. He or she will be contacting you soon to schedule some time to meet with you. In the meantime, please feel free to contact Renaissance toll-free at RENAL ( ) with any questions. Sincerely, Naim Munir, MD Vice President, Health Services/Chief Medical Officer GENPL0101 PacifiCare 5001 LBJ Freeway, Suite 600, Tower II Dallas TX Renaissance Health Care, Inc

188 Figure G-8 Dear PacifiCare Physician: Interactive Heart Management Corporation (QMed/IHMC), together with PacifiCare of Texas, is pleased to announce an innovative system for managing coronary artery disease and stroke. This program uses a system called ohms cad (online heart management system for coronary artery disease). ohms cad is a patented and technologically advanced process used to risk stratify patients and modify risk factors for coronary artery disease and stroke. What s in it for you? Getting Started Eligibility This physician driven program is designed to enhance the relationship between you and your patient, promote coronary wellness, decrease the risk for a future cardiovascular event or stroke and improve clinical outcomes. The program provides a consultative service as an adjunct to the care you provide your patients. It also helps your patients with CAD and stroke take an active role in their own daily monitoring and self-care. Physician participation involves completion of a letter of agreement and a W-9 Form (attached) in order to efficiently process reimbursement. Physicians will be reimbursed $25 for their time involved in each medical record review to determine appropriateness for enrollment in ohms cad. Physicians will also be reimbursed $50 for monitoring those members who are tested and for following the recommended treatment plan. Please Note: Reimbursement cannot be provided without an appropriate Tax Identification Number (TIN) and signature. Eligible patients with the following indications may be enrolled in the program: Documented cardiovascular disease (CVD) defined as those with a history of myocardial infarction, stroke or TIA; angiographically documented coronary obstructions; CABG; PTCA or CEA. Stable angina pectoris or a history of angina in the past; or inducible ischemia, whether symptomatic or silent; or the detection of ambulant ischemia during a previous ambulatory ECG recording. Positive carotid vascular studies. Recent onset of chest pains consistent with angina. Males over the age of 45 and females over the age of 55 with any two of the following risk factors: Family history of coronary artery disease appearing in a first degree relative before the age of 60 Hyperlipidemia and elevated lipoprotein Diabetes Hypertension Smoking Verify Patient Status Please verify your patient s clinical status before recommending this program.

189 Patient List Enrolling a Patient Study Results For more information Please find attached a list of PacifiCare/Secure Horizons patients in your practice who have been identified as meeting eligibility requirements and who are likely candidates for the program. These patients have been identified through claims and pharmacy data. The program is voluntary and completely free for your patient there is no co pay. If you would like to enroll a patient in the program, please indicate on the attached Physician Member List. Your member list can then be faxed to QMed/IHMC at fax # Results from a pilot with a PacifiCare participating provider group show a 26% reduction in heart attacks, 23% reduction in hospitalizations for ischemic heart disease, and a 10% reduction in strokes after the first year for the entire pilot population, comprised of Secure Horizons Members. If you have any questions or would like more information on the program, please call the QMed/IHMC Coordinator, at or (972) We appreciate the importance of your role in the success of this program. In fact, the heart of this program is built on the trusting relationship between patient and physician. This approach to managing this chronic illness has achieved positive clinical results with high patient and physician satisfaction. We hope that you will consider referring appropriate patients to the program. Sincerely, Naim Munir, M.D. Chief Medical Officer