Quick Reference Guide

Transcription

1 Quick Reference Guide Denver Health and Hosptial Authority (DHHA) Point of Service (POS) 2015

2 Member Services at or toll-free at

3 Welcome to DHMP...4 Network Options... 4 Your Primary Care Provider (PCP)... 4 Changing Your PCP... 4 Your DHMP Identification Card... 5 Copays and Out-of-Pocket Expenses... 5 Out-of-Pocket Maximums... 5 PCP Appointments... 5 Specialty Appointments... 6 Hospital Care... 6 Urgent Care Services... 6 Emergency Services... 6 When You Are Out of Town... 7 NurseLine... 7 Language Line Services... 7 Pharmacy Benefits... 8 Where You Can Fill Your Prescription... 8 Denver Health Pharmacies... 9 Formulary... 9 Generic and Brand Copays Refilling Your Prescription Mail Order Pharmacy Denver Health Pharmacy by Mail Day Supply at Retail Mental Health Services Care Support Services Preventive Care Intensive Case Management Health & Wellness Confidential Information Notice of Privacy Practices Website Member Services New Technologies Affirmative Statement about Incentives.. 23 Quality Improvement Program Healthy Heroes Club Acupuncture/Massage Therapy Member Rights The Difference Between a Grievance and an Appeal Who Can File an Appeal How to File a Grievance How to File an Appeal External Appeal Reviews Expedited Appeal Reviews The Division of Insurance Utilization Management/ Authorization Process Visit our website at 3

4 Welcome to DHMP We are pleased you have selected Denver Health Medical Plan, Inc. (DHMP) as your health plan. In this quick reference guide, you will find an overview of the plan, how it works and a summary of your benefits. Take a few moments to review this guide and keep it handy to answer questions in the future. For more detailed information, check your Member Handbook which is available online at or you may call Member Services at for a printed copy. Member Services is available to answer your questions from 8 a.m. through 5 p.m. Monday through Friday. We look forward to caring for you and your family. Network Options As a member of DHMP s Point of Service (POS) Plan, you can choose where you receive your health care. There are 3 tiers of providers you may choose from: Tier 1: DHMC providers and facilities. Tier 2: DHMP Cofinity contracted providers and facilities. Tier 3: All other licensed providers and facilities (non-network providers). However, deductibles, coinsurance and coverage limitations apply to Tiers 2 and 3. See the Summary of Benefits later in this guide for more details. If you have an emergency, go to the closest hospital or dial You are not required to get a referral for emergency care and cost sharing is the same in and out of network. Your Primary Care Provider (PCP) Primary care providers include family doctors, internal medicine doctors, pediatric doctors, physician assistants, and nurse practitioners. You ll find a complete list of in-network primary care providers on our website, Member Services can also help you find physicians and provide details about their services and professional qualifications. While you are not required to select a PCP, these practitioners can assist you in maintaining and monitoring your health as well as access the wide range of medical services from our network specialists and facilities. Changing Your PCP If you decide to select a new PCP, there is no need to tell us. You can change your selection at any time. Our website provides the most up-todate information on providers that participate in the DHMP network. Or call Member Services at if you need more information. 4 Member Services at or toll-free at

5 When a PCP leaves the Denver Health network, a notification will be sent to all members who received care from this provider recently. If this was your PCP, you will need to choose a new PCP. Your DHMP Identification Card You, and each member of your family, will receive a member identification (ID) card. The ID card lists the most common copays. You can find definitions for this list below. You will need to have this card with you when accessing care. If you did not receive your card or have misplaced it, call Member Services at for a replacement. Card Issued: Member ID#: Member Name: Group # Medical Record #: DH Payer Plan: N02 RxBIN RxPCN ASPROD1 RxGrp DHM04 Pharmacy #: PRE PCP SPC ER UC Denver Health Medical Plan, Inc. Point of Service CO-DOI Denver Health PRE/PCP/SPC/ER/UC/Hospital 0/25/30/150/50/400 DHMP Cofinity PRE/PCP/SPC/ER/UC/Hospital 0/30/40/150/50/Ded&Co-ins Out of Network PRE/PCP/SPC/ER/UC/Hospital Ded&Co-ins /150/50/Ded&Co-ins ID Card Abbreviations Preventive Care Primary Care Provider Specialist Emergency Room Urgent Care Copays and Out-of-Pocket Expenses Applicable copays are due at the time of service. These copays are also listed in the Summary of Benefits found later in this guide. Detailed information regarding copays can be found in the Member Handbook on our website at If you would like a printed copy, call Member Services at Out-of-Pocket Maximums Your out-of-pocket maximum is the maximum amount of expenses for covered medical services you and all your dependents must pay each year. There is a separate maximum for each family member until the total family maximum is reached. Refer to the Summary of Benefits for details. Generally, any deductible, coinsurance and copay amounts (including prescription drug copays) will apply to your out-of-pocket maximum. PCP Appointments To set up an appointment, call the central appointment line at and a representative will assist you. If you need assistance making an appointment, call Member Services at Hospital Inpatient stay Identify yourself as a DHMP member when calling for an appointment. Visit our website at 5

6 Same-day appointments may be available, call as early as possible for the best results. When necessary to cancel an appointment, we encourage you to call at least 72 hours ahead, if possible. This allows for that appointment slot to be filled with another patient. When you come to your appointment always bring your DHMP Identification Card and a picture ID. It may be helpful to write down questions you want to ask your doctor so that you won t forget important questions when you come in. Bring a list of all medications to visits. Specialty Appointments If you think you need to see a specialist or other provider, contact your PCP. Your PCP can refer you for care with a specialist. You may self refer for the following services: OB/GYN, Behavioral Health, routine eye care and Chiropractic services. Hospital Care Any admission to a hospital, other than an emergency admission, must have a prior authorization from the DHMP Utilization Management Department. Emergency hospitalization should be reported to DHMP at as soon as reasonably possible, preferably within 48 hours. Urgent Care Services An urgent medical problem is a minor medical emergency that is not life-threatening. DHMP members can access urgent care services at any location that is convenient; cost sharing is the same no matter where you go. DHMP contracts with Walgreens Take Care Clinics as a convenience for members. Members may also call the NurseLine at for assistance. Emergency Services Emergencies are life-threatening conditions or symptoms that arise suddenly and unexpectedly. These symptoms are so severe that you need medical attention now to prevent loss of life or limb. If you, or a family member, need emergency care, go to the closest emergency room or call You are not required to get a referral for emergency care and cost sharing is the same in and out of network. If you are admitted to the hospital directly from the Emergency Department, you will not have to pay the emergency department copayment, but will be responsible for the applicable inpatient copayment. 6 Member Services at or toll-free at

7 Non-emergency care delivered by an emergency department is not covered unless you are referred to the Emergency Department for care by DHMP, the NurseLine, or your PCP. Follow-up care after an emergency department visit must be received from a DHMP network provider, unless you are traveling outside the network area and cannot reasonably travel to the network area for a follow-up visit. If you are admitted to a non-denver Health Medical Center facility as the result of an emergency and then subsequently transferred to Denver Health, you will only be responsible for the inpatient copayment for the first hospital admission. When You Are Out of Town As a DHMP member, you can always go to any hospital or urgent care center that is convenient for you. If you need emergency care, go to the nearest hospital or call Following an emergency or urgent care visit out of the DHMP service area, one follow up visit is covered if you cannot reasonably travel back. Travel expenses back to the DHMP network are not a covered benefit. If you plan to be outside the DHMP service area and need your prescription filled, we have many network pharmacies across the country that you may use. Please check with Member Services at If you are a dependent residing, attending school or traveling outside of the Denver Health Medical Plan service area, you can call Member Services at for assistance in finding a network provider. Prescriptions are covered when filled at a network pharmacy, DHMP has a national prescription network. When urgent care or emergency services are needed, visit the closest facility or call Depending on the provider, DHMP members may have to pay out of-network providers directly and request reimbursement from DHMP for emergency and urgent care services. NurseLine DHMP members can call the Denver Health NurseLine 24 hours a day/7 days a week at This service is staffed by nurses trained to answer your questions. In some cases the NurseLine representative can call in a prescription and save you a trip to urgent care. Language Line Services DHMP is committed to meeting our plan members needs. DHMP contracts with Language Line Services, Inc. to provide translation services at no cost to our plan members. If you need an interpreter during your clinic visit, please tell the Appointment Center representative when you make your appointment. For further assistance, Visit our website at 7

8 please contact Member Services at or toll-free at Our TTY/TDD number is Pharmacy Benefits DHMP provides a pharmacy benefit that covers medically necessary drugs as required by the requirements and guidelines discussed below. Depending upon where you have your prescription filled, copays and restrictions may vary. Prescription copay information for your plan is listed in the Pharmacy Benefits table. For more detailed information and to find out about the Pharmaceutical Management Procedures, please visit our website at where you will find: A list of pharmaceuticals, including restrictions and preferences Pharmacy Benefits Drug Class Discount Information on how to use the Pharmaceutical Management Procedures An explanation on limits or quotas Information on how practitioners must provide information to support an exception request The process for generic substitution, therapeutic interchange and step-therapy protocols You may also call and request a printed copy of this information by calling Member Services. Where You Can Fill Your Prescription DHMP offers thousands of pharmacies nationwide for you to fill your prescriptions. These pharmacies include any Denver Health Pharmacy, Albertsons, King Soopers, Rite-Aid, Safeway, Target, Walgreens, and more. Preferred Generic (Tier 1) Preferred Brand (Tier 2) Non- Preferred Brand (Tier 3) Specialty (Tier 4) DH Pharmacy (30 day supply) $4 $15 $20 $35 $35 DH Pharmacy or Pharmacy by mail (90 day supply) Non-DH Pharmacy (30 day supply) (Examples: King Soopers, Target, etc.) Non-DH Pharmacy (90 day supply) (Examples: King Soopers, Target, etc.) $8 $30 $40 $70 N/A $8 $30 $40 $70 $70 $16 $60 $80 $140 N/A MedVantx by mail (90 day supply) $16 $60 $80 $140 N/A 8 Member Services at or toll-free at

9 DHMP has conveniently located Denver Health Pharmacies in many of the Denver Health clinics. While you have the choice to fill your prescription at any network pharmacy, filling your prescriptions at Denver Health Pharmacies will give you the lowest copay and allows your provider to see your prescription fill information. This helps your provider to give you the most complete care at each visit. Remember, to fill a prescription at a Denver Health Pharmacy your prescription must be written by a Denver Health provider. Denver Health Pharmacies Denver Health Refill Request Line DH-REFIL ( ) Denver Health Pharmacy by Mail (requires credit card and registration/ order form) or Primary Care Pharmacy West 6th Avenue Gipson Eastside Pharmacy , # th Street Infectious Disease (ID) Pharmacy Bannock Street La Casa/Quigg Pharmacy Navajo Street Lowry Yosemite St., Suite 100 Montbello Pharmacy Albrook Drive Sandos Westside Pharmacy Federal Blvd To find a pharmacy near you visit or call Member Services. Formulary The DHMP formulary is a list of covered drugs that shows the copayment tier and prior authorization requirements for each medication. We have selected the tiers and determined the criteria for prior authorization based on efficacy and cost-effectiveness. There is a different copayment for each tier. The formulary helps providers choose the most appropriate and costeffective drug for you. You can view the current formulary, restrictions, and Pharmaceutical Management Procedures at Visit our website at 9

10 or call Member Services to ask for a printed copy. Generic and Brand Copays You can save money by using generic drugs which have lower copays. Generic drugs are approved by the U.S. Food and Drug Administration for safety and effectiveness and are made using the same strict standards that apply to the brand name alternative. A generic preferred program is in place. This means if you fill a prescription with a brand name drug when a generic is available, you will have to pay the copay plus the difference in cost between the generic and the brand name drug. For more information check your Member Handbook. Refilling Your Prescription It is best to call to refill your prescription 3-5 working days before you need your refill. Your prescription may be refilled once 75% has been used. This is calculated using the original prescription directions. If the directions have changed please contact your pharmacy or provider for an updated prescription. If your prescription directions have changed or you need an early refill, please let the pharmacy know ahead of time. The pharmacy will need extra time to talk to your provider to get a new prescription or get authorization to fill your prescription early. You can refill prescriptions filled at the Denver Health Pharmacies by calling the Denver Health Refill Request Line (which is also the number on your prescription bottle), or by visiting You can also use the Denver Health Pharmacy Services smart phone app. Mail Order Pharmacy You can save time and money by signing up to have your prescriptions delivered to your home by mail. Ask your provider to write your prescriptions for a 90 day supply so you can get your prescriptions by mail. A registration/order form is required to sign up and you must keep a credit card on file to pay for your medications. As a POS member you have two mail order pharmacy choices. Denver Health Pharmacy by Mail will give you the lowest copay, but remember to have your prescription filled at a Denver Health Pharmacy, your prescription must be written by a Denver Health provider. 10 Member Services at or toll-free at

11 Denver Health Pharmacy by Mail Monday Friday, 9am- 5pm. Prescriptions must be written by a Denver Health provider You can pick up a registration/ order form from any of the Denver Health Pharmacies, by calling Denver Health Pharmacy by Mail to have one sent to you, or by visiting www. denverhealthmedicalplan.org. MedVantx You can download the registration form at www. denverhealthmedicalplan.org or call Member Services. 90-Day Supply at Retail Your pharmacy benefit allows you to get a 90 day supply of medication at any Choice 90 participating retail pharmacy. To find out if your drug and/ or pharmacy are eligible for this benefit visit and click the Drug Formulary Search link for your plan or call Member Services. Call Pharmacy Customer Service at: or toll free at , Monday through Friday, 9 am to 5 pm Prescriptions must be written by a Denver Health provider Visit our website at 11

12 Deductible Individual Family Out-of-Pocket-Maximum Individual $6,350 Family $12,700 Denver Health Medical Plan, Inc. Point of Service Plan 2015 Summary of Benefits Denver Health Network Cofinity Network Out-of-Network No deductible applies. $500 $1,000 Coinsurance applies to deductible. All individual deductible amounts will count toward the family deductible; an individual will not have to pay more thathe individual deductible amount. $2,000 $4,000 $1,500 $3,000 Coinsurance applies to deductible. All individual deductible amounts will count toward the family deductible; an individual will not have to pay more than the individual deductible amount. $10,000 $20,000 All copays apply to the out-of-pocket maximum. The out-of-pocket maximum includes the annual deductible, coinsurance and copays. It does not include premiums. All individual out-of-pocket amounts will count toward the family out-of-pocket maximum; an individual will not have to pay more than the individual out-ofpocket maximum. The out-of-pocket maximum includes the annual deductible, coinsurance and copays. It does not include premiums. All individual out-ofpocket amounts will count toward the family out-of-pocket maximum; an individual will not have to pay more than the individual out-ofpocket maximum. *Prior authorization required This form is not a contract. It is only a summary. The contents of this form are subject to the provisions of the Member Handbook, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified poviders or facilities). Consult the Member Handbook to determine the exact terms and conditions of coverage and how to file claims for covered services. 12 Member Services at or toll-free at

13 Denver Health Network Cofinity Network Out-of-Network Lifetime maximum No lifetime maximum. Covered Providers Denver Health and Hospital Authority providers and Denver Health Medical Center. Columbine network for chiropractic. See provider directory for a complete list of current providers. Medical Office Visits Personal $25 copay per visit. providers (Family Medicine, Internal Medicine and Pediatrics) Specialist $30 copay per visit. Preventive Services No lifetime maximum. Cofinity network providers and facilities. Columbine network for chiropractic. See provider directories for a complete list of providers. $30 copay per visit deductible and coinsurance do not apply. $40 copay per visit Deductible and coinsurance do not apply. No lifetime maximum. All providers licensed or certified to provide covered benefits in the United States. customary charges. customary charges. Children Adults This applies to all preventive services with an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF) No copayment (100% covered). Annual well visit, well women exams, prenatal visits, colonoscopy, mammogram. See USPSTF list on our website at No copayment (100% covered). Annual well visit, well women exams, prenatal visits, colonoscopy, mammogram. See USPSTF list on our website at customary charges. Immunizations are not covered in this tier. *Prior authorization required Visit our website at 13

14 Denver Health Network Cofinity Network Out-of-Network Maternity Prenatal Care $0 copay per visit. Delivery, $200 copay per Inpatient/Well hospitalization. Baby Care Prescription Drugs DH Pharmacy (30-day supply). Discount: $4 copay. Generic: $15 copay. Preferred Brand: $20 copay. Non-preferred Brand: $35 copay. Specialty: $35 copay. DH Pharmacy/Denver Health Pharmacy by Mail (90-day supply). Discount: $8 copay. Generic: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Specialty: N/A Non-DH Pharmacy (30-day supply). Discount: $8 copay. Generic: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Specialty: $70 Non-DH Pharmacy (90-day supply). Discount: $16 copay. Generic: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. Specialty: N/A $0 copay per visit. Deductible and 20% coinsurance apply. Non-DH Pharmacy (30-day supply). Discount: $8 copay. Generic: $30 copay. Preferred Brand: $40 copay. Non-preferred Brand: $70 copay. Specialty: $70 copay. Non-DH/MedVantx Mail Order (90-day supply). Discount: $16 copay. Generic: $60 copay. Preferred Brand: $80 copay. Non-preferred Brand: $140 copay. Specialty: N/A customary charges. Not covered in this tier. 14 Member Services at or toll-free at

15 Denver Health Network Cofinity Network Out-of-Network Inpatient Hospital $400 copay per hospital stay. * Maximum on surgical treatment of morbid obesity of once per lifetime. Outpatient/Ambulatory Surgery $200 copay per surgery. * Diagnostics Laboratory and Radiology Laboratory, No copay X-ray and CT (100% covered). MRI and PET $150 copay per test. scans $150 copay per test. Other Diagnostic and Therapeutic Services Sleep study $150 copay per visit. Radiation $10 copay per visit. therapy Infusion $10 copay per visit. therapy (includes chemo-therapy) Injections $10 copay per visit (immunizations, allergy shots and any other injection given by a nurse is a $0 copay). Renal Dialysis Covered at 100%. Deductible and 20% coinsurance apply. * Maximum on surgical treatment of morbid obesity of once per lifetime. Deductible and 20% coinsurance apply. * Deductible and 20% coinsurance apply. $250 copay per test. $150 copay per test. $250 copay per visit. $10 copay per visit. $10 copay per visit. $25 copay per visit (immunizations, allergy shots and any other injection given by a nurse is a $0 copay). Covered at 100%. customary charges: (If admitted after emergency care, Preferred Provider deductible applies then Plan pays 80%). * customary charges. * customary charges. customary charges. customary charges. Not covered in this tier. Not covered in this tier. Not covered in this tier. customary charges. *Prior authorization required Visit our website at 15

16 Denver Health Network Cofinity Network Out-of-Network Emergency Care $150 copay per visit. $150 copay per visit (deductible and coinsurance do not apply). Urgent Care $50 copay per visit. $50 copay per visit. (deductible and coinsurance do not apply). Ambulance $150 copay per trip. $150 copay per trip (deductible and coinsurance do not apply). Behavioral Health, Mental Health Care and Substance Abuse Outpatient: $25 copay per visit. $30 copay per visit. Deductible and coinsurance do not apply. Inpatient: $400 copay per visit. * Deductible and 20% coinsurance apply. * Therapies Rehabilitative: $10 copay per visit. Deductible and 20% Physical, 20 of each therapy per coinsurance apply. Occupational, calendar year. 20 of each therapy per and Speech calendar year. Therapy Habilitative: $10 copay per visit.* Deductible and 20% Physical, 20 of each therapy per coinsurance apply. * Occupational, calendar year. 20 of each therapy per and Speech calendar year. Therapy Pulmonary $10 copay per visit.* Deductible and 20% Rehabilitation 20 of each therapy per coinsurance apply. calendar year. 20 of each therapy per calendar year. $150 copay per visit (deductible and coinsurance do not apply). $50 copay (deductible and coinsurance do not apply). $150 copay per trip (deductible and coinsurance do not apply). $0 deductible, 20% coinsurance applies. customary charges. * customary charges. 20 of each therapy per calendar year. customary charges. * 20 of each therapy per calendar year. customary charges. 20 of each therapy per calendar year. 16 Member Services at or toll-free at

17 Denver Health Network Cofinity Network Out-of-Network Cardiac Rehabilitation $10 copay per visit.* 20 of each therapy per calendar year. Deductible and 20% coinsurance apply. 20 of each therapy per calendar year. customary charges. 20 of each therapy per calendar year. Durable Medical Equipment 20% coinsurance 20% coinsurance Not covered in this tier. applies; maximum benefit is $2,000 per calendar year. * applies; maximum benefit is $2,000 per calendar year. * Hearing Aids Adults Medically-necessary hearing aids prescribed by a DHMP Network provider are covered every 5 years in network. $1,500 benefit maximum every 5 years. Charges exceeding the $1,500 hearing aid maximum benefit, are the responsibility of the member. * Hearing aids no longer apply to the annual DME limit. Cochlear implants are now covered. The device is covered at 100%; applicable inpatient/outpatient surgery charges will apply. Children Children under age 18 are covered at 100%, no maximum benefit applies. Hearing screens and fittings for hearing aids are covered under office visits and the applicable copayment applies. * Hearing aids no longer apply to the annual DME limit. Cochlear implants are now covered for children under age 18. The device is covered at 100%, applicable inpatient/outpatient surgery charges will apply. Prosthetics 20% coinsurance applies; no maximum benefit. * Does not apply to DME maximum. 20% coinsurance applies; no maximum benefit. * Does not apply to DME maximum. Not covered in this tier. Orthotics Medically necessary orthotics are reimbursed up to $100 per calendar year. Oxygen/Oxygen Equipment Oxygen 100% Covered. * 100% Covered. * customary charges. * Equipment 20% coinsurance applies; no maximum benefit. * Does not apply to DME maximum. 20% coinsurance applies; no maximum benefit,. * Does not apply to DME maximum. 50% coinsurance. * Does not apply to DME maximum. *Prior authorization required Visit our website at 17

18 Denver Health Network Cofinity Network Out-of-Network Organ Transplants $400 copay per admission. Only covered at authorized facilities. Coverage no less extensive than for other physical illness. Covered transplants include: cornea, kidney, kidney-pancreas, heart, lung, heart-lung, liver and bone marrow for Hodgkin s, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer and Wiskott-Aldrich Syndrome only. Peripheral stem cell support is a covered benefit for the same conditions listed above for bone marrow transplants. * Home Health Care No copay (100% Deductible, then 100% covered) for prescribed covered for prescribed medically necessary medically necessary skilled home health skilled home health services. * services. * Hospice Care No copay (100% Deductible, then 100% covered). * covered. * Skilled Nursing Facility No copay (100% Deductible, then100% covered). * covered. * Maximum benefit is Maximum benefit is days per calendar days per calendar year at year at authorized authorized facility. facility. Dental Care Not covered except for fluoride varnish at PCP visit. Vision Care $30 copay per $40 copay per visit visit for routine eye for routine eye exams exams (deductible and (deductible and coinsurance waived.) Limit of one coinsurance waived.) Limit of one routine eye routine eye exam every exam every 24 months. 24 months. Self-referral Self-referral allowed in allowed in network. network. Not covered in this tier. customary charges for prescribed medically necessary skilled home health services. * customary charges. * customary charges. * Maximum benefit is 100 days per calendar year at authorized facility. Not covered. Not covered in this tier. 18 Member Services at or toll-free at

19 Denver Health Network Cofinity Network Out-of-Network Plan pays up to $350 one time per 24 month period for prescription eyewear. Only one claim can be submitted in a 24 month period, i.e. if you are using the benefit for contacts, you may want to wait until you have accumulated $350 in charges before submitting a claim in order to use full benefit. $200 toward Lasik surgery once per lifetime. This benefit can be used at any time regardless of whether or not the $350/24-month benefit has been used. Chiropractic $20 copay per visit. $20 copay per visit. Maximum 20 visits per calen- Not covered in this tier. Maximum 20 visits per calendar year. Services dar year. Services must be must be provided by provided by Columbine Columbine Chiropractic Chiropractic in order to be in order to be covered. covered. Note: Massage therapy is not a plan benefit but DHMP offers a discount program through Columbine Chiropractic. Many chiropractic offices offer massage therapy as well. DHMP will not pay for massage therapy received at a Columbine Chiropractic office. Member must pay through discount program. Additional Benefits Weight Watchers Discount. DHMP will share the cost of Weight Watchers with members. Join Weight Watchers through DHMP and the plan will pay 35% of your cost! Curves Wellness program. DHMP will pay $20 toward the monthly fee for every month that members who join Curves work out at least 8 times per month. elearning module for parents-to-be. Online childbirth classes, free of charge to members. Take Control of Your Health incentive plan. *Prior authorization required Prior Authorization is required for, but not limited to, the following services: Durable medical equipment, genetic testing, home health care (including home infusion therapy); all hospital stays (including mental health or substance abuse-related stays), outpatient surgery (except those procedures performed in a physician s office), reconstructive surgery, non-formulary medications, skilled nursing facility care, transplant evaluations and hospice care, cochlear implants, clinical trials or study. Contact your primary care provider to request these services and provide the medical necessity information. Visit our website at 19

20 Utilization Management/ Authorization Process Some medical services must be reviewed and approved (prior authorization) by DHMP to ensure payment. It is the sole responsibility of your doctor or other provider to send a request to DHMP for authorization. DHMP will notify you and your provider when the request has been approved or denied. Sometimes, requests are denied because the care is either not a covered benefit or is not medically necessary. If you disagree with the decision to deny, you can appeal the decision see the Appeals and Complaints section in the Member Handbook at for more detailed information. The following are examples of services that require approval before receiving the service (prior authorization): Hospital admissions (including mental health, inpatient rehabilitation, and substance abuse admissions) Outpatient surgery (except those procedures performed in a physician s office) Genetic testing Cochlear implants for children under age 18 Coverage for services in a clinical trial or study Home health care (including home infusion therapy) Durable medical equipment Skilled nursing facility admissions Hospice care Transplant evaluations/procedures Referral to out-of-network specialists or facilities Urgent/emergent care admissions do not require prior authorization, but will be reviewed concurrently. The Utilization Management (UM) staff is available to answer UM questions Monday through Friday, from 8 a.m. to 5 p.m., except on holidays. If you have questions or concerns about the authorization process, specific cases, or UM decisions, please call us at or toll-free, A TTY/TDD line is available for the hearing- or speechimpaired at We also have bilingual staff and language assistance services available at no charge. Contact your PCP or Specialist to request these services. Mental Health Services You may obtain mental health services from any Denver Health and Hospital or Cofinity provider without a referral from your PCP. Note: Members may use the Cofinity network ONLY for mental health services. See your member handbook for more information and covered services. 20 Member Services at or toll-free at

21 Care Support Services Health care navigators are available Monday through Friday, 8 a.m. to 5 p.m. to assist members with all aspects of receiving care in the Denver Health network. They are a complement to the Member Services department and work with members whose needs may be more detailed and clinical in nature. Staff help members maximize health care benefits and reduce barriers from getting necessary services, as well as referrals to programs/ specialists in Case Management, Health and Wellness or Pharmacy for additional assistance as needed. Preventive Care DHMP has developed clinical and preventive care guidelines and health management programs to assist members with common health conditions, including diabetes management, asthma, and pregnancy care. For more information regarding these guidelines, visit our website at or call Member Services at Intensive Case Management We know that it can be hard to understand everything that needs to be done to manage your health, but we are here to assist you. We take your health personally and offer specialized programs and services that are focused on you and your needs. Our programs include: Complex Case Management (CCM) Intensive Care Transitions (ICT) Targeted Case Management (TCM) Our Case Managers are available to: Help coordinate care among your different doctors. Help find community resources to meet your needs. Advocate to ensure you get the care and services you need. Help improve your health or function. Help you use and understand your health benefits. Provide one-on-one health care information, guidance and support. Members or their caregivers may selfrefer to gain access to these voluntary programs and services. Intensive Case Management is provided at no cost to you and will not affect your plan benefits. To participate in any of these programs or to learn more, please call Care Support Services at You can also obtain more information about our program eligibility and services at 21

22 Health & Wellness Health Coaching is a no-cost benefit offered through the Behavioral Health and Wellness Services department. Our health coaches help members take a more active role in their health care and control of illness. They help boost motivation by encouraging and supporting members in making lifestyle changes to improve their health. Health Coaches can help you with: Starting an exercise program Eating better/losing weight Stopping smoking Lowering stress Taking your medications Community resources Health Coaches can help you control chronic diseases such as asthma, diabetes, COPD, congestive heart failure and depression. To speak with a Health Coach, call Care Support Services at Confidential Information DHMP is committed to protecting your privacy. All patient information is kept confidential. In addition, we will not discuss any of your Protected Health Information (PHI) with anyone other than you without approval. If you d like for us to discuss your information with another family member, you will need to fill out the Designation of Personal Representative (DPR) form (see Attachment B in your handbook). Your handbook can be accessed on our website at www. denverhealthmedicalplan.org, or you may call Member Services at and request that a hard copy be mailed to you. Notice of Privacy Practices (HIPAA-Health Insurance Portability and Accountability Act of 1996) The DHMP Notice of Privacy Practices is available on the DHMP website at A new notice will be provided if there is any material change in our practices. You may, at any time, obtain a copy of the notice by contacting Member Services at or by calling toll-free at Website Our website is always expanding to provide you with more information about DHMP, your benefits, physicians and health information. Visit the website regularly for updates. Member Services We want you to be satisfied with the care and services you receive through DHMP. If you are having any difficulty, please let us know right away so that we can assist you promptly. You can call Member Services from 8 a.m. to 5 p.m. Monday through Friday at You can also visit our website at: 22 Member Services at or toll-free at

23 click on Contact Us. Our representatives are specially trained to: Answer questions about your health network Provide additional information about how to receive services Answer questions about your benefits Check eligibility Complete address, phone number or PCP changes Send you a variety of information upon request. New Technologies As new technologies or new indications for current technologies are identified that may have broad applicability for DHMP members, an ad hoc committee is convened that includes experts in the area under evaluation. The committee reviews technology assessments, published studies and deliberations of other expert panels including coverage decisions by other insurance companies to determine appropriate coverage guidelines. Affirmative Statement about Incentives DHMP wants to assure its membership that all covered benefits are open to its members without regard to any financial gains from reduction in utilization. DHMP affirms the following regarding (UM) practices: UM decision-making is based only on appropriateness of care and services and the existence of coverage; Practitioners or other individuals are not rewarded for issuing denials of coverage or service of care; and, UM decision makers do not receive financial incentives to encourage decisions that result in underutilization. Please feel free to contact DHMP at should you have questions regarding this practice. Quality Improvement Program DHMP continually strives to improve the quality of care and service to our members by ongoing monitoring of services. DHMP s Quality Improvement Program: Monitors and measures the level and quality of service and care Monitors compliance with certain preventive health measures Identifies opportunities to improve patient care and service Addresses identified disparities through appropriate intervention and education Please visit or call Member Services to learn Visit our website at 23

24 more about our Quality Improvement Program such as program goals, processes, outcomes and specific measurements. $40. Simply present your ID card to take advantage of this discount. Providers may have different definitions for visit, it could be 30 minutes, 45 minutes or 1 hour. Check with specific provider for details. Healthy Heroes Club Healthy living can start at any age and it s never too early to teach children how to be healthy and safe. DHMP offers the Healthy Heroes Club for children ages 3-12 as a fun way to encourage these habits. Healthy Heroes Membership Card and Certificate; Activity Sheets; Health Tips Postcards and special newsletters are mailed to them monthly. With 3 different Healthy Hero groups, this program is designed to grow with your child: Explorers (ages 3-6); Rangers (ages 7-9); X-Kidz (ages 10-12). Acupuncture/Massage Therapy DHMP offers a discount program for Acupuncture and Massage Therapy, this is not a plan benefit. Providers participating in this program can be found in Provider Directory located on our website at There is no limit on visits, each visit is DHMP has teamed with Weight Watchers to bring our members effective weight management offerings at a special price. Not only does this offer include special prices but in addition DHMP offers subsidy of 35% to all members who join Weight Watchers. There are three Weight Watchers options: At Work meetings, Local Meeting vouchers, Online subscription. You can pick the option that best suits your lifestyle. Detailed information about this program can be found on the DHMP website at Or, contact Member Services at for more information. DHMP has partnered with Curves to offer a wellness subsidy for members who workout at Curves at least 8 times each month. The way the program works: Go to the Curves location that you would like to join: Show them your DHMP member ID and photo ID. 24 Member Services at or toll-free at

25 Curves staff will automatically sign you up for the program. If you have questions, contact Member Services at Member Rights Know what your rights and responsibilities are. Direct any questions, comments or problems to the DHMP Member Services Department at or DHMP is committed to partnering with you and your doctor. You have the right: To have access to practitioners and staff who are committed to providing quality health care to all members without regard for religion, race, national origin, handicap, sex or sexual orientation, or age. To receive medical/behavioral health care that is based on objective scientific evidence and human relationships. A partnership based on trust, respect, and cooperation among the provider, the staff and the member will result in better health care. To be treated with courtesy, respect, and recognition of your dignity and right to privacy. To receive equal and fair treatment, without regard to race, religion, color, creed, national origin, age, sex, sexual preference, political party, disability, or participation in a publicly financed program. To choose or change your primary care provider within the network of providers, to contact your primary care provider whenever a health problem is of concern to you and arrange for a second opinion if desired. To expect that your medical records and anything that you say to your provider will be treated confidentially and will not be released without your consent, except as required or allowed by law. To get copies of your medical records or limit access to these records, according to state and federal law; To ask for a second opinion, at no cost to you; To know the names and titles of the doctors, nurses, and other persons who provide care or services for the member. To a candid discussion with your provider about appropriate or medically necessary treatment options for your condition regardless of cost or benefit coverage. To a right to participate with providers in making decisions about your health care. To request or refuse treatment to the extent of the law and to know Visit our website at 25

26 what the outcomes may be. To receive quality care and be informed of the DHMP Quality Improvement program. To receive information about DHMP, its services, its practitioners and providers and members rights and responsibilities, as well as prompt notification of termination or other changes in benefits, services or the DHMP network. This includes how to get services during regular hours, emergency care, after-hours care, out-of-area care, exclusions, and limits on covered service. To learn more about your primary care provider and his/her qualifications, such as medical school attended or residency, go to and click on Find a Doctor for our web based provider directory or call Member Services at To express your opinion about DHMP or its providers to legislative bodies or the media without fear of losing health benefits. To receive an explanation of all consent forms or other papers DHMP or its providers ask you to sign; refuse to sign these forms until you understand them; refuse treatment and to understand the consequences of doing so; refuse to participate in research projects; cross out any part of a consent form that you do not want applied to your care; or to change your mind before undergoing a procedure for which you have already given consent. To instruct your providers about your wishes related to advance directives (such issues as durable power of attorney, living will or organ donation). To receive care at any time, 24 hours a day, 7 days a week, for emergency conditions and care within 48 hours for urgent conditions. To have interpreter services if you need them when getting your health care. To change enrollment during the times when rules and regulations allow you to make this choice. To have referral options that are not restricted to less than all providers in the network that are qualified to provide covered specialty services; applicable copays apply. To expect that referrals approved by DHMP cannot be changed after Prior authorization or retrospectively denied except 26 Member Services at or toll-free at

27 The Difference Between a Grievance and an Appeal As a member of DHMP, you have the right to voice grievances and appeals. A grievance is a written or oral request that DHMP investigate the quality of the care you receive, the failure of a provider or DHMP to accommodate your needs, an unpleasant experience or any other service issue, including but not limited to access to care. An appeal is a written or oral request that DHMP reviews an adverse decision about requested medical service, care or treatment, e.g., DHMP s decision to deny pre-authorization for a test, or to deny a particular type of treatment. Who Can File an Appeal An appeal can be requested by you (the member), a person that you designate, such as a relative, friend, advocate, ombudsman, an attorney, or any physician, to act on your behalf as your appointed representative. To be appointed by a member, both the member making the appointment and the representative accepting the appointment (including attorneys) must sign, date, and complete a Designation of Personal Representative form. You may obtain a copy of the Designation of Personal Representative Form at the end of this Member Handbook or call the Member Services Department at (303) to learn how to name your appointed representative. Upon receipt of the completed Designation of Personal Representative Form, we will process the appeal. How to File a Grievance You may file a grievance by writing or calling the Grievance and Appeal Department at or the Member Services Department at (303) or toll-free at , TTY/ TDD users should call You may also file a grievance by completing the Member Complaint and Appeal Form located in the Member Handbook on our website at You may mail or fax your grievance to the following address: DHMP Complaint Coordinator 777 Bannock St., MC 6000 Denver, CO The grievance team will conduct an investigation of your grievance. You will receive a written letter providing a resolution to your grievance within 30 calendar days. How to File an Appeal If you have received a letter stating that the requested service, care or treatment was denied, the decision is called an adverse determination and is subject to the appeal process. Before an appeal is filed, your physician may Visit our website at 27

28 hold a peer-to-peer conversation with the Medical Director who rendered the adverse determination. External Appeal Reviews You have the option of an independent external review by qualified experts upon the denial of a request for coverage. In order to request an independent external review, you must have pursued at least one level of the internal appeal process or have pursued an expedited review of a denial of a benefit. You must file the request for an external review within four (4) months of receipt of the first level review decision or within sixty (60) calendar days of receipt of the second level review decision. You may also request an expedited external review. Upon timely receipt of your request for an independent external review, DHMP will send you a letter describing the certified independent review entity that the Division of Insurance has selected to conduct the review. Please contact the Grievance and Appeal Department at (303) to have the consent form sent to you. External review is provided at no cost to you and is arranged by the Colorado Division of Insurance. The Division will assign an independent external review agency to perform a thorough review of your appeal. You will receive a decision from the external review agency within 45 calendar days of its receipt of your request. Expedited external reviews are available, if necessary. Expedited Appeal Reviews If the timeframe of the standard review procedures set forth above could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or for the persons with a physical or mental disability, create an imminent and substantial limitation on their existing ability to live independently, you may request an expedited review. Expedited Appeal reviews can also be requested if in the opinion of a physician with knowledge of the covered person s medical condition would subject the covered person to severe pain that cannot be adequately managed without the health service, care or treatment that is subject of the request, a decision will be made and you and your provider will be notified as quickly as your medical condition requires; however, the decision shall not be more than 72 hours after the review is started. Initial notification will be made by telephone or sent by facsimile and, written confirmation sent within three 28 Member Services at or toll-free at