Medicare Advantage PPO participation Termination - Practice Name (Tax ID #: <TaxID>)

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Kristopher Bryant
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1 July xx, 2013 INDIVDUAL PRACTICE VERSION <Practice Name> <Address> <City, State Zip Code> RE: Medicare Advantage PPO participation Termination - Practice Name (Tax ID #: <TaxID>) Dear <Practice Name>: To meet the changing demands of the Medicare Advantage market and help ensure affordable benefits for our Medicare Advantage members, ANTHEM BLUE CROSS will begin offering a more limited provider network for our Medicare Advantage health plans in CMS regulations support Medicare Advantage plans ongoing evaluation of their provider networks to help ensure that plans are able to manage the cost and quality of care while maintaining appropriate access to care for their members. To that end, ANTHEM BLUE CROSS has decided to limit our provider network to help better manage the network through improved oversight of quality, efficiency and access for our members. Therefore, in accordance with the Term and Termination Section, of your Medicare Advantage Attachment (Exhibit F) to the Prudent Buyer Plan Participating Physician Agreement, this letter serves to notify you that consistent with the terms of your agreement, ANTHEM BLUE CROSS is hereby providing you with the required notice of termination of your participation in the Medicare Advantage network. This means that as of JANUARY 31, 2014, you will be a nonparticipating provider in the Anthem Blue Cross Medicare Advantage network. Although we are terminating your participation in our Medicare Advantage network without cause as permitted by, and pursuant to, your Provider Agreement with us, CMS requires that we also provide you with the reason for the termination, apart from our contractual right to do so. In the context of our efforts to offer a more limited provider network, ANTHEM BLUE CROSS used the various criteria to decide which providers would be terminated from our Medicare Advantage network without cause. These criteria included member access to care, network composition, the volume of membership attributed to a provider, as well as the cost of care associated with a provider relative to other providers. In your case, your low volume of members served was the reason for our decision to terminate your participation in the Medicare Advantage network. If you would like more detail, please contact your Network Representative. Please understand that our decision to terminate your participation as a network provider is limited to Medicare Advantage networks and does not change your current participation status in Medicare Supplement or ANTHEM BLUE CROSS other provider network(s), including Medicaid and Commercial business networks. This decision is limited to Medicare Advantage networks and does not change your current participation status in any of ANTHEM BLUE CROSS other provider network(s) in which you currently participate. You may appeal this decision: Within 30 calendar days following the receipt of this letter, you may request an appeal of this decision by sending written notice to the address below. Please provide all supporting documentation at that time, but understand that your termination from the Medicare Advantage network is based on the provision in the Provider Agreement permitting termination without cause by either party. In addition, if you want to request a hearing as part of your appeal, please note that in your written notice. As stated above, such a request must be made within 30 calendar days following receipt of this notification.

2 GROUP PRACTICE VERSION <DATE> <Practice Name> <Address> <City, State Zip Code> RE: Medicare Advantage PPO participation Termination - Practice Name (Tax ID #: <TaxID>) Dear <Practice Name>: To meet the changing demands of the Medicare Advantage market and help ensure affordable benefits for our Medicare Advantage members, ANTHEM BLUE CROSS will begin offering a more limited provider network for our Medicare Advantage health plans in CMS regulations support Medicare Advantage plans ongoing evaluation of their provider networks to help ensure that plans are able to manage the cost and quality of care while maintaining appropriate access to care for their members. To that end, ANTHEM BLUE CROSS has decided to limit our provider network to help better manage the network through improved oversight of quality, efficiency and access for our members. Therefore, in accordance with the Term and Termination Section of your Medicare Advantage Attachment (Exhibit F) to the Prudent Buyer Plan Participating Physician Group Agreement, this letter serves to notify you that consistent with the terms of your agreement, ANTHEM BLUE CROSS is hereby providing you with the required notice of termination of your participation in the Medicare Advantage network. This means that as of JANUARY 31, 2014, you will be a non-participating provider in the Anthem Blue Cross Medicare Advantage network. Although we are terminating your participation in our Medicare Advantage network without cause as permitted by, and pursuant to, your Provider Agreement with us, CMS requires that we also provide you with the reason for the termination, apart from our contractual right to do so. In the context of our efforts to offer a more limited provider network, ANTHEM BLUE CROSS used the various criteria to decide which providers would be terminated from our Medicare Advantage network without cause. These criteria included member access to care, network composition, the volume of membership attributed to a provider, as well as the cost of care associated with a provider relative to other providers. In your case, your low volume of members served was the reason for our decision to terminate your participation in the Medicare Advantage network. If you would like more detail, please contact your Network Representative. Please understand that our decision to terminate your participation as a network provider is limited to Medicare Advantage networks and does not change your current participation status in Medicare Supplement or ANTHEM BLUE CROSS other provider network(s), including Medicaid and Commercial business networks. This decision is limited to Medicare Advantage networks and does not change your current participation status in any of ANTHEM BLUE CROSS other provider network(s) in which you currently participate. You may appeal this decision: Within 30 calendar days following the receipt of this letter, you may request an appeal of this decision by sending written notice to the address below. Please provide all supporting documentation at that time, but understand that your termination from the Medicare Advantage network is based on the provision in the Provider Agreement

3 permitting termination without cause by either party. In addition, if you want to request a hearing as part of your appeal, please note that in your written notice. As stated above, such a request must be made within 30 calendar days following receipt of this notification. If you wish to exercise your right to appeal, please mail your written request to: ANTHEM BLUE CROSS PO Box Nashville, TN If we do not receive any additional information from you within this 30-day period, your file will be closed. In accordance with CMS regulations Medicare Advantage members will be notified of the change in your Medicare Advantage participation status prior to January 31, If you have any questions or require additional information please contact our Network Relations staff -via at networkrelations@wellpoint.com or by phone at (Monday-Thursday 9-4 Pacific Time). Sincerely, Aldo De La Torre Vice President, Provider Engagement and Contracting

4 If you wish to exercise your right to appeal, please mail your written request to the following address: ANTHEM BLUE CROSS PO Box Nashville, TN If we do not receive any additional information from you within this 30-day period, your file will be closed. In accordance with CMS regulations Medicare Advantage members will be notified of the change in your Medicare Advantage participation status prior to January 31, If you have any questions or require additional information please contact our Network Relations staff -via at -or by phone at (Monday-Thursday 9-4 Pacific Time). Sincerely, Aldo De La Torre Vice President, Provider Engagement and Contracting

5 <date> INDIVIDUAL PRACTICE VERSION <Practice Name> <Address> <City, State Zip Code> RE: Medicare Advantage PPO participation Termination - Practice Name (Tax ID #: <TaxID>) Dear <Practice Name>: To meet the changing demands of the Medicare Advantage market and help ensure affordable benefits for our Medicare Advantage members, ANTHEM BLUE CROSS will begin offering a more limited provider network for our Medicare Advantage health plans in CMS regulations support Medicare Advantage plans ongoing evaluation of their provider networks to help ensure that plans are able to manage the cost and quality of care while maintaining appropriate access to care for their members. To that end, ANTHEM BLUE CROSS has decided to limit our provider network to help better manage the network through improved oversight of quality, efficiency and access for our members. Therefore, in accordance with the Term and Termination Section, of your Medicare Advantage Attachment (Exhibit F) to the Prudent Buyer Plan Participating Physician Agreement, this letter serves to notify you that consistent with the terms of your agreement, ANTHEM BLUE CROSS is hereby providing you with the required notice of termination of your participation in the Medicare Advantage network. This means that as of JANUARY 31, 2014, you will be a nonparticipating provider in the Anthem Blue Cross Medicare Advantage network. Although we are terminating your participation in our Medicare Advantage network without cause as permitted by, and pursuant to, your Provider Agreement with us, CMS requires that we also provide you with the reason for the termination, apart from our contractual right to do so. In the context of our efforts to offer a more limited provider network, ANTHEM BLUE CROSS used the various criteria to decide which providers would be terminated from our Medicare Advantage network without cause. These criteria included member access to care, network composition, the volume of membership attributed to a provider, as well as the cost of care associated with a provider relative to other providers. In your case, your higher cost of care relative to other network providers was the reason for our decision to terminate your participation in the Medicare Advantage network. The enclosed report provides additional details. If you would like more information, please contact your Network Representative. Please understand that our decision to terminate your participation as a network provider is limited to Medicare Advantage networks and does not change your current participation status in Medicare Supplement or ANTHEM BLUE CROSS s other provider network(s), including Medicaid and Commercial business networks. You may appeal this decision: Within 30 calendar days following the receipt of this letter, you may request an appeal of this decision by sending written notice to the address below. Please provide all supporting documentation at that time, but understand that your termination from the Medicare Advantage network is based on the provision in the Provider Agreement permitting termination without cause by either party. In addition, if you want to request a hearing as part of your appeal, please note that in your written notice. As stated above, such a request must be made within 30 calendar days following receipt of this notification. If you wish to exercise your right to appeal, please mail your written request to the following address:

6 Anthem Blue Cross PO Box Nashville, TN If we do not receive any additional information from you within this 30-day period, your file will be closed. In accordance with CMS regulations Medicare Advantage members will be notified of the change in your Medicare Advantage participation status prior to January 31, If you have any questions or require additional information please contact our Network Relations staff -via at or by phone at (Monday-Thursday 9-4 Pacific Time). Sincerely, Aldo De La Torre Vice President, Provider Engagement and Contracting, West Region

7 GROUP PRACTICE VERSION <Date> <Practice Name> <Address> <City, State Zip Code> RE: Medicare Advantage PPO participation Termination - Practice Name (Tax ID #: <TaxID>) Dear <Practice Name>: To meet the changing demands of the Medicare Advantage market and help ensure affordable benefits for our Medicare Advantage members, ANTHEM BLUE CROSS will begin offering a more limited provider network for our Medicare Advantage health plans in CMS regulations support Medicare Advantage plans ongoing evaluation of their provider networks to help ensure that plans are able to manage the cost and quality of care while maintaining appropriate access to care for their members. To that end, ANTHEM BLUE CROSS has decided to limit our provider network to help better manage the network through improved oversight of quality, efficiency and access for our members. Therefore, in accordance with the Term and Termination Section of your Medicare Advantage Attachment (Exhibit F) to the Prudent Buyer Plan Participating Physician Group Agreement, this letter serves to notify you that consistent with the terms of your agreement, ANTHEM BLUE CROSS is hereby providing you with the required notice of termination of your participation in the Medicare Advantage network. This means that as of JANUARY 31, 2014, you will be a non-participating provider in the Anthem Blue Cross Medicare Advantage network. Although we are terminating your participation in our Medicare Advantage network without cause as permitted by, and pursuant to, your Provider Agreement with us, CMS requires that we also provide you with the reason for the termination, apart from our contractual right to do so. In the context of our efforts to offer a more limited provider network, ANTHEM BLUE CROSS used the various criteria to decide which providers would be terminated from our Medicare Advantage network without cause. These criteria included member access to care, network composition, the volume of membership attributed to a provider, as well as the cost of care associated with a provider relative to other providers. In your case, your higher cost of care relative to other network providers was the reason for our decision to terminate your participation in the Medicare Advantage network. The enclosed report provides additional details. If you would like more information, please contact your Network Representative. Please understand that our decision to terminate your participation as a network provider is limited to Medicare Advantage networks and does not change your current participation status in Medicare Supplement or ANTHEM BLUE CROSS s other provider network(s), including Medicaid and Commercial business networks. You may appeal this decision: Within 30 calendar days following the receipt of this letter, you may request an appeal of this decision by sending written notice to the address below. Please provide all supporting documentation at that time, but understand that your termination from the Medicare Advantage network is based on the provision in the Provider Agreement permitting termination without cause by either party. In addition, if you want to request a hearing as part of your appeal, please note that in your written notice. As stated above, such a request must be made within 30 calendar days following receipt of this notification.

8 If you wish to exercise your right to appeal, please mail your written request to the following address: Anthem Blue Cross PO Box Nashville, TN If we do not receive any additional information from you within this 30-day period, your file will be closed. In accordance with CMS regulations Medicare Advantage members will be notified of the change in your Medicare Advantage participation status prior to January 31, If you have any questions or require additional information please contact our Network Relations staff -via at -or by phone at (Monday-Thursday 9-4 Pacific Time). Sincerely, Aldo De La Torre Vice President, Provider Engagement and Contracting, West Region

9 ETG definitions The following definitions may be helpful as you review your report. EPISODE TREATMENT GROUP or ETG ETG is an industry standard grouping methodology that enhances raw data by grouping it into case-mix adjusted ETG categories. The ETG evaluates the diagnosis and procedure codes in each patient s data and groups those data into episodes of care. The ETG assigns a disease classification to each episode based on the underlying medical condition and any modifiers of that disease, such as relevant co-morbid conditions. EPISODE SEVERITY - describes how severe a member s condition is, and plays an important role in understanding cost and services rendered within an episode. Beyond the ETG number, complications, comorbidities, and member demographics are used to determine the severity of the member s condition. The ETG methodology takes advantage of the relevant complication and comorbidity factors (indicating a sicker member who may require more extensive treatment for a related condition) when determining an episode s severity. The result is a severity score and severity level for episodes. Typically, the higher the severity score, the more severe that condition is than for other members with a lower severity score for the same condition. RESPONSIBLE PROVIDER - Responsible provider for an episode is the provider who is primarily accountable for the episode. This provider gets credit for the episode s cost and utilization within analysis. Based on this premise, ETG determines episode responsibility based on providers who have a visit with the member. Only one provider is deemed the responsible provider for the episode. The determination of responsible provider for an episode is based on which provider has the highest combined charges for management and surgery records (i.e. anchor records) in the episode. If this results in more than one choice, the responsibility is given to the provider with the earliest claim record. The assignment of a responsible provider may not always be a clinician. For instance, if a facility provider submits a claim for CPT-4 code (Emergency department visit for E&M), ETG assigns it a record type value of M (management). If this is the only anchor record within the episode, this facility provider is assigned as the responsible provider. EPISODE VOLUME (Vol) Volume represents the total number of ETGs for a provider or a provider group. ALLOWED AMOUNT (Total $ Allowed) is the total contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. EXPECTED ALLOWED AMOUNT is the total expected dollar amount for the specialty peer average within an ETG and then summarized for the Tax/Specialty ALLOWED/EPISODE This is a calculation (Total Allowed amount / Total Episode Volume)

10 EXPECTED ALLOWED/EPISODE This calculation (peer allowed amount for that ETG makeup/volume of the peer ETG makeup.) EFFICIENCY PERFORMANCE RATIO: (Weight Mean ETG Index) A performance index is a ratio of actual weighted average episode costs to the same casemix and same specialty expected costs. Expected costs are defined by the specialty peer average within an ETG. Actual costs are then compared to the specialty peer average costs to calculate a performance index. CONFIDENCE INTERVAL Due to underlying variability and low episode volume the calculated performance index is not precise. The statistical confidence interval is calculated for this index, and it shows the level of uncertainty associated with the estimate. For example, for a 90% confidence interval, we have 90% confidence that the true index value lies between the lower and upper confidence intervals. MANAGEMENT A claim record submitted by a clinician for services related to the evaluation of a member's condition.

11 Dear Provider, The following information describes the methodology used to determine participation status in the Medicare Advantage network. Episode of Care Methodology Analysis was performed using an Episode of Care methodology. The methodology relies on an Episode Treatment Group patient classification system that encompasses all costs of care, including professional, institutional inpatient, institutional outpatient, ancillary and pharmacy. Each identified episode of care was risk adjusted based on the patients associated risk score. Differences in patient age, condition, comorbities and treatments are accounted for in developing the score. The calculated cost for each episode of care was then compared to the calculated Expected Episode Cost, which was derived based on network averages, to arrive at a performance ratio. These norms were calculated separately by medical specialty and by region; comparisons were made within a physician s specialty peer group to recognize the inherent differences in treatment patterns, even when caring for similar patients, across specialties. The physician s specialty was determined at the individual physician level. The performance ratio of each group member was used to determine participation in the network This diagram illustrates the ETG Analysis Process Calculate the 90% confidence level for the weighted mean index ETG Grouper Identifies usable episodes Adjusts Episodes for Homogeneity in Norm Setting Adjusts paid amounts for Chronic incomplete so all paid amounts reflect the same time period Combines ETG Base with Severity Levels Produces Normalized ETG s Aggregate the physician results Compare the Physicians actual costs to the Expected Calculate Norms for ETG s Within each specialty and then for each physician calculate the average cost/etg

12 The enclosed report describes your results against the above stated methodology. If you have any questions or require additional information please contact our Network Relations staff -via at -or by phone at (Monday-Thursday 9-4 Pacific Time). Sincerely,

Frequently Asked Questions (FAQ) The Harvard Pilgrim Independence Plan SM

Frequently Asked Questions (FAQ) The Harvard Pilgrim Independence Plan SM Plan Year: July 2010 June 2011 Background The Harvard Pilgrim Independence Plan was developed in 2006 for the Commonwealth of Massachusetts