Arise Health Plan Provider Manual

Transcription

1 Arise Health Plan Provider Manual 2018

2 TABLE OF CONTENTS Table of Contents...2 Welcome...3 About Us and Our History...4 Our Service Area...5 Contact Arise Product Overview...8 Member Identification (ID) Cards...9 Primary Care Access Model...9 Appointment Scheduling Guidelines...10 Medical Record Requirements...11 Overview of Integrated Care Management (ICM) Integrated Care Management Program...14 Integrated Care Management Definitions Prior Authorization...17 iexchange Web Portal...18 Paper Submissions...18 Prior Authorization and Referral Request Form...19 Prior Authorization Determination Prior Authorization Special Programs Concurrent Review Decisions Post-Service Determination Case Management Behavioral Health Care Management Chiropractic Care Management Pharmacy Management Drug Prior Authorization Technology and Incentives Resources/Tools Medical Policy Guidelines Quality Improvement Program Emergency/Urgent Care Member Rights and Responsibilities Member Grievance Procedures Claim Payment Policies Provider Credentialing, Re-Credentialing, and Updates Continuity of Care Provider Contracting Arise Health Plan Provider Directory

3 WELCOME Arise Health Plan welcomes you as a partner The Arise Health Plan Provider Manual is designed specifically for Arise Health Plan providers. It is supplied to you by Arise Health Plan (Arise) to promote a clear understanding of our policies and procedures, including provider services, prior authorization, claims, and eligibility. This manual should be used as a reference guide. Its purpose is to answer some of the questions you may have regarding Arise operations. As changes evolve, this manual is revised on a routine basis. Arise reserves the right to revise or alter the material and information detailed in this manual. When accessing the Provider Manual, please refer to our website, arisehealthplan.com, for the most current information. 3 Arise Health Plan Provider Directory

4 ABOUT US AND OUR HISTORY Arise was created in 2005 when WPS Health Solutions purchased the assets of Prevea Health Plan and formed a new, wholly owned subsidiary: WPS Health Plan, Inc. In late 2006, the plan was named Arise Health Plan. This acquisition allowed Arise to continue its tradition of Wisconsin-based service, thanks to new resources, technologies, and the expertise to introduce innovative health plan products. Arise provides businesses and their employees insurance options to fit their needs and accessible, local service delivered without compromise. Arise offers Health Maintenance Organization (HMO) and Point-of-Service (POS) health plans to group and individual markets throughout northeast Wisconsin. Group health plans are also available to encourage employees to live healthier lifestyles. The National Committee for Quality Assurance (NCQA) awarded Arise an accreditation status of Commendable. Our accreditation status was awarded after an evaluation of all aspects of our plan, including preventive health services, satisfaction, physician credentialing, and quality improvement. Founded in 1946, WPS Health Solutions is a leading Wisconsin not-for-profit health insurer, offering affordable individual health insurance, family health insurance, and high-deductible health plans, as well as flexible and affordable group health plans and cost-effective benefit plan administration for businesses. 4 Arise Health Plan Provider Directory

5 OUR SERVICE AREA Throughout eastern Wisconsin, Arise offers comprehensive and affordable health plans with a service area that covers most of the state. We understand how important it is for our members to have access to great doctors. That s why our members get access to top-quality providers with a full range of health care services, striking a balance between choice and cost. To ensure our members get the best quality and value, we ve selected providers with a strong commitment to health and wellness. Not all providers in our service area are participating. We include major providers in more than 50 Wisconsin counties. To see which networks and providers are included, please search our online provider directory. Visit arisehealthplan.com, click on Visitors, and then select Find a Doctor. The following is a county map of the Arise Health Plan service area. 5 Arise Health Plan Provider Directory

6 CONTACT ARISE Website arisehealthplan.com Provider Member Services Phone Fax Hours Monday through Friday, 7:30 a.m. 5 p.m., CT Contact Provider Services for: Coverage verification Provider verification Questions regarding claim processing or payment Benefit and policy determination Claims Filing Address: Arise Health Plan P.O. Box Eagan, MN Claim Correspondence Address (Questions on claim processing or payment): Arise Health Plan P.O. Box Green Bay, WI Electronic Data Interchange (EDI) Help Desk Toll-Free , Option 1 edi@wpsic.com Web wpsic.com/edi/index.shtml Hours Monday through Friday, 7:55 a.m. to 4:30 p.m. CT Contact the EDI Help Desk for: Questions about online registration How to log in Missing files Other technical concerns Integrated Care Management Phone Fax Contact Integrated Care Management for: Prior authorization Status of an authorization 6 Arise Health Plan Provider Directory

7 Network Management Phone or , ext Fax Call Network Management for: Provider additions, terminations, and changes Fee schedule questions Assistance with provider issues Provider directory/website listings Provider Relations Fax Contact the Provider Relations team for: Fee schedule inquiries Provider contracts Reimbursement policies Northwestern/North-Central Wisconsin Stacy Willems, Provider Network Coordinator Janis Roesslein, Provider Relations Director Northeastern Wisconsin Jessie Evans, Provider Network Coordinator Amy Anderson, Provider Relations Director Southwestern/South-Central Wisconsin Lori Olivares, Provider Network Coordinator Jayne Thompson, Health Plan Manager Southeastern Wisconsin Jessie Evans, Provider Network Coordinator Amy Anderson, Provider Relations Director Provider Credentialing Credentialing Manager Senior Credentialing Specialist Phone or , ext Fax or Contact Provider Credentialing with questions concerning: Initial credentialing Re-credentialing 7 Arise Health Plan Provider Directory

8 PRODUCT OVERVIEW Arise offers a broad range of insurance and employee benefit products to meet the needs of our group and individual customers, from traditional Health Maintenance Organization (HMO) and Point-of-Service (POS) plans to self-funded administration and consumer-driven options. Individual and Family Plans Available plan options include HMO plans with great value and POS plans that give you more choices, as well as consumer-driven qualified high-deductible health plans (HDHPs) that can be paired with a Health Savings Account (HSA). Small Group Plans Arise offers carefully designed small group health plans to employers with 2 50 employees. Plan options include HMO plans with great value and POS plans that give you more choices, as well as consumer-driven qualified highdeductible health plans (HDHPs) that can be paired with a Health Savings Account (HSA). Large Group Plans Arise offers a variety of large group health plans to employers with 51 or more employees. Plan options include HMO plans with great value and POS plans that give you more choices, as well as consumer-driven qualified highdeductible health plans (HDHPs) that can be paired with a Health Savings Account (HSA). Plan features include $0 copay, deductible, or coinsurance on preventive care; $0 copay on select preventive drugs that target common conditions, such as high blood pressure, cholesterol, heart conditions, and asthma; fitness program reimbursement; and lower copays at convenient care clinics, depending on plan. Self-funded Group Plans/Administrative Services Only (ASO) Arise Administrators Arise contracts with employers or other group entities to administer self-funded health plans under an ASO arrangement. This self-funded business is administered under the name Arise Administrators. An employer can hire a third party, like Arise Administrators, to deliver employee benefit claim administrative services for the employer. These services typically include health claims processing, billing, and Integrated Care Management. The employer bears the risk for health care expenses under a self-funded plan. What does this mean for our contracted providers? ID cards for this business will use Arise Administrators name and logo. Claims can be remitted to the same address used for Arise. For plans administered under a self-funded arrangement, no withholding will be taken if your contract includes withhold language. 8 Arise Health Plan Provider Directory

9 MEMBER IDENTIFICATION (ID) CARDS Arise members receive ID cards containing information needed by providers to check eligibility and benefits, as well as submit claims. The ID card includes the member name, member ID number, the group number, and Arise contact information. Arise member ID numbers are randomly generated. PRIMARY CARE ACCESS MODEL Primary Care Practitioners (PCP) are the core of Arise Health Plan. The objective of our Primary Care Access Model is to guide members into an ongoing relationship with a PCP. The PCP is the provider responsible for coordinating the medical care for each member. We define PCPs as: Family practice General practice Internal medicine Obstetrics/gynecology Pediatrics We believe this PCP model provides members with medical services within a time frame that allows safe treatment of emergency and urgent conditions and maintains effective preventive health care practices. A list of PCPs is available for members on our website at arisehealthplan.com or in our provider directory. It is important for members to always identify themselves as Arise members whenever they make an appointment with a provider. Arise members have reasonable access to care and services within the Arise service area with respect to geographic location, hours of operation, and waiting times. Arise contracts with a sufficient number of PCPs, specialists, and other health care providers who are in the geographic service area to meet the medical needs of our plan members. 9 Arise Health Plan Provider Directory

10 APPOINTMENT SCHEDULING GUIDELINES Member requests appointment for care. Clinic receptionist, nurse, or specified person determines type of care (if unable to determine type of care or patient/ member has additional concerns, the situation is referred to the nurse or physician). Preventive Care: Involves asymptomatic patient/member; visit is for wellness, annual exam, scheduled immunization, or other non-illness/injury-related issue. Routine Problem: Involves patient/member with stable, non-urgent symptoms or conditions that: are not likely to change in the next 48 hours; do not cause concern about an illness or injury; do not interfere with normal daily activities. Urgent Problem: Involves patient/member with active symptoms or conditions that: are likely to escalate in the next 48 hours; cause concern about an illness or injury; interfere with normal daily activities. Emergent Problem: Involves severe active symptoms or conditions that are life-threatening; will become life-threatening if not treated; require medical care immediately or within the next two hours. Clinic receptionist schedules appointment and strives to meet the following standards: Type of Medical Care Appointment Max. Time from Patient Request to Appointment Date Preventive Care Routine Problem Urgent Problem Emergent Problem 30 days 7 days Same-day access Immediate access Type of Behavioral Care Appointment Max. Time from Patient Request to Appointment Date Routine Care Urgent Care Non-Life-Threatening Emergency 30 days 7 days 6 hours A consult is an appointment made at the request of the PCP. The clinic schedules a consult appointment based on the same guidelines set forth for Preventive Care, Routine Problem, and Urgent Problem, as defined above. If the PCP or consulting physician cannot see the patient within the time frame indicated by the clinic and Arise guidelines, an appointment will be offered with an alternate physician/same site or, if unavailable, with an alternate physician/different Arise site. The patient may decline the alternate arrangement and accept a delayed appointment with the PCP. 10 Arise Health Plan Provider Directory

11 MEDICAL RECORD REQUIREMENTS Arise has adopted the NCQA (National Committee for Quality Assurance) medical record documentation guidelines, which are designed to provide consistent, current, and complete information regarding the care of our members. The medical record documentation guidelines include the following requirements: Patient s name or ID number on each page. Patient s demographic information to include the home address, primary and secondary phone numbers, and employer and marital statuses. A problem list to indicate significant illnesses/medical conditions. Documentation of any known anaphylactic reaction and allergic trigger. All medication allergies and adverse reactions or documentation of no known allergies. A medication list. An immunization record if primary care. A patient history record to include medical history, surgical history, and social history. An organized medical recordkeeping system as evidenced by easily identifiable, retrievable, individualized records. All entries must be dated and contain the author s identification. Author s identification may be a handwritten signature, unique electronic identifier, or initials. Documentation of clinical findings and evaluation for each visit. Working diagnoses are consistent with findings. Treatment plans are consistent with diagnoses. No evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure. A written medical record policy that addresses the ease of retrieval, timeliness of completion, and release and retention of medical records. To protect the confidentiality of medical records and guard against unauthorized disclosure of patient information, provider practices will have written policies/procedures that address confidentiality and storage of medical records in an area not accessible to the public. Information filed in medical records includes, but is not limited to: All services provided directly by a PCP. All ancillary services and diagnostic tests ordered by a practitioner. All diagnostic and therapeutic services for which a member has been referred by a practitioner, such as: Home health nursing reports Specialist reports Hospital discharge reports Physical therapy reports The Arise performance goal for participating practitioners and physicians is %. 11 Arise Health Plan Provider Directory

12 OVERVIEW OF INTEGRATED CARE MANAGEMENT (ICM) The design of the Integrated Care Management (ICM) Program is to monitor the appropriateness, medical necessity, and benefit coverage for services, concurrent review, and post-service care delivered to Arise members. The Arise ICM team collaborated with contracted health care providers to develop the ICM Program. The strategy of our ICM Program is to promote optimal practice while accounting for the structure of local delivery systems. All components of the program comply with federal and state regulations and strive to meet the nationally recognized utilization standards of the National Committee for Quality Assurance (NCQA). The program design is to make utilization decisions affecting the health care of members in a fair, impartial, and consistent manner. The ICM Program provides a systematic method to manage member utilization of services. The management of services focuses on the ongoing monitoring and evaluation of medical necessity, appropriateness of level of care, place of service, and availability of resources and benefits, while ensuring confidentiality of personal health information for all members. The main goals of the ICM Program are to ensure all members receive the right care, at the right time, in the right place and to reduce the amount of low-value and unproven care, thereby being a wise steward of limited resources. The Arise Medical Affairs Department is staffed by RN Integrated Care Managers, Pharmacists, Behavioral Health Care Specialists, Physician Medical Directors, and other non-licensed support personnel who are available to assist our network physicians with ICM issues and questions. Objectives 1. Provide a structured process to continually monitor and evaluate the delivery of health care and services to our members by: Establishing system-wide health management processes across the continuum of care. Providing access to high quality, medically necessary health care services in the most appropriate and costeffective setting. Ensuring effective and efficient utilization of health care services and benefits through appropriate allocation of resources and services in the inpatient, outpatient, and rehabilitative settings. Ensuring health care services are coordinated, timely, medically effective, and efficient. Establishing a process for provider feedback regarding utilization and the ICM program. Monitoring indicators to detect possible under- and over-utilization. Auditing denial decision timeliness and consistency. Conducting inter-rater reliability audits of all Arise Integrated Care Managers (utilization management nurses) and Medical Directors. 2. Improve clinical outcomes via: System-wide collaboration to identify, develop, and implement clinical practice guidelines and programs that address key health care needs of the members. Implementation of clear, consistent ICM requirements and key indicators of success. Facilitation and coordination of health care services for members in need of acute and chronic health care services, and facilitation of communication with providers to support appropriate utilization of health care benefits. Implementation of behavioral health care management processes. Development of mechanisms to measure and implement actions to improve under- and over-utilization of services. Collaboration among the Quality Improvement (QI) Committee/Department, Medical Director, Director, and ICM Manager to assess and implement actions to improve continuity and coordination of care. Data and support to identify areas of improvement, establish priorities, and assist with interventions for service, adverse events, and quality-of-care concerns with the QI department. 12 Arise Health Plan Provider Directory

13 3. Improve practitioner and member satisfaction by: Assessing practitioner and member satisfaction with ICM policies and procedures. Promoting appropriate use of Arise resources through efficiency of service. Educating providers and members regarding ICM goals, regulatory standards, criteria used for review, and processes for providing cost-effective and quality care. Incorporating Arise providers input into the ongoing development and implementation of ICM program components. 4. Meet or exceed established quality standards by: Complying with NCQA standards for the accreditation of Managed Care Organizations. Measuring program performance in accordance with the Health Care Effectiveness Data and Information Set (HEDIS) specifications. Meeting all appropriate regulatory requirements. Ensuring consistency in ICM decision-making. Rendering timely ICM determinations and issuing timely notifications of decisions. The scope of the ICM Program consists of the following components: Affirmative statement on incentives Behavioral health care management program Chiropractic care management program Complex case management program Concurrent review decisions Emergency services Grievances and appeals Health care informatics Health management program for chronic conditions Pharmacy and specialty drug management program Post-service review decisions Primary care model of care Prior authorization (PA) determination for medical services Radiology benefit management program Reporting Satisfaction with the utilization management (UM) process Technology assessment The following resources and tools support the ICM Program: Clinical experts Clinical practice guidelines Conference/seminars Definitions from the Certificate of Coverage External review Literature Nationally published utilization management criteria Policies and procedures The ICM Department collects data on practitioner satisfaction with the UM process and reports this information to the Quality Improvement (QI) Committee for review and action, as the committee deems necessary. 13 Arise Health Plan Provider Directory

14 INTEGRATED CARE MANAGEMENT PROGRAM Arise operates under a Primary Care Access model. The Primary Care Access Model provides high-quality health care by increasing opportunities for continuity of care; coordinating care among multiple providers; and effectively using the services of Primary Care Practitioners (PCPs), specialty physicians, and other providers. Arise members must select a PCP upon enrollment in the health plan. PCPs include the following specialties: family practice, pediatrics, general practice, internal medicine, or obstetrics/gynecology. Members have direct access to participating plan PCPs and specialists. Specialists may refer to another specialist upon concurrence with the member s PCP. It is the member s responsibility to have the PCP or specialist submit a written prior authorization request to Arise for all nonparticipating practitioners and tertiary care specialists/facilities. Specialists who have a prior authorization approval to see a member are accountable to communicate the results of the consultation and recommended treatment to the member s PCP. The PCP is responsible to assess, direct, and coordinate the member s need for specialty care. The ICM Department maintains the ICM Program and reviews and/or revises the ICM Program annually with final approval from the QI Committee. The Medical Director is responsible for the key aspects of the ICM Program. This includes setting policies, reviewing cases as needed, and participating on a variety of ICM Committees, including the Medical Policy Committee and Credentialing Committee, and the QI Committee as committee chair. The Medical Director oversees the prior authorization, concurrent review, and post-service review programs; complex case management; health management for chronic conditions; and the pharmacy management program. The Medical Directors are responsible for all medical necessity, experimental, and investigational denial decisions for inpatient, concurrent, pre-service, and post-service care. The Medical Directors also provide peer-to-peer consultations with external physicians who provide care to our members. The Medical Directors may consult with an appropriate board-certified specialist if a medical necessity review is outside of the Medical Directors scope of expertise. ICM activities and initiatives are coordinated within the framework of the QI Program. Arise has a participating behavioral health care practitioner involved in the behavioral health care program in conjunction with the Medical Directors. That role oversees and provides professional expertise for continual improvement of the behavioral health care program. The Medical Directors consult with this practitioner regarding behavioral health care issues/reviews as needed. The Arise Medical Affairs Department is staffed by Medical Directors, behavioral health care specialists, pharmacists, RN Integrated Care Managers, and other non-clinical support staff who are available to assist our network providers with ICM issues and questions. Integrated Care Management Confidentiality Member health information that is identifiable, including medical records, claims, benefits, and administrative data, obtained in connection with the performance of duties in utilization management, shall not be revealed or disclosed in any manner or under any circumstance, except to a member s attending physician. Information required to study and evaluate the quality of care and/or policies or services focused on members shall be available only to the persons directly involved in presenting, reviewing, evaluating, or acting upon the information. Program descriptions, manuals, forms, and all related documentation are proprietary business information and are treated as confidential. 14 Arise Health Plan Provider Directory

15 INTEGRATED CARE MANAGEMENT DEFINITIONS Many of the definitions below are derived from Arise member certificates, which may vary depending on the type of plan the member purchased. Concurrent Review: A request for coverage of medical care or services made while a member is in the process of receiving the requested medical care or services, even if Arise did not previously approve the initial care. Experimental or Investigational/Unproven: Any health care service, treatment, supply, or facility that meets at least one of the following: Is not currently recognized as accepted medical practice as determined by our Medical or Chiropractic Director. Is not recognized as accepted medical practice at the time the charges were incurred, as determined by our Medical or Chiropractic Director. Has not been approved by the United States Food and Drug Administration upon completion of Phase III clinical investigation. Is used in a way that is not approved by the United States Food and Drug Administration (FDA) or listed in the FDA-approved labeling, except for off-label uses that are accepted medical practice. Has not successfully completed all phases of clinical trials, unless required by law. Is a treatment protocol based upon, or similar to, those used in ongoing clinical trials. Prevailing peer-reviewed medical literature in the United States has failed to demonstrate that the treatment is safe and effective for the condition. There is not enough scientific evidence to demonstrate or make a convincing argument that (a) it can measure or alter the sought-after changes to the illness or injury or (b) such measurement or alteration will affect the health outcome; or support conclusions concerning the effect of the drug, device, procedure, service, or treatment on health outcomes. Is associated with Category III CPT code developed by the American Medical Association. A service, supply, treatment, or facility may be considered experimental, investigational, unproven, and not medically necessary even if the provider/practitioner performed, prescribed, recommended, ordered, or approved it, or if it is the only available procedure or treatment for the condition. We have full discretionary authority to determine whether a health care service is experimental/investigational/ unproven. In any dispute arising because of our determination, such determination will be upheld if the decision is based on any credible evidence. If our decision is reversed, the only remedy will be our provision of benefits in accordance with the member s policy. The member will not be entitled to receive any compensatory, punitive damages, attorney s fees, or any other costs in connection therewith or as a consequence thereof. References used in the evaluation include, but are not limited to, Medical Affairs Medical Policy, MCG Health, Hayes, The American Cancer Society, The American Medical Association, FDA, U.S. Department of Health & Human Services (i.e., CMS), National Library of Medicine Search, National Institutes of Health, PubMed (Medicine), Cochrane Library, National Comprehensive Cancer Network (NCCN), National Guidelines Clearinghouse, National Cancer Network, Recommendations of the U.S. Preventive Services Task Force (USPSTF), and/or Specialty Society guidelines and standards (e.g., The American Academy of Pediatrics, American Colleges Physicians), and review of information from appropriate government regulatory bodies. Medically Necessary: A health care service, treatment, supply, or facility that Arise determines to be: Consistent with and appropriate for the diagnosis or treatment of the member s illness or injury. Commonly and customarily recognized and generally accepted by the medical profession in the United States as appropriate and standard care for the condition being evaluated or treated. Substantiated by clinical documentation. The most appropriate and cost-effective care that can be safely provided to the member. Appropriate and costeffective does not necessarily mean the least expensive. Proven to be useful, or likely to be successful, yield additional information, or improve clinical outcome. Not primarily for the convenience or preference of the covered person, his or her family, or any health care provider. 15 Arise Health Plan Provider Directory

16 A health care service, supply, treatment or facility may be considered not medically necessary, even if the provider or practitioner performed, prescribed, recommended, ordered or approved the service, or if the service is the only available procedure or treatment for the condition. As defined by NCQA, Integrated Care Management uses the following definitions to assist in making authorization decisions. Non-Urgent Request: A request for medical care or services for which application of the time period for making a decision does not jeopardize the life or health of the member or the member s ability to regain maximum function and would not subject the member to severe pain. Prior Authorization Request: Also referred to as prospective or pre-service review. This is a request for coverage of medical care or services that Arise must approve, in whole or in part, prior to the member obtaining that medical care service. Post-Service Request: Also referred to as a retrospective request. This is a request for coverage of medical care or services that were already rendered to the member. Urgent Request: A request for medical care or services where application of the time frame for making routine or non-life-threatening care determinations could seriously jeopardize the life, health, or safety of the member or others, due to the member s psychological state, or in the opinion of a practitioner with knowledge of the member s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request. 16 Arise Health Plan Provider Directory

17 PRIOR AUTHORIZATION What is a prior authorization? Prior authorization is the process of receiving written approval from Arise for services or products prior to being rendered. The provider requests and submits the prior authorization. Services are still subject to all plan provisions including, but not limited to, medical necessity and plan exclusions. When is prior authorization needed? Prior authorization is required for specialized services under our HMO and POS health plans. Please refer to arisehealthplan.com for the Prior Authorization List to verify prior authorization requirements. Prior authorization is also required under our HMO plans when members are seeking care from or being referred to non-participating providers and tertiary care specialists/facilities. A prior authorization is not required for: Services performed by a participating provider, including a participating provider who specializes in obstetrics or gynecology, except for those services listed on the prior authorization list located on arisehealthplan.com. Emergency care or urgent care at an emergency or urgent care facility Covered radiologist, pathologist, and anesthesiologist services at a participating facility Prior authorization process: Based on the medical complexity of services, we expect participating providers to follow prior authorization guidelines. We encourage members to verify prior authorization is requested by their provider and approved by Arise. Providers should verify member eligibility and benefits through the Provider Portal or by calling Member Services at Providers should enter the prior authorization request, along with clinical information, in iexchange or via fax. Members should review their health plan for specific authorization requirements, excluded services/treatments, and referral requirements. Services that are exclusions of the member s health plan or listed on the Non-Covered Services and Procedures Medical Policy are not typically prior authorized. Services on this list are not covered so we don t advise providers to submit prior authorization. Prior authorization is required for most inpatient admissions: Different standards apply depending on whether the admission is elective or acute. Elective admissions: Providers must submit a prior authorization request a minimum of three days prior to an elective (non-emergency) hospital admission or admission to a residential treatment program for treatment of alcoholism, drug abuse, or nervous or mental disorders. Acute admissions: The facility must notify Arise within two days of an acute (direct or emergency) admission. Notification may be provided in writing or by calling the phone number located on the member ID card or by calling Member Services. Providers should submit clinical information to support the admission. Information requested for concurrent review should be sent within 24 hours of our request. Inpatient admissions include a member s admission to: Inpatient hospital Hospice inpatient facility Inpatient rehabilitation facility Skilled nursing facility, when Medicare is not primary Inpatient and residential facility for Behavioral Health Services 17 Arise Health Plan Provider Directory

18 iexchange WEB PORTAL iexchange is a web-based tool offered by Arise that allows clinical staff to electronically submit prior authorization requests for inpatient and outpatient services to Arise via the internet in a secure environment. We strongly recommend providers submit prior authorization requests via the secure iexchange web portal. We offer telephonic training to assist your staff so they can be prepared for future submissions of cases. Benefits of iexchange Direct electronic submission Immediate feedback from Arise Assignment of a Case ID number Monitoring the status of the request Communication with Arise staff through iexchange Alerts when the case is updated Ability to electronically attach medical records to iexchange Printable requests/approvals for the provider By giving providers access to the iexchange web portal, we hope to improve communication and collaboration with our provider community, recognizing that your patients are our members. Enroll in iexchange To begin using the iexchange web portal, please request access using one of the following methods: Online: Phone: Register on our iexchange web page iexchange@wpsic.com and ask to speak with an iexchange representative To learn more about iexchange and request passwords or training, visit the iexchange web page at wpsic.com/arise/iexchange/index.shtml PAPER SUBMISSIONS A printable Prior Authorization Form can be found by visiting arisehealthplan.com, clicking on Providers, and then Prior Auth. Complete the form in its entirety and submit to the address or fax number listed on the form. The Prior Authorization Form is provided in this manual for your reference. You may request additional paper copies from the Member Services team at: Arise Health Plan P.O. Box Green Bay, WI Phone: Fax: Arise Health Plan Provider Directory

19 Arise Health Plan Prior Authorization and Referral Request Form You may submit this request electronically via iexchange: Auth Referral Fax Completed Form and applicable supporting clinicals to: Mail Completed Form to: Arise Health Plan P.O. Box 11625, Green Bay, WI Phone: ; PATIENT INFORMATION First Name: Last Name: Date of Birth: Subscriber Number: Date of Request / / Start Date of Service / / Authorizing/Ordering Provider: PRIOR AUTHORIZATION INFORMATION TIN: Clinic Contact: NPI: Phone Number: Site/Location: Fax: Referred To: Clinic Contact: TIN: Phone Number: Site/Location: Comments: (Indications for treatment) NPI: Site/Location: Fax: Authorizing/Ordering Provider: REFERRAL INFORMATION Clinic Contact: TIN: NPI: Phone Number: Patient s Request MD Preference Unavailable In Network Health Plan Requirement Servicing Provider: TIN: Clinic Contact: Phone Number: NPI: Site/Location: Fax: Site/Location: Comments: (Indications for referral to specialist) Site/Location: Fax: SERVICES REQUESTED (Supporting clinical documentation must accompany this request) Consult Only Follow-up DME Lab / X-Ray Home Care Hospice Skilled Nursing Surgery: Inpatient Outpatient Other Primary Diagnosis Code: Description: Procedure/HCPCS Code(s): Description: Workers Compensation Motor Vehicle Accident/Subro Other Coverage Attach Applicable Office Notes and Diagnostic Testing Results For This Request Yes Yes Yes No No No Date of Injury / Loss / / Date of Injury / Loss / / Insurance Company NOTE: The prior authorization of any procedure does not guarantee benefits or payment. Approval is based on medical necessity as defined in the patient s benefit plan or certificate. All benefits are subject to the term, conditions, and exclusions of the benefit plan or certificate. This may include policy language regarding pre-existing conditions or signed affidavits stating that the insurance bears no responsibility, as signed by the insured. Policy exclusions for certain types of services may also apply. Verify prior authorization requirements. For additional benefit information, please contact Arise Health Plan at A release of information form included in the application for insurance was signed by our member WPS Health Plan, Inc. All rights reserved JO Arise Health Plan Provider Directory

20 PRIOR AUTHORIZATION DETERMINATION The Integrated Care Management (ICM) Program requires prior authorization (PA) for all services referred to inpatient facilities (including rehabilitation and skilled nursing facilities), non-participating practitioners/providers, tertiary care specialist/facility and providers, and for other select services. We review these services for member eligibility, medical necessity, potential redirection to an appropriate participating practitioner/provider, benefit coverage, and/or coordination of care/services. Utilization management (UM) decision making is based only on appropriateness of care and service and existence of coverage. Arise does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. REVIEW PROCESS Providers submit requests online through iexchange (preferred method) or via fax, phone, or mail. The ICM team obtains all data and relevant information, including, but not limited to, medical records and communications with practitioners or other consultants. We use UM criteria to review relevant information as described in the resources/tools section. We review inpatient facility care, such as observation, acute, rehabilitation, and/or skilled nursing care, prior to or within 24 business hours of admission, then concurrently according to accepted criteria and guidelines. We provide non-urgent PA approval determinations to practitioners and members via verbal, written, or electronic notification within 15 calendar days of the request. We provide non-urgent PA denial determinations within 15 calendar days of the request via written or electronic notification. We provide urgent PA approval determinations and denial determinations to practitioners and/or members via verbal, written, or electronic notification within 72 hours of the request. We send PA approval determination letters for select services and all denial determinations to the member, the PCP (if applicable), the rendering practitioner, and the facility, if appropriate. The Medical Director reviews and renders a determination for all potential medical necessity denials. The ICM team attempts to contact the attending practitioner prior to making an acute inpatient medical necessity denial. All written denial determination notifications include: The specific reason for the denial. A reference to the benefit provision, guideline, protocol, or other similar criterion used for the denial decision. An offer to provide a copy of the actual benefit provision, guideline, diagnosis/treatment codes, protocol, or other similar criterion on which the denial decision was based upon request. A description of appeal/grievance rights, including the right to submit written comments, documentation, or other information relevant to the appeal/grievance. An explanation of the appeal/grievance process, including the right to member representation, and time frames for deciding appeals/ grievances. A description of the expedited appeal/grievance process for urgent prior authorization or urgent concurrent denials. Notification that expedited external review can occur concurrently with the internal appeal process for urgent care and ongoing treatment. Notice of the external review process, if applicable. Contact information for language assistance. 20 Arise Health Plan Provider Directory

21 PRIOR AUTHORIZATION SPECIAL PROGRAMS RADIOLOGY BENEFIT MANAGEMENT Arise contracts with National Imaging Associates, Inc. (NIA)/Magellan Health (magellanhealth.com), an accredited leader in the management of outpatient radiology benefits, to review high-tech imaging requests. This program uses evidence-based guidelines for decisions. Procedures requiring prior authorization: CT Scan MRI/MRA/MRS Nuclear Cardiology PET Scan A separate authorization is required for each procedure ordered. Note: Inpatient and emergency department imaging studies do not require prior authorization. Prior authorization process: Visit RadMD.com or call The ordering provider submits the clinical information to NIA Magellan. NIA Magellan uses evidence-based criteria to review relevant information. Each ordered procedure requires a separate authorization. Procedures without proper authorization will not be reimbursed, and the member cannot be balance billed as indicated in your provider agreement. The ordering provider may request a peer-to-peer discussion with a physician reviewer. PEDIATRIC VISION MANAGEMENT Based on the Affordable Care Act (ACA), a pediatric vision care benefit is offered on limited plans to members who are under age 19. Please contact Member Services for specific coverage information and prior authorization guidelines. Arise contracted with Classic Optical Laboratories Inc. to provide covered eyeglasses and eyeglass component parts to Arise members who have the pediatric vision hardware benefit. A selection of frames can be viewed and purchased for display at ClassicOptical.com. Through the Classic Optical Laboratories website, providers can place and track orders for covered eyeglasses, verify frame availability, and make changes to selection. When ordering online, Classic Optical s order form will only allow covered materials and frames. To access these online options, providers are required to have a username and password that can be requested in one of two ways: Online: Complete and submit a request form online. To access the form, visit ClassicOptical.com and click the Contact Us button. Phone: Call , 8 a.m. to 6 p.m., Monday through Friday. Eyeglasses and eyeglass component parts not provided by the Arise contracted vendor will not be reimbursed by Arise without prior authorization. Providers cannot bill the member without prior written acknowledgement and consent of the member. 21 Arise Health Plan Provider Directory

22 CONCURRENT REVIEW DECISIONS Concurrent review decisions are reviews for the extension of previously approved, ongoing care. This includes the review of inpatient care as it is occurring or ongoing ambulatory care. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care and supports the health care provider in coordinating a member s care across the continuum of health care services. CONCURRENT REVIEW PROCESS Integrated Care Management (ICM) team completes inpatient concurrent review telephonically or via fax. The ICM team obtains all data and relevant information, including, but not limited to, medical records and communications with practitioners or other consultants. We use UM criteria to review relevant information as described in the resources/tools section. We review inpatient facility care, such as acute, hospice, rehabilitation, and/or skilled nursing care concurrently for the duration of the stay, according to accepted UM criteria and guidelines. We provide urgent approval determinations to practitioners via verbal, written, or electronic notification communicated through the facility case managers or discharge planners within 24 hours of receipt of the request. We provide urgent concurrent denial determinations within 24 hours of the receipt of the request verbally or electronically followed by written notification. The Medical Director reviews and renders a determination for all potential medical necessity denials. POST-SERVICE DETERMINATION POST-SERVICE PROCESS Post-service decisions are determinations of medical necessity and/or appropriate level of care when the member already received services (e.g., retrospective review). We communicate post-service determinations electronically or in writing to the practitioner and member within 30 calendar days of the request. We use UM criteria to review relevant information and data as described in resources/ tools section. The Medical Director reviews and renders a determination for all potential medical necessity or inappropriate level of care denials. PEER-TO-PEER REVIEW We offer a peer-to-peer discussion with an Arise physician reviewer or Medical Director to the ordering provider for the denial of services that we determine to be not medically necessary or are experimental, investigational, and unproven. It s another opportunity to provide additional information relevant to the denial decision. Prior to requesting a peer-to-peer review, please review our medical policies and MCG guidelines related to the service or issue to be discussed. These guidelines and policies may help to provide insight on what Arise uses as criteria for decisions on a case review. The discussion will be with the requesting provider and an Arise physician medical director or a contracted physician reviewer. It may involve a chiropractor, rehabilitation therapist, or a pharmacist when appropriate. If the decision for denial for services is upheld, the next step is a grievance, which only the member may request according to the directions provided in the denial letter. 22 Arise Health Plan Provider Directory

23 CASE MANAGEMENT Case Management provides a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet a member s health needs. We use communications and available resources to promote high-quality, cost-effective outcomes. We select members for case management based on criteria that address various demographics, including, but not limited to, age, psychosocial and economic status, support systems, diagnoses, and/or complexity of the treatment plan. We identify cases through utilization reports, health promotion activities, claim activity reports, complicated inpatient admissions, prior authorizations, and practitioner or member referrals for case management. We conduct case management in collaboration with the practitioner to support the practitioner/member relationship, and promote adherence to an established treatment plan. We notify members of their selection for case management. COMPLEX CASE MANAGEMENT PROGRAM Complex Case Management (CCM) is the coordination of care and services provided to members who experienced a critical event; have a diagnosis that requires the extensive use of resources; or require assistance in navigating the system to receive the appropriate delivery of care and services. The CCM program is an opt-in program. This allows all eligible members to choose whether or not to participate in the program. Evidence used to develop the CCM Program: We developed the CCM Program based upon MCG Health guidelines and/or nationally recognized, evidence-based clinical guidelines. Criteria to identify members who are eligible for the program: Currently Arise uses the following data sources to identify members for case management: Claims or encounter data: These reports identify transplant, high-dollar, trauma, and chronic illness cases that result in high utilization. Hospital discharge data: Inpatient prior authorization and concurrent review for all members allow the opportunity to evaluate the need for coordination of services for members with complex conditions and help them access needed resources. Discharge planner referrals: The Nurse Integrated Care Manager and hospital discharge planner evaluate the member s discharge needs for continued services and determine if there is a need for case management intervention. Pharmacy data: Data that identify categories such as high-dollar expenditure, therapeutic drugs, new to therapy, and high pharmacy utilization. Data obtained through utilization management: The prior authorization process assists nurse care managers to identify members with complex conditions and to evaluate the need for assistance with coordination of care. Data supplied by purchasers, if applicable Services offered to members During the CCM process, the Nurse Case Manager: Performs a detailed assessment and clinical history of the member s health status specific to identified health conditions and likely co-morbidities. Reviews available certificate benefits and directs the member to in-network providers. Facilitates referrals to resources, such as community resources, Employee Assistance Programs (EAP), Health Management Program, etc., as well as follows up on whether the member acted on these referrals as needed. Interacts with providers including the member s PCP, specialist, DME/infusion company, etc., based on the member s current needs. Develops and communicates a member self-management plan with the identification of goals and any barriers to meet those goals. The Case Manager creates a communication schedule with the member during the CCM process. 23 Arise Health Plan Provider Directory

24 Defined program goals The purpose of the Arise CCM Program is to assist members to regain optimum health or improved functional capability in the most appropriate and cost-effective care setting to meet their needs. The following goals will ultimately assist the organization to reduce costs and add value to members: Members will be able to obtain access to high-quality care and appropriate services through coordination of care of their health care needs. Case Managers will provide support and education to the members to reach their maximum achievable health potential and independence. The member or caregiver will be self-empowered to know what steps to take if the member s medical condition changes. Arise has the following goals to measure the success of the CCM Program: To achieve member satisfaction of 80% or greater as reflected in the annual member satisfaction survey of the CCM Program. To identify improvement measures to increase the effectiveness of its CCM Program (if applicable). Based on the results of these measures, Arise implements interventions and re-measurement, if applicable. HEALTH MANAGEMENT The Health Management Program identifies members with chronic conditions, such as asthma and hypertension, to target their interactions with the health plan to improve outcomes. The objective is to provide innovative and effective support to members and providers in managing these conditions. The scope of the Health Management Program consists of the following components: Members have regular interaction with the Health Management Case Manager, who teaches them about their condition and how to stay well. The Case Manager sends relevant health education materials with additional wellness topics to the member. The Case Manager bridges any communication gaps that may occur between the provider and the member. The Case Manager develops timely alerts to the provider regarding changes in the member s condition. The Case Manager obtains current information to effectively manage members before an emergent event occurs. Members have access to our 24/7 online tools and resources on our website: arisehealthplan.com. Those who qualify for interventions also receive: Highly trained Case Managers to answer questions and provide guidance Care plan follow up and reminders Medication management Referrals to wellness coaching, if needed Self-management tools Screening for depression For referrals, questions, or more information, please call Tracey Bishop at , or tracey.bishop@arisehealthplan.com. s 24 Arise Health Plan Provider Directory

25 BEHAVIORAL HEALTH CARE MANAGEMENT The Behavioral Health Care (BH) Management program provides a mechanism to optimize use of the member s health care benefits while providing high-quality, integrated health care to members with mental and/or substance abuse disorders. Services include, but are not limited to: Inpatient and concurrent authorization Prior authorization request review (if applicable) Post-service review The BH Management program does not require the prior authorization (PA) process or triage prior to a member contacting or making an appointment with a behavioral health care practitioner. It s the practitioner s responsibility to provide a treatment plan to Arise for certain services. The BH Management Program requires a prior authorization determination for all services referred to inpatient and residential facilities. Our HMO plan requires a prior authorization determination for services referred to nonparticipating providers. We review these services for member eligibility, medical necessity, and potential redirection to an appropriate participating practitioner, benefit coverage, and/or coordination of services. Providers submit requests via fax, phone, mail, or online via iexchange; iexchange is the preferred method. The Integrated Care Management team obtains all data and relevant information, including, but not limited to, medical records and communications with practitioners or other consultants. We use UM criteria to review relevant information as described in the resources/tools section. We review inpatient facility care prior to or within 24 business hours of admission, then concurrently according to accepted criteria and guidelines. Non-urgent PA approval and denial determinations are provided to practitioners and members via verbal, written, or electronic notification within 15 calendar days of the request. Urgent PA approval and denial determinations are provided to practitioners and members via verbal, written, or electronic notification within 72 hours of the request. We provide PA determination letters for select services to the member, PCP (if applicable), rendering practitioner, and facility, if appropriate. The Medical Director or Behavioral Health (BH) Consultant reviews and renders a determination for all potential medical necessity denials. All written denial determination notifications include: The specific reason for the denial. A reference to the benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based. An offer to provide a copy of the actual benefit provision, guideline, protocol, diagnosis/ treatment codes, or other similar criterion on which the denial decision was based upon request. A description of appeal/grievance rights, including the right to submit written comments, documentations, or other information relevant to the appeal/grievance. An explanation of the appeal/grievance process, including the right to member representation and time frames for deciding appeals/grievances. A description of the expedited appeal/grievance process for urgent prior authorization or urgent concurrent denial. Notice of the external review process, if applicable. Notification that expedited external review can occur concurrently with the internal appeal process for urgent care and ongoing treatment. Contact information for language assistance. CONCURRENT REVIEW 25 Arise Health Plan Provider Directory

26 Concurrent review decisions are reviews for the extension of previously approved ongoing care. An example includes the review of inpatient care as it is occurring. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care, and supports the health care provider in coordinating a member s care across the continuum of health care services. Integrated Care Management (ICM) team completes inpatient concurrent review via phone or fax. The ICM team obtains all data and relevant information, including, but not limited to, medical records and communications with a practitioner or other consultants. We use UM criteria to review relevant information as described in the resources/tools section. We review inpatient facility care for acute and rehabilitation treatment concurrently for the duration of the stay according to accepted UM criteria and guidelines. We provide urgent approval determinations to practitioners via verbal, electronic, or written notification communicated through the facility case managers or discharge planner within 24 hours of receipt of the request. We provide urgent concurrent denial determinations within 24 hours of the receipt of the request verbally or electronically followed by written notification. The Medical Director or BH Consultant reviews and renders a determination for all potential medical necessity denials. POST-SERVICE PROCESS Post-service decisions are determinations of medical necessity and/or appropriate level of care when the member already received services (retrospective review). We communicate post-service determinations electronically or in writing to the practitioner and member within 30 calendar days of the request. We use UM criteria to review relevant information and data as described in the resources/tools section. The Medical Director or BH Consultant reviews and renders a determination for all potential medical necessity or inappropriate level of care denials. 26 Arise Health Plan Provider Directory

27 CHIROPRACTIC CARE MANAGEMENT Chiropractors have limited access to specialty imaging services and laboratory testing with appropriate authorization. The Arise Director of Chiropractic Services reviews chiropractic services. The Director of Chiropractic Services works collaboratively with the Medical Director and Integrated Care Management (ICM) in accordance with appropriate state statute and is able to render chiropractic clinical management decisions autonomously. Arise chiropractors are encouraged to collaborate directly with primary care and specialty medical services to facilitate the most costeffective and expeditious authorizations within the network. The Chiropractic Care Management Program consists of post-service determinations of all services from nonparticipating practitioners, for medical necessity and/or coordination of care/services for care the member already received. The ICM team receives chiropractic claims via a claims report. The ICM team obtains medical records related to the visits for medical review. We use UM criteria to review relevant information as described in the resources/tools section. The Director of Chiropractic Services reviews and renders all decisions for coverage for both approvals and medical necessity denials. The provider s Provider Remittance Advice (PRA) and the member s Explanation of Benefits (EOB) identify the approved services. We send notification of post-service decision denial determinations electronically or in writing to the chiropractor and member within 30 calendar days of the receipt of the claim. All written denial determination notifications include: The specific reason for the denial. A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based. An offer to provide a copy of the actual benefit provision, guideline, diagnosis/treatment codes, protocol, or other similar criterion on which the denial decision was based, upon request. A description of appeal/grievance rights, including the right to submit written comments, documentations, or other information relevant to the appeal/grievance. An explanation of the appeal/grievance process, including the right to member representation and time frames for deciding appeals/grievances. Notice of the external review process, if applicable. Notification that expedited external review can occur concurrently with the internal appeal process for urgent care and ongoing treatment. Contact information for language assistance. 27 Arise Health Plan Provider Directory

28 PHARMACY MANAGEMENT Arise offers a comprehensive prescription drug program, including a suitable array of products, to allow practitioners to appropriately manage their patients. The Arise Director of Pharmacy and Medical Director provide the program leadership. The Arise Pharmacy Program is overseen by the Quality Improvement Committee and administered by Express Scripts. The Pharmacy Management Program is reviewed at least annually and updated as needed. Changes to the program are communicated to practitioners via direct mail, , and/or our website. Arise contracts with Express Scripts to process pharmacy claims. Express Scripts is also our exclusive provider of home delivery pharmacy services. Note: Not all members receive their drug benefits through Arise. Please verify drug benefits by checking the member s ID card. Arise uses a formulary designed and maintained by Express Scripts. It can be accessed through the Drug Formulary section of our website, arisehealthplan.com. A formulary is a list of drugs that can be used by practitioners to identify drugs that offer the greatest overall value. It does not guarantee coverage and should only be used as a guide. MEMBER RESPONSIBILITY DETERMINATION The most common pharmacy benefit is tiered. The copay/coinsurance levels vary based upon the tier of the drug prescribed. Generic drugs are on the formulary and carry the lowest responsibility (first tier). Brand-name drugs that are on the formulary are the middle responsibility (second tier). Brand-name drugs that are not on the formulary carry the highest responsibility (third tier). Some plans have a fourth tier that is unique for specialty drugs; in this situation, specialty drugs, whether brand or generic/formulary or non-formulary, are subject to specific cost-sharing. Note: Qualified high-deductible health plans have a combined medical and pharmacy benefit that does not typically incorporate a tiered benefit. COVERED DRUGS In general, the prescription drug benefit covers FDA-approved drugs that, by law, require a prescription from a licensed practitioner, and, by certificate, are medically necessary. Insulin and disposable diabetic supplies that, by law, may not require a prescription, are also eligible for coverage. However, to be eligible for coverage, Arise requires they must be medically necessary and a prescription must be written. 28 Arise Health Plan Provider Directory

29 COMMONLY EXCLUDED DRUGS Drugs to treat toenail or fingernail fungus. Drugs used for fertility or whose primary use is fertility. Compounded medications that do not contain at least one legend ingredient. Non-legend drugs (those available without a prescription). Experimental/investigational drugs. Drugs from non-participating pharmacies, except for emergencies outside of the geographical service area. Replacement medications resulting from loss, theft, or damage. Any drug used for weight control. Any drug used for cosmetic purposes or whose use is not medically necessary. A covered drug related to a non-covered medical encounter. Anabolic steroids, unless prior authorization is obtained. Medical supplies not specified as covered in the member certificate. Injectable medications, except as determined by Arise or its designee. Any drug without the proper plan authorization as outlined in the certificate. MEMBER GIVEN GENERIC DRUG WHEN BRAND-NAME DRUG IS PRESCRIBED When an FDA-approved generic version of a brand-name drug is available, Arise may limit coverage to the generic form of a drug. The active ingredient(s) in a generic drug is chemically identical to its brand-name counterpart. Pharmacists will dispense the generic medication in this situation. If the member requests the brand, the member will be responsible for the appropriate copay/coinsurance plus the difference in cost between the brand and the generic. DRUG THERAPY SITE OF CARE PROGRAM Most Arise member benefit plans contain language that permits us to direct care to the most cost-effective place of service that is clinically appropriate for the member s situation. Examples include having a patient self-administer a drug instead of receiving it in the provider s office. It could also mean using home care services in place of an infusion center or outpatient hospital setting. 29 Arise Health Plan Provider Directory

30 DRUG PRIOR AUTHORIZATION The list of drugs requiring prior authorization is available online at wpsic.com/files/drugpreauth.pdf. The list outlines whether Diplomat, Express Scripts, or Arise performs the review for the drug in question. Arise has engaged Diplomat to assist with specialty drug management. Arise requires an approved prior authorization for most specialty drugs. On behalf of Arise, Diplomat reviews specialty drug requests for all service settings (e.g., outpatient, office, home), except inpatient. Treatments subject to this program include, but are not limited to, specialty drugs for cancer, multiple sclerosis, and inflammatory conditions. Coverage policies for specialty drugs can be found by visiting arisehealthplan.com and clicking on Drug Prior Authorization Program. Specialty drugs dispensed without proper authorization will not be reimbursed, and the member cannot be balance billed. In each situation, when a provider is seeking a review, please call the correct company at the phone number below. Phone calls are preferred to efficiently identify the necessary clinical information to complete the review. Diplomat (Specialty Drugs) Express Scripts (Traditional Drugs) Arise (Drugs most policies do not cover, e.g., fertility) When calling, please have available the patient s Arise ID number (from his/her card), date of birth, and access to the medical record. You will be asked questions related to diagnosis, medication history, and other relevant clinical information. The provider s office should contact the member regarding the decision. TECHNOLOGY AND INCENTIVES TECHNOLOGY ASSESSMENT Arise has a policy that establishes procedures for the assessment of new technologies and new applications of existing technologies, including, but not limited to, medical and surgical procedures, pharmaceuticals, and devices. Arise has procedures and criteria for the submission and selection of a technology to be considered. The roles of the Medical Policy Committee, Quality Improvement Committee, and Benefits Committee are to determine if the technology will be covered as an Arise benefit. AFFIRMATIVE STATEMENT ON INCENTIVES Utilization Management decision making at Arise is based only on appropriateness of care and service and existence of coverage. Arise does not specifically reward practitioners or other individuals for issuing denials of coverage. No financial incentives are given to encourage decisions that result in underutilization. 30 Arise Health Plan Provider Directory

31 RESOURCES/TOOLS UTILIZATION REVIEW CRITERIA Medical necessity decision-making requires the consistent application of Utilization Management (UM) criteria. Arise uses both nationally published and locally developed criteria in collaboration with actively practicing providers. The Medical Policy Committee reviews and approves criteria for appropriateness. Arise reviews and updates the decisionmaking criteria annually or more frequently if there are significant changes in standards of care. Criteria: Criteria are applied consistently to medical necessity decisions, and in a manner that is responsive to individual member needs and the characteristics of the local delivery system. The criteria are used as a guideline and not intended to replace appropriate clinical judgment. The ICM decision-maker considers the member s medical and psychological status (age, comorbidities, complications, and progress of treatment); home situation and supports; community supports; provider and practitioner network; and availability of services. Certain categories of services may not be reviewed for medical necessity if screening reveals that they represent clear certificate or benefit exclusions. Arise uses the following criteria, which is not an all-inclusive list: Cochrane Library Council on Chiropractic Guidelines and Practice Parameters (CCGPP) Hayes Medical Technology Directory Information from appropriate government regulatory bodies (e.g., Centers for Medicare & Medicaid Services (CMS), Food & Drug Administration (FDA), U.S. Department of Health & Human Services MCG Care Guidelines Medical Affairs Medical Policy National Comprehensive Cancer Network (NCCN) National Guidelines Clearinghouse National Imaging Associates Clinical Guidelines National Institutes of Health National Library of Medicine Search PubMed (Medicine) Specialty Society guidelines and standards (e.g., The American Academy of Pediatrics, American College of Physicians, The American Cancer Society, The American Medical Association) United States Preventive Services Task Force (USPSTF) preventive services only UpToDate consensus-based vendor resource Note: MCG, Hayes, and all other guidelines are used in conjunction with the independent professional medical judgment of a qualified health care provider. Arise practitioners/providers may request to review our ICM criteria at any time. If requested, we will provide a copy of specific criteria used for decision-making to the requesting Arise practitioner. This copy is for the practitioner s own use, and may not be released to others without permission from Arise. We also inform Arise practitioners of the process to request criteria during practitioner orientation and via the provider newsletter. POLICIES Policies are statements that define how Arise intends to administer its Integrated Care Management (ICM) program. The QI Committee reviews all ICM policies. Each department is responsible for development of procedures for functions within its responsibility. 31 Arise Health Plan Provider Directory

32 CLINICAL EXPERTS In addition to the Medical Director, ICM staff have access to clinical experts through the Arise practitioner panel, many of whom are board certified and participate on various committees at Arise. Arise also purchases a variety of expert services through external vendors. Examples of expert vendors used are: ALLMED Medical Review Institute of America National Medical Review, Inc. Clinical Practice Guidelines: ICM team members have access to clinical practice guidelines from multiple professional organizations, which are also published on the Arise website for providers. Some sources for clinical practice guidelines utilized are referenced below. For a complete list, see the Medical Policies section of our website. American Academy of Family Practice (AAFP) American Academy of Pediatrics (AAP) American College of Cardiology (ACC)/American Heart Association (AHA) American College of Physicians (ACP) Institute for Clinical Systems Improvement Healthcare Guideline (ICSI) National Institute for Health and Care Excellence National Institute of Health (NIH) U.S. Preventive Services Task Force (USPSTF) EXTERNAL REVIEW The Medical Director, or designee, consults with board-certified practitioners, when appropriate, to accommodate the medical necessity review process. Arise also has access to external review agencies that employ board-certified practitioners for case review as noted above. 32 Arise Health Plan Provider Directory

33 MEDICAL POLICY GUIDELINES Medical Policies provide guidelines for determining coverage for specific medical technologies and/or procedures. The principal component of the medical policy development and review process is to evaluate new and existing medical technologies, procedures, pharmaceuticals, devices, and criteria for use in medical necessity and experimental and investigational determinations. The Arise Medical Policy Committee is responsible for the development of internal medical policies. The goal of the Medical Policy Committee is to ensure that the Medical Policies are: (a) reviewed on a regular basis; (b) consistent with the most current, evidence-based scientific literature; and (c) in line with accepted standards of medical practice. Practitioners and other providers may obtain the Medical Policy guidelines used for making medical coverage determinations for an Arise member under their care. We base the Medical Policy guidelines on sound medical and clinical evidence with the involvement of appropriate medical specialists. If you receive a determination and would like to review the medical policy guidelines used in that determination, you may contact us. To obtain medical policy guidelines for a specific subject through the Integrated Care Management (ICM) Department, please submit your request via phone, fax, or in writing to: Arise Health Plan Attn: Integrated Care Management Department P.O. Box Green Bay, WI Phone: or Fax: Note: If applicable, please include the member name and number along with the subject (procedure/service/ treatment) for which you are requesting the medical policy guidelines. The medical policy guidelines are an informational resource and not an authorization, an explanation of benefits, or a contract to provide benefits. By following the medical policy guidelines, payment of health insurance benefits is not guaranteed. Receipt of benefits is subject to satisfaction of all terms and conditions of the member s contract in effect at the time services are rendered. Medical technology is constantly changing, and we reserve the right to review and update our medical policy guidelines as necessary. If you have comments or suggestions regarding a guideline, please submit in writing to: Arise Health Plan Attn: Medical Policy Committee P.O. Box Green Bay, WI medical.policies@wpsic.com 33 Arise Health Plan Provider Directory

34 QUALITY IMPROVEMENT PROGRAM MISSION, VISION, AND COMMITMENT TO OUR MEMBERS In today s health care environment, effective Integrated Care Management (ICM) requires rigorous data analysis. We ve invested in a powerful collaborative care management platform that streamlines data collection, applies clinical rules, automates workflows, and electronically connects patients with their providers. This system allows us to more intelligently administer ICM services, improving health care quality and reducing costs. Our Quality Improvement (QI) Program drives organizational improvement for excellence through efficiencies, increasing the competitive advantage, and building trust and recognition in the community to improve the health status and satisfaction of our members. We commit to our members and providers our dedication to professional standards, evidence-based medicine and ethical practice behavior. On an ongoing basis, we integrate clinical advances, implement innovations and measure health outcomes of our members. We continually refine our health care team and member know-how to: Conduct and support research on the effectiveness of treatments. Ensure that clinicians, patients, and policymakers have the information they need to enhance the quality of care. Identify any gaps in access to or use of our health care. PROGRAM STRUCTURE QI Committee provides structure for promoting and achieving excellence in all areas and at all levels of the organization. The QI Committee will have oversight for the structure and resources that are to be reviewed throughout the calendar year. OBJECTIVES Monitor the QI Program quarterly to assess progress and resource allocation. Develop, review and report on the annual QI Program work plan. Assess and evaluate effectiveness of health plan activities. Monitor Quality of Care for all members including responding and facilitating resolution to member complaints. Assess and evaluate delegated activities. Monitor and align accreditation with process improvement teams. The QI Committee relies on industry standards set by regulators or accrediting organizations and best practices to guide them throughout the year. The use of data collection and analysis is critical to identifying populations, problem-solving and process improvement. Compliance with NCQA Standards and achievement of accreditation demonstrates commitment to quality improvement. Information about the QI Program is available for members and providers upon request. PURPOSE OF THE QUALITY IMPROVEMENT PROGRAM The QI Program is the framework for a formal process to assess and monitor our performance through a systematic approach of monitoring and evaluating the quality and the effectiveness of care for our members. This approach enables us to focus on issues of appropriateness, efficiency, safety, as well as health outcomes and satisfaction of our members and their providers. This is achieved by continuous monitoring of our performance according to, or in comparison with, objective measurable performance standards. The QI Program promotes accountability and ensures identification and evaluation of issues that impact our ability to better our performance and improve health care and administrative services provided to our customers. 34 Arise Health Plan Provider Directory

35 PROGRAM GOALS AND KEY OBJECTIVES The primary goal is to integrate all existing quality activities into one comprehensive program for monitoring activity, share ideas over multiple programs, focus resources, and promote programs and maintain National Committee for Quality Assurance (NCQA) accreditation for Arise and the Qualified Health Plans (QHPs). The QI Program goals are achieved through the integration and coordination of clinical and non-clinical services guided by specific goals and key objectives. Our guiding principle is to provide services with the following characteristics of evidence-based, data-driven decisions for the safety and welfare of our members. PROGRAM FUNCTIONAL AREAS AND RESPONSIBILITIES The QI Program includes all aspects of services provided by health plan practitioners, providers, and staff. The plan arranges for the provision of comprehensive health care delivery through a network of primary care and specialty practitioners, behavioral health practitioners and clinicians, ancillary care provider hospitals, and other health facilities. The program s scope, which is determined following an annual analysis of the population and its demographic and clinical characteristics, includes the monitoring and evaluation of high-volume, high-risk, clinical, and service issues. Performance goals and thresholds are established for all measures, and are trended over time. The QI Program provides an organizational process that supports ongoing improvement of care and service, and improvement of the health of its members. The program is responsive to the changing needs of the health care environment and the standards established by our local medical community, and national regulatory and accrediting bodies. REPORTING RELATIONSHIPS OF QI DEPARTMENT STAFF AND COMMITTEE Medical Director Network and Quality: The Medical Director or Designee is responsible for ensuring the implementation of all aspects of the QI Program. The Medical Director chairs the QI, Credentialing, and the Medical Policy Committees. Director of Quality and System Support: The Director, Quality and System Support is responsible for coordinating the operational components of the QI Program under the direction of the Medical Director. This position reports directly to the Medical Affairs Senior Director. Manager of Integrated Care Management (ICM) Quality and Operations: The Manager of ICM Quality and Operations is responsible for coordinating the operational components of the ICM Program and the QI Program. This position reports to the Director, Quality and System Support. Quality Improvement Specialists: QI Specialists are responsible for assisting with the operational components of the QI Program. This includes project coordination of Healthcare Effectiveness Data and Information Set (HEDIS), the Consumer Assessment of Healthcare Providers and Systems surveys (CAHPS) and other quality initiatives and state and federal reporting requirements. The QI Specialists report to the Manager of ICM Quality and Operations. Health Care Informatics Manager: The Health Care Informatics Manager is responsible for having the Health Care Informatics Team generate reports and statistical analysis to assist with HEDIS/CAHPS, NCQA Accreditation and other quality initiatives. This position reports to the Director of Quality and System Support. Behavioral Health Care Practitioners: The BH Practitioners are involved in the behavioral health care aspects of the QI Program. BH practitioners serve on the QI, Medical Policy, Credentialing, and other ad hoc committees and teams. Committee Organizational Chart The committee structure, line of authority, and responsibility for the QI Committee is described as follows. The Medical Director oversees the QI Committee. The QI Committee oversees the Credentialing Committee, and Medical Policy Committee. Each committee is required to contemporaneously record meeting minutes. The Grievance Committee is an exception, since meeting content is primarily protected health information. Database information and individual files are maintained. All other meetings are dated and signed by the committee chair when approved. Summary reports are submitted to the QI Committee for annual and semi-annual review when appropriate. 35 Arise Health Plan Provider Directory

36 QI Committee Oversight The Board of Directors has designated the QI Committee to oversee our quality improvement activities. The QI Committee has delegated responsibility for the direction and oversight of the QI Committee to the Medical Director. The QI Committee annually reviews, makes recommendations for, and approves our QI Program. The Medical Director reports to the Executive Staff, which ultimately reports to the appropriate Board of Directors. RESOURCES AND ANALYTICAL SUPPORT Systems Resources currently available for support of the quality improvement activities include the following: FACETS System: System used for enrollment, premium billing, claims payment, member services, phone log and complaint tracking. Data from system populates data warehouse and is used for a variety of purposes. Aerial and iexchange: Medical management system and provider portal for prior authorizations and ICM operations. Amisys Advance: Legacy system before FACETS for HEDIS look back. Verscend Health Inc.: Decision support software used to support various QI activities. HEDIS data collection and reporting is done via Quality reporter. Grievance: Database used to track Grievances. Includes various coding for report generation to use in tracking and trending data. Provider Network Intranet: Database used to track provider contract information, locations, specialties, and billing addresses. It is used to generate provider directories. Vistar: Credentialing database that houses all credentialing information. MetaStar: Auditor of HEDIS data. DSS Research Vendor: Conducts standard survey and analysis for HEDIS and CAHPS. Eloquence: Generates letters. Other resources allocated as needed. Analytical Support The Health Care Informatics Manager is responsible for having the Health Care Informatics Team generate reports and statistical analysis to assist with HEDIS/CAHPS, NCQA Accreditation and other quality initiatives. This position reports to the Director of Quality and System Support. Delegated QI Activities We delegate specialty drug management, pharmacy benefit management, and radiology management for some plans. The QI Committee monitors delegated agency performance through approval of the delegate s program, routine reporting, and annual or more frequent evaluations and/or on-site audits to determine whether the delegated activities are being carried out in accordance with our NCQA and the Quality and Patient Safety Division (QPSD) Health Insurance standards. If monitoring reveals deficiencies in the delegate s processes, we will work with the delegate to set priorities and correct the problems. We also hold several provider credentialing delegations with various organizations. The Credentials Committee monitors the delegated agency performance through initial review and approval of the delegate s program, routine reporting, and annual evaluations to determine whether the delegated activities are being carried out in accordance with the health plans standards. If monitoring reveals deficiencies the health plan will work with the delegate to establish a corrective action plan and resolve the problems. Collaborative QI Activities One of the primary focuses of the QI Committee in conjunction with the Quality Team and Code Governance Committee is to perform a significant amount of outreach with provider groups. Each of the QI Specialists on the Quality Team reach out to providers. The goals for the outreach are in four main categories: quality improvement project collaboration, HEDIS improvement opportunities, medical coding best practices, and iexchange outreach. This will allow us to collaboratively identify areas in need of improvement, and work together on these projects to strengthen the level of service for our members. 36 Arise Health Plan Provider Directory

37 HEDIS Improvement Opportunities The Quality Team meets in person with each of our major provider groups prior to HEDIS data collection to identify nuances in each providers EMR system. By meeting in person and performing a dry run of HEDIS audits with our provider partners, we are able to overcome hurdles ahead of time rather than during the data collection process. Following the completion of HEDIS, we will be returning to our provider partners with metrics showing how their individual sections scored by measure. This should help drive best practices in future HEDIS runs. Medical Coding Best Practices The Medical Coding team identifies common medical coding errors seen in claims from providers. The purpose is to find trends that can be easily corrected through outreach and education to reduce errors and speed up the claims process. In 2018, the Code Governance Committee will measure the progress of the education by monitoring the coding practices seen on incoming medical claims. Members of the Quality Improvement Committee are also members and active participants in the Wisconsin Chronic Disease Quality Improvement Project through the University of Wisconsin Population Health Institute, the Chronic Disease Prevention and Control Partnership through the Wisconsin Department of Health Services, and the Dane County Immunization Coalition. Behavioral Health Care (BH) Develop collaborative partnerships and initiatives to monitor and improve behavioral health care. OBJECTIVES Review the BH medical consultant roles and responsibilities annually. Actively participate with our BH network providers to identify and resolve gaps of access for our members. Patient Safety We foster a supportive environment to help practitioners and providers improve safety of their practices through the following activities: Clinical Practice and Guideline Process: Establishes best practice criteria founded on national evidence-based practice guidelines to reduce variation in the care delivered to members. Measures practitioner performance against guidelines occurs annually. Credentialing/Re-credentialing Process: Ensures members are provided with a choice of qualified, competent practitioners and providers. The Credentialing Committee meets monthly for the ongoing monitoring of practitioner sanctions and complaints between credentialing cycles. Continuity and Coordination of Care: Identifies potential problems to ensure quality of care. Health Management Program: Monitors members and alerts physicians if member becomes a higher risk. Expedited Appeals Process: Provides for the assessment of and action on an appeal of a medical necessity denial based on the urgency of the request. Develop claims reporting and pharmacy data to identify the behavioral health needs of our members. Collaborate with our BH provider participants of the QI Committee to improve member access to in-network BH providers. Medical Technology Request: Allows for review of the efficacy of the technology based on national research data and local medical practice. Member Complaint Process: Tracks and trends member complaints by category and reports semiannually to Quality Committee. If a complaint indicates potential for poor quality of care, the complaint is referred to the Medical Director for review. If the Medical Director determines there is a question of poor quality of care or unsafe practice, the occurrence is referred to the Credentialing Committee. Quality of Care Complaints: A documented process for addressing member quality of care complaints to ensure patient safety. Pharmaceutical Management Program: Develops and maintains drug usage criteria, assesses efficacy of new drugs or a new use for an existing drug, and monitors indicators relating to polypharmacy and misuse of medication. Monitors drug interactions to ensure patient safety. 37 Arise Health Plan Provider Directory

38 Annual QI Work Plan The QI Program Work Plan is formulated annually by the Quality Specialist. The Work Plan includes the following: Annual objectives Program scope Annual planned activities Quality and safety initiatives Time frames for achievement Staff member(s) responsible for each activity QI Program evaluation Serving a Diverse Membership Objectives for serving a culturally and linguistically diverse membership are to: Evaluate membership demographics using the U.S. Census Report by county. Monitor availability of practitioners speaking foreign language with sufficient fluency to treat a member who only speaks that language. Monitor response from the new member survey regarding cultural, ethnic, racial, or linguistic needs/ preferences for practitioners. Monitor complaints related to cultural, ethnic, racial, or linguistic issues on a semi-annual basis. Monitor responses from the group enrollment questionnaire regarding languages spoken by employees. Maintain a policy on underserved populations and cultural competency. Maintain and monitor the Language Line Services agreement to support culturally competent communication. Monitor and review an action plan to address the cultural and linguistic needs of our membership if warranted by the above activities including availability of appropriate educational materials and information updates for members. Serving Members with Complex Health Needs We help members with multiple or complex conditions to obtain access to care and services and coordinate their care through the Complex Case Management program. The Complex Case Management program annually assesses the needs of the member population, identifies candidates for the program through a series of algorithms and clinical intelligence rules, and then assists the identified population using an evidence-based program. Clinical Outcomes Clinical quality and outcomes will meet or exceed regionally and/or nationally established standards. Objectives Incremental positive improvements to attain Arise and QHP HEDIS scores at or above the specified National Percentile of the Quality Compass. Incremental positive improvements to strive to move the organization to an excellent five-star rating by NCQA for the QHP and Arise Health Insurance Plans. Design a project for the Quality Effectiveness Committee to address member medication adherence for the following conditions: Asthma, Hypertension, and Chronic Low Back Pain. Adopt and disseminate updated Clinical Practice Guidelines to be published on our website. Promote preventive care guidelines to improve HEDIS effectiveness such as well-child visits and immunizations. Collaborate and participate with the Chronic Disease Quality Improvement Project for the State of Wisconsin to promote our Health Management Program of hypertension and asthma. Support member wellness through our Wellness/ Prevention Program. Support and collaborate with network providers for the exchange of data analytics for population health management. Analyze and address the existence of significant health care disparities in clinical areas. 38 Arise Health Plan Provider Directory

39 Member Service Outcomes Customers will experience the highest level of quality service. This includes positive interactions between our members and our team. We train our team members to be well informed on how to best serve our members. Objectives Analyze CAHPS survey results annually and target improvement initiatives for low scoring areas. Analyze member complaints and grievances monthly to initiate improvements as needed. Analyze Member Service and telephone access indicators semi-annually. Conduct an annual Practitioner Satisfaction Survey regarding utilization management process and implement improvements as needed. Survey key leaders of provider networks regarding clinical criteria for utilization management decisions and new technology. Build a robust website for members and providers to increase the health plan s transparency on member requirements and medical criteria. Continue Health Literacy initiatives to improve customer understanding and satisfaction with service provided. Collaborate with the Arise Member Advocates for addressing general member concerns. Continue to assess the need for culturally competent communication and provide information, training and tools as needed. QI Program Components Regulatory and Compliance: Arise health plans are designed to comply with all applicable state and federal legislation, regulations and NCQA Accreditation Standards. Credentialing and Re-credentialing: Please see the Credentialing section of this manual for more detailed information regarding the process. Integrated Care Management (ICM): Our ICM Program is designed to monitor the appropriateness, medical necessity, and benefit coverage for pre-service care, concurrent review, and post-service care delivered to plan members. A full description is included in the ICM section of this manual. Behavioral Health Care: The scope of the Behavioral Health Care program is included in the Behavioral Health Care section of this manual. Health Management: The Health Management Program identifies members with specific chronic conditions. Additional information is outlined in the Health Management section of this manual. Supporting Community-Based Self-Support Tools: The QI Committee s role is to work with the communitybased programs to assist individuals with chronic conditions to better self-manage their conditions. Pharmacy Management: The Pharmacy Management Program provides the framework for continual and systematic monitoring, assessment, and improvement of the medically necessary pharmaceutical products and services delivered to members. A detailed explanation of the program is included in the Pharmacy Management section of this manual. Quality of Care and Service: We review and evaluate the quality of health care and service in all delivery settings including both inpatient and outpatient care. QI Program Evaluation The QI Program is evaluated annually by the QI Committee. The assessment and evaluation includes the following: Description of completed and ongoing quality improvement activities from the work plan that addresses quality and safety of clinical care and quality of service. Trending of measures to assess performance in quality and safety. Analysis of the results of quality improvement initiatives, including barrier analysis. Assessment and evaluation of the overall effectiveness of the Quality Improvement Program. The QI Program evaluation findings are used to identify issues, to demonstrate the impact of the program, and to develop the Work Plan for the following year. 39 Arise Health Plan Provider Directory

40 EMERGENCY/URGENT CARE EMERGENCY MEDICAL CARE Emergency Medical Care is defined as health care services to treat a medical emergency. A medical emergency is a condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that would lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following: 1. Serious jeopardy to the person s health, or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child; 2. Serious impairment to the person s bodily functions; or 3. Serious dysfunction of one or more of the person s body organs or parts. Examples of emergency conditions include, but are not limited to: Loss of consciousness Severe burns Heavy bleeding Possible heart attack For emergency conditions in our service area, the member should access the closest in-network hospital emergency facility. When out of our service area, the member should access the closest hospital emergency facility. Follow-up care should be arranged through the PCP. URGENT CARE Urgent Care is defined as care received for an illness or injury with symptoms of sudden or recent onset that require medical care the same day. Examples of urgent care situations include, but are not limited to: sprained ankle, minor cut, minor burn, and children with fever. In these situations, the member should contact their PCP. During business hours, services for urgent situations should be received in the PCP office whenever possible. For after-hours services, the PCP office should be contacted for assistance. EMERGENCY ROOM AND URGENT CARE COVERAGE In the event of a medical emergency, hospital care is covered wherever it is received. However, if a member is admitted, a participating PCP must be notified within 48 hours of being medically able. When urgent care is needed for a non-life-threatening illness or injury, members should contact their PCP prior to seeking care for direction to the appropriate medical facility. Arise provides, arranges for, or otherwise facilitates needed emergency services or instructs members to call 911. Arise will not deny coverage for emergency services for a member without prior authorization when: Such care is received to screen and stabilize the member where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. Arise will provide coverage for emergency services rendered during the treatment of an emergency medical condition by a non-participating provider as though the services were provided by a participating provider. Arise will also provide coverage if the enrollee cannot reasonably reach a participating provider, or as a result of the emergency, is admitted for inpatient care subject to any restriction which may govern payment to a participating provider for emergency services. 40 Arise Health Plan Provider Directory

41 EMERGENCY ROOM AND URGENT CARE COVERAGE COLLEGE STUDENTS In the event of a medical emergency, the member is covered regardless of where medical care is received. After receiving emergency care, the member must call his/her PCP or Arise Member Services at on the following business day or when able. If the member is admitted to the hospital, the member must call Member Services the next business day. If the member is away at college and an acute medical problem develops, the member should call his/her PCP first. If the PCP cannot handle the member s problem, the PCP will refer the member to the college s health center, a local physician s office, or an urgent care center. If the member receives care from a non-participating provider and additional services are needed, the member will need a prior authorization from his/her PCP and approval from the Arise Medical Director. The member may need to return home to receive treatment from a participating provider. If the member requires ongoing medical care, the member will need a prior authorization from his/her PCP and approval from the Arise Medical Director. Some out-of-area medical facilities not in the Arise participating provider network may require the member to pay for care at the time it is provided. To arrange for reimbursement, send itemized bills and proof of payment within 90 days to: Arise Health Plan P.O. Box Eagan, MN The member will be responsible for out-of-area charges that exceed the maximum out-of-network allowable fee. Routine care should be received from a participating PCP when the member is in the Arise service area. If the member has additional questions, contact Member Services at or Arise Health Plan Provider Directory

42 TELEMEDICINE Telemedicine is defined as the delivery of clinical health care services via telecommunications technologies, including, but not limited to, phone, interactive audio, video conferencing, and . Telemedicine does not include teleradiology. Telemedicine services are provided by a health care provider at a distant site to a covered person at an originating site via interactive audio-visual telecommunication. The originating site and the distant site must be: A health care practitioner s office A convenient care clinic A hospital A skilled nursing facility Interactive audio-visual telecommunication is telecommunication that allows medical information to be communicated in real-time via interactive audio and video communications. The real-time audio and video communication is between the patient and a distant physician or health care provider furnishing the health care services. The patient must be present and participating throughout the communication. Phone calls do not qualify as interactive audio-visual telecommunication because they are not face-to-face medical discussions and do not include direct, in-person contact between the patient and health care provider. The following services are not considered telemedicine: Telemedicine services that do not include direct, in-person contact between the health care provider and the covered person Phone evaluation and management services Transmission fees Website charges for online patient education material Online medical evaluations CONVENIENT CARE CLINIC A Convenient Care Clinic is defined as a medical clinic located within a retail store, supermarket, or pharmacy. The clinic must provide covered health care services by a health care practitioner. The covered health care services must be provided within the scope of the health care practitioner s respective license. Under our member s health care plans a health care practitioner is generally defined as one of the following licensed practitioners who perform services payable under the member s plan: a Doctor of Medicine (MD); a Doctor of Osteopathy (DO); a Doctor of Podiatric Medicine (DPM); a Doctor of Dental Surgery (DDS); a Doctor of Dental Medicine (DMD); a Doctor of Chiropractic (DC); a Doctor of Optometry (OD); a physician assistant (PA); a nurse practitioner (NP); a certified nurse midwife (CNM); a psychologist (Ph.D., Psy.D.); a licensed mental health professional, including but not limited to, a clinical social worker, marriage and family therapist, or professional counselor, a physical therapist, an occupational therapist, a speech-language pathologist, an audiologist, or any other licensed practitioner that is acting within the scope of their license and performing a service that would be payable under the member s health care plan. 42 Arise Health Plan Provider Directory

43 MEMBER RIGHTS AND RESPONSIBILITIES The Member Rights and Responsibilities listed below set the framework for cooperation among covered persons, practitioners, and Arise. MEMBER RIGHTS AS A HEALTH PLAN MEMBER The right to be treated with respect and recognition of dignity and right to privacy. The right to a candid discussion of appropriate or medically necessary treatment options for his/her conditions, regardless of cost or benefit coverage. The right to participate with practitioners in making decisions about his/her health care. The right to receive information about us, our services, our network of health care practitioners and providers, and the member s rights and responsibilities. The right to voice complaints or appeals about us or the care we provide. The right to make recommendations regarding our member rights and responsibilities policies. MEMBER RESPONSIBILITIES AS A HEALTH PLAN MEMBER The responsibility to supply information (to the extent possible) that we and our practitioners and providers need in order to provide care. The responsibility to understand the member s health problems and participate in developing mutually agreed upon treatment goals to the degree possible. The responsibility to follow the treatment plan and instructions for care that have been agreed on with the member s practitioners. MEMBER S PROTECTED HEALTH INFORMATION Arise takes our members privacy seriously and we only use or disclose protected health information in accordance with state and federal law. Arise uses and discloses health information about members for payment and health care operations (including efforts to track QI activities), and for their treatment. Members may give us written authorization to use their health information, or to disclose it to anyone, including themselves, for any purpose. If members give us an authorization, they may revoke it at any time. We may disclose a member s health information to a family member, friend, or other person to the extent necessary to help with their health care or with payment for their health care. In the event of a member s incapacity or an emergency, we will disclose their health information based on our professional judgment of whether the disclosure would be in the member s best interest. Members have the right to look at or receive copies of their health information, with limited exceptions. Please visit arisehealthplan.com for more information. We are committed to protecting the confidentiality and privacy of every aspect of service and care across the organization. We have developed, implemented, maintained, and used appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information and to prevent intentional or unintentional use or disclosure in violation of law. We may disclose summary information about the participants in a particular group plan to the employer. This summary is stripped of any personal information and contains only general statistics about the types and costs of claims. Employers may use this information to obtain premium bids for health insurance coverage. Your agreement with Arise requires you to safeguard all individually identifiable health information to protect the confidentiality and integrity of all health care information exchanged with Arise. You must comply with all applicable laws regarding health information, including, but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent amendments concerning privacy, security, and electronic transactions. If you want more information about our privacy practices, or have questions or concerns, visit our website at arisehealthplan.com, or contact our Privacy Officer at: Arise Health Plan WPSprivacyofficer@wpsic.com Privacy Office Phone: W. Broadway P.O. Box 8190 Madison, WI Arise Health Plan Provider Directory

44 MEMBER GRIEVANCE PROCEDURES This section includes the appeal rights and grievance procedure for covered persons of plans that are governed by the Employee Retirement Income Security Act of 1974 (ERISA). Members of ERISA plans have the right to file a civil action under Section 502 (a) of ERISA if a health plan fails to establish or follow claims procedures, or after all appeals outlined in this section have been completed. Many grievances are based on adverse benefit determinations which deal with a denial, reduction, or termination of, or a failure to provide or make payment for a benefit. For fully insured plans, a grievance can also be based on any dissatisfaction with the administration, claims practices, or provision of services by Arise that is expressed in writing to the Arise Grievance department, by, or on behalf of, a covered person. A Grievance Committee is convened every other Tuesday to review all grievances. The Grievance Committee is comprised of Arise representatives, including a clinical representative, and an enrollee. Any covered person who files a grievance will be notified of his/her right to appear in person before the Grievance Committee. The covered person, or an authorized representative, may present written or oral information and ask any questions relating to the grievance. Arise will send the covered person written notice of the time and place the covered person may appear before the Grievance Committee at least seven calendar days prior to the appearance date. Following a thorough review of the case, the Grievance Committee votes on the resolution. A resolution letter is sent within 10 calendar days. Grievances are generally resolved within 60 calendar days. If the person s medical condition warrants, the grievance may be expedited and resolved within 72 hours. INDEPENDENT REVIEW The independent review process provides members with an opportunity to have an independent review organization (IRO) review their dispute. An IRO will be randomly selected by Arise to review the dispute. Only disputes that involve medical judgment can be decided through independent review. Members may request an independent review if they were denied coverage for treatment because we have determined that the treatment is primarily for one of the following: Cosmetic purposes Not medically necessary Experimental Investigative This includes the denial of a referral request if the member has a provisional referral benefit on their PPO plan. Members may also request an independent review if they disagree with our determination regarding the diagnosis and level of service for treatment of autism. Members may also request an independent review based on a rescission of coverage. The treatment must be a covered benefit under the insurance contract; benefits specifically excluded from the member s benefit contract are not eligible for independent review. Within four (4) months after receiving notice of the disposition of their grievance, members may send a written request for an independent review to: Arise Health Plan Attn: Grievance Coordinator PO Box Green Bay, WI Fax: RECONSIDERATIONS In addition, a practitioner has the opportunity to appeal an adverse determination (denial) by submitting any additional information orally and/or in writing with a request for reconsideration. CONTACT INFORMATION For additional information on grievance, appeals, independent review, and reconsiderations, please see our website at arisehealthplan.com for more information 44 Arise Health Plan Provider Directory

45 CLAIM PAYMENT POLICIES PAPER CLAIM SUBMISSIONS If you choose to submit paper claims, the claim must be submitted using industry-standard formats, on industry standard forms, using the required specific code set as promulgated by HIPAA. The claim submission must communicate all of the following required elements to ensure accurate and timely claim payment: Who was treated and why Services provided Amount billed for those services Where those services were rendered Who rendered those services The above data is also essential for state, national, and accrediting body reporting requirements. Paper claims submission address: Arise Health Plan P.O. Box Eagan, MN ELECTRONIC SUBMISSION INFORMATION Arise strongly recommends submitting claims electronically in order to expedite claim processing. This submission format is available for situations in which Arise is the primary, as well as the secondary carrier. The WPS Corporate Services EDI (Electronic Data Interchange) department has a dedicated team whose primary function is to consult and assist providers with the EDI process. Our team is experienced in dealing with a variety of provider specialties, billing services, and software vendors. To begin taking advantage of EDI transactions, you will need to complete our Electronic Transaction Enrollment process at wpsic.com/edi/edi-forms.shtml. If you currently send your claims through ClaimsNet clearinghouse, you may continue to do so, and ClaimsNet will forward them to Arise. If you have questions, edi@wpsic.com or call the EDI Help Desk at , option 1. TIMELY FILING OF CLAIMS If you are an Arise contracted participating provider, please refer to your Arise Participating Provider Agreement for timely filing provisions. Claims must be received within the time frame specified, so please submit as soon as possible following the date of service to expedite the claim payment process. The timely filing period for coordination of benefits (COB) claims begins from the date of the primary payer s explanation of benefits (EOB). Arise is not obligated to pay claims received after the timely filing provisions of the Arise Participating Provider Agreement or the member s benefit plan. CES Arise uses CES software to automatically review claim submissions for appropriate claim coding. This includes edits for procedures that are age-specific, bundling/unbundling, global billing and follow-up services, and thresholds for billed units. CES reviews may result in an adjustment of the claim and/or payment as a result of the rules contained within the CES software. Arise provides an online tool for providers to simulate code combinations for professional services billed on a HCFA 1500 claim form. It offers the capability to view edit results and rationale. Providers can enter procedure codes, modifiers, diagnosis codes, date of service, patient gender, date of birth, and place of service parameters to review results specific to the procedure codes being billed. The results and rationale will be displayed and can be downloaded as a PDF. This online tool allows for greater transparency of the code combination edits applied by Arise. 45 Arise Health Plan Provider Directory

46 This web application is available to all contracted providers through the Provider Portal on arisehealthplan.com/providers. To register for a Provider Portal account, register@wpsic.com with the following information: administrator name, address, tax ID, and practice name. Once your account is set up, the Site Administrator Guide and Sub Users Guide can help walk you through the various site areas. Hospital bill audit Arise uses HealthDataInsights (HDI) to perform on-site audits of large hospital bills. HDI has signed a Business Associate Agreement with Arise to comply with appropriate HIPAA privacy requirements. The primary focus of HDI is to audit hospital inpatient bills for potential errors and to work with hospitals to: Issue any refunds due to Arise from these audits Identify charges that were not previously billed to Arise, which can result in adjustments Reimbursement Policies When processing claims, we follow industry standards relating to standard billing modifiers and coding similar to those established in UB-04 and CMS Medicare Database. To view our reimbursement policies, visit arisehealthplan.com, and click Providers, then Policies, and finally Reimbursement. CORRECTED CLAMS/RESUBMISSION Electronic Claim On occasion, you may need to correct a claim that was already filed with Arise electronically. When you refile the claim electronically, be sure to use the appropriate bill type for the services provided, along with the original claim identification number supplied on the 835 remit. This will help expedite the reprocessing of a corrected claim and help reduce the time it will take to finalize the claim. When submitting corrected claims electronically: Enter Claim Frequency Type code (billing code) 7 for a replacement/correction, or 8 to void a prior claim, in the 2300 loop in the CLM* Enter the original claim number in the 2300 loop in the REF*F8*. Paper Claim When submitting a corrected claim via paper submission, include the Corrected Claim Form found on the Provider Forms area of our website. Be sure to use the appropriate bill type for the services being provided in box 4 of the UB form and box 22 of the HCFA form. This will allow us to process your corrected claim in a timelier manner. Paper corrected claims sent without the cover sheet will be returned to you. If you are unsure of the correct bill type to use, please refer to your HIPAA implementation guide for institutional and professional claims. Remember to re-file the claim using the Arise original claim identification number referenced on your 835 remit. Corrected claims, along with any other claims or claim-related correspondence, should be sent to: Arise Health Plan P.O. Box Eagan, MN Arise Health Plan Provider Directory

47 PROVIDER CREDENTIALING, RE-CREDENTIALING, AND UPDATES Arise has its own internal Credentialing Department. This department is responsible for the processing of initial and re-credentialing practitioner/provider applications. New/renewed licensures, malpractice insurance, DEA, and other pertinent certifications are submitted to this department. Arise credentials practitioners that have an independent relationship with us. An independent relationship exists when Arise selects and directs its members to see a specific practitioner or group of practitioners, including all practitioners that can be selected as PCPs. Arise conducts a pre-contractual assessment (initial credentialing) and an ongoing assessment (re-credentialing), thereafter, at least every three years, of the following professionals: Doctors of: Medicine (MD) Osteopathic medicine (DO) Podiatric medicine (DPM) Chiropractic (DC) Optometry (OD) Doctors of dental science (DDS); doctors of medical dentistry (DMD) who provide care under the medical benefit program Behavioral health care practitioners, including, but not limited to: Psychiatrists and other physicians Addiction medicine specialists Doctoral or master s level clinical psychologists (Ph.D. or Psy.D.) Master s level clinical nurse specialists or psychiatric nurse practitioners (NP, APNP) Licensed marriage and family therapists (LMFT) Licensed professional counselors (LPC) Licensed social workers (APSW, ISW, LCSW) Substance abuse counselors (SAC, CSAC) Master s level counselors (MA, MS, MSE, MSW, etc.) Behavioral analysts (LBA) Allied health professionals who are not hospital-based providers, including, but not limited to: Advanced practice nurse prescribers (APNP) Masters level nurse practitioners (NP, FNP, WHNP, etc.) Certified nurse midwives (CNM) Physician assistants (PA or PAC) Audiologists (AuD) Registered dietitians (RD) Physical therapists (PT) Occupational therapists (OT) Speech and language pathologists (SLP) Other allied health professionals who have an independent relationship with us and are not part of an organization or group of practitioners: Covering practitioners (Locum Tenens) who provide services for a period of time longer than six (6) months. Practitioners who are hospital-based, but see members outside of the inpatient hospital setting or outside freestanding, ambulatory facilities as a result of their independent relationship with the plan (pain medicine, radiation oncology). Rental networks that are part of the Arise network and have members who reside in the rental network area OR are specifically for out-of-area care and members may see only those practitioners or are given an incentive to see rental network practitioners. Telehealth practitioners who provide care to members under Arise medical benefits. 47 Arise Health Plan Provider Directory

48 The decision to credential or re-credential a practitioner is based on the information assembled, including, but not limited to, the information gathered through a completed application and primary source verification. Credentialing/ re-credentialing criteria are used to establish consistent, clear objectives for the credentialing/re-credentialing of practitioners. The credentialing/re-credentialing decision to approve or deny the applicant is determined by the Credentials Committee. Arise credentialing decisions are not based on an applicant s race, ethnic/national identity, gender, age, sexual orientation, or the types of procedures or patients in which the practitioner specializes. This does not preclude Arise from including in its network practitioners who meet certain demographic or specialty needs. During the credentialing process You may request, in writing, all application and credentialing verification policies and procedures. You have the right to review information submitted to support your credentialing application. You may request information regarding the status of your application at any time. You will be promptly notified of information that varies significantly from the information you have provided and be given the opportunity to submit updated/additional documentation or corrections. Notification of the Credentials Committee decision regarding your application will be sent via written letter promptly after the meeting at which your application is presented. Note: Approval of your credentialing application is not indicative of contract effective date. Contact the Network Development Department at or GBNetworkDevelopmentDept@AriseHealthPlan.com for your official effective date. Organizational Provider Credentialing Arise conducts a pre-contractual assessment of each organizational provider that it is contracted with, and an ongoing assessment at least every three years. Organizational providers include: Hospitals Home health agencies Skilled nursing facilities Hospices Freestanding surgical centers Behavioral health facilities providing mental health or substance abuse services in an inpatient, residential, or ambulatory setting Dialysis centers Clinical laboratories Comprehensive Outpatient Rehabilitation Facilities (CORFs) Portable X-ray supplies Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Arise shall confirm that the organizational provider: Meets all state and federal licensing and regulatory requirements in good standing Has proof of adequate liability insurance Has evidence of accreditation or site visit by a recognized accrediting body or current CMS certification. For questions, contact the Credentialing Department at: Arise Health Plan P.O. Box Green Bay, WI Phone: or Fax: or GBCredentialingDepartment@AriseHealthPlan.com 48 Arise Health Plan Provider Directory

49 CONTINUITY OF CARE Under certain circumstances, if a covered person s PCP or specialist leaves our network, the covered person may continue to receive care from that practitioner. We will continue to provide coverage for services from a practitioner who terminates from Arise under the following circumstances: The practitioner continues to practice within the geographical service area. The practitioner did not terminate with the health plan due to misconduct. We represented that the practitioner was, or would be, participating in Arise marketing materials available to the covered person at the time of their initial enrollment, most recent coverage renewal, or most recent openenrollment period, whichever is later. If the practitioner is the covered person s PCP at the time of termination, we will continue to cover services provided by that practitioner until the end of the plan year. If the covered person is undergoing a course of treatment with a specialist who terminates, we will continue to cover non-maternity services from that specialist for the following period of time: For the remainder of the course of treatment or for 90 days after the specialist s participation terminates, whichever is shorter. Certain groups cover specialty services until the end of the current plan year for which it was represented that the specialist was, or would be, participating. If the covered person is receiving maternity care from a practitioner other than the covered person s PCP, and the covered person is in the second or third trimester of pregnancy when the practitioner s participation terminates, we will continue to cover practitioner s services from that provider until the completion of postpartum care for the mother and infant. NOTIFICATION TO MEMBERS AFFECTED BY THE TERMINATION OF A SPECIALIST OR PCP Arise takes responsibility for notifying affected members of specialist or PCP terminations from the network and options for receiving continued care. Notification is not done if the specialist or PCP moves outside the service area, is terminated for cause, retires, or is no longer caring for patients in the same manner as their prior practice. 49 Arise Health Plan Provider Directory