Privacy Information Services Not Covered by UPMC for Life Review and Approval of Medical Procedures
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1 2016 Privacy Information Services Not Covered by UPMC for Life Review and Approval of Medical Procedures Y0069_16_1075 Accepted
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3 Review this important information about your health care coverage. This booklet contains information that can help you if you decide to become a member of UPMC for Life. Please keep this with your important papers for future reference. These materials will help you understand: UPMC Health Plan s responsibility to keep your personal health information private. Which services are not covered by UPMC for Life. The process used to review utilization of health care resources. You can also access these materials online at under the Additional Documents and Forms page. UPMC for Life Member Contact Information If you have questions or need help while you are a member of UPMC for Life, please call our Member Services Department at , seven days a week from 8 a.m. to 8 p.m. TTY users should call Our hours of operation change twice a year. You can call us October 1 through February 14, seven days a week from 8 a.m. to 8 p.m. From February 15 through September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. UPMC for Life has a contract with Medicare to provide HMO and PPO plans. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., and UPMC Health Benefits Inc. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 1
4 Privacy Statement That s right your personal information is private and confidential. We at UPMC Health Plan want to take this opportunity to remind you of this trust that we establish with you. It is a pledge that we take seriously. Whether you are a prospective, current, or former member, living or deceased, we respect and safeguard the privacy and confidentiality of the information we have about you on file. Privacy is one of your rights as a consumer as well as a UPMC Health Plan member. It also is a right that you retain even when you are no longer a member of UPMC Health Plan. But what does private and confidential really mean? When you fill out your enrollment or renewal application form and sign it you are doing two important things: 1. Verifying the correctness and truthfulness of the information that you have provided to us. 2. Acknowledging that UPMC Health Plan can only use the information we collect or receive about you and your family for very well-defined routine purposes: Arranging for the provision of health care treatment and services to you and your family members that you are enrolling as dependents on your application. Making payment to doctors, hospitals, and other health care professionals for the treatment and services you and your family receive. Performing certain health care operations that UPMC Health Plan uses to monitor the quality of the health care coverage and services you have chosen for you and your family. These operations include measurement and review of all our data to see how many of our members receive certain services, such as childhood immunizations, mammograms, and other preventive health services. All of these measurements are used so we can assess how well we are doing in providing quality health care to all our members. Your personal information covers a number of elements that all have one thing in common: they are all unique to you; they can be used to identify you. This means that any files containing information that include such things as your name, address, social security number, and birth date are considered protected health information. It is our responsibility to ensure the privacy of the protected health information of all our members prospective, current, or former. 2
5 The files that a managed care organization collects or maintains include things such as the claims we have received and paid for, the services provided to you, or the health care premiums that you or your company have paid. So whether the protected health information we have is considered health information or non-public personal financial information we only use the information we have in our files within our company and with our contracted providers, vendors, and agents for the purposes of your health care insurance. Other than for the well-defined, routine purposes described above, or as required by law, the only one who has access to your personal information and records is you. UPMC Health Plan does not share your protected health information with anyone else including employers unless you provide us with permission to do so. Any reports to employers about the services provided to their employees are based only on total employee group percentages and totals and not on any individual member data or information. Not only do all the physicians and providers in our network know that your information is private and confidential, but our Health Plan employees know that too. In fact, we have training programs for our employees to seek to assure that they know the procedures they need to follow to make sure that your information whether in oral, written, or electronic format is secure and safeguarded. We will not disclose information for any purposes beyond the provision of your health care coverage, unless authorized by you in writing or required to do so by law. If we have any additional programs that we feel would be beneficial to you and that would require us to use your specific personal information in order to let you participate in the program, we would contact you and let you know all the details. We would request your permission and signed authorization before we would use your personal information for anything other than routine purposes that we have explained. If you decline such a request, your information will not be part of the special program enrollment. You undoubtedly have heard a great deal about privacy in the news especially as it concerns federal legislation about privacy of health information. In addition to any new legislation, all health insurance carriers and health care providers are following the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and several important sets of regulations that government agencies have recently issued for HIPAA implementation and compliance. In fact, because the HIPAA Privacy Regulations require doctors, hospitals, and health care insurers as well as employee benefit plans that are involved in your health care to have a Notice of Privacy Practices, you will probably be receiving several of these notices. In addition to this Privacy Statement, UPMC Health Plan s Notice of Privacy Practices will give you even more specific information and details about how we ensure the privacy of your protected health information. The Notice will also explain all the rights that you have concerning the privacy of your health information and how you can exercise those rights. 3
6 UPMC Health Plan, through its Compliance Committee and Quality Improvement Committee, monitors all applicable laws and government regulations. We continually review our policies and procedures to seek to assure that we are meeting the needs of privacy laws and our commitment to our members. As new laws are passed and new regulations are issued or clarified, we will be providing you with revised information with any changes or updates. If you become a UPMC for Life member, you will receive your Notice of Privacy Practices in your member welcome kit. You can also find this information online on the UPMC for Life website at under Additional Plan Documents and Forms. If you have any questions concerning your right to the privacy and confidentiality of your personal information and data that have been entrusted to UPMC Health Plan, please contact our Member Services Department at the phone number listed on page 1 of this booklet. Contact Information: Specific inquiries about this statement regarding HIPAA readiness and compliance should be directed to: HIPAA Privacy Officer U.S. Steel Tower 600 Grant Street Pittsburgh, PA HealthPlanHIPAAOffice@upmc.edu 4
7 Services Not Covered by UPMC for Life The following is a list of medical services that are not covered and will not be paid for by UPMC for Life plans. For complete details regarding covered and non-covered services, UPMC for Life members should refer to their Evidence of Coverage Please Note: For UPMC for Life members enrolled in an HMO plan, services that you get from non-plan providers will not be covered. Only a few exceptions apply to care received in a medical emergency, urgently needed care, renal (kidney) dialysis services that you get when you are temporarily outside the plan s service area, and care from non-plan providers that is arranged or approved by our plan in advance. 1. Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as covered services. 2. Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under a Medicare-approved clinical research study or by our plan. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. 3. Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare. 4. Private room in a hospital, except when it is considered medically necessary. 5. Private duty nurses. 6. Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television. 7. Full-time nursing care in your home. 8. Custodial care is care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing. 9. Homemaker services include basic household assistance, including light housekeeping or light meal preparation. 10. Fees charged by your immediate relatives or members of your household. 11. Meals delivered to your home. 12. Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary. 13. Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. 5
8 14. Routine dental care, such as cleanings, fillings or dentures. Some individual and employer group plans may provide coverage for these services. However, nonroutine dental care required to treat illness or injury may be covered as inpatient or outpatient care. 15. Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines, is generally not covered under the plan (with the exception of routine visits that may be covered on some of our plans). 16. Routine foot care, except for the limited coverage provided according to Medicare guidelines, is generally not covered under this plan (with the exception of routine visits that may be covered on some of our plans). 17. Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease. 18. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease. 19. Routine hearing exams, hearing aids, or exams to fit hearing aids. Some individual and employer group plans may provide coverage for these services. 20. Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy and other low vision aids. Some individual and employer group plans may provide coverage for these services. However, eyeglasses are covered for people after cataract surgery. 21. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies. 22. Acupuncture. 23. Naturopath services (uses natural or alternative treatments). 24. Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at VA hospital and the VA cost-sharing is more than the cost-sharing under our plan, we will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts. 25. The plan will not cover the excluded services listed above. Even if you receive the services at an emergency facility, the excluded services are still not covered. 6
9 Review and Approval of Medical Procedures UPMC Health Plan is committed to the delivery of appropriate care and does not use incentives to reward inappropriate restrictions of care. UPMC Health Plan affirms that: Utilization Management decision-making is based on reasonable clinical evidence, UPMC Health Plan policies, and nationally recognized utilization guidelines. UPMC Health Plan does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. No financial incentives are given to utilization management decision-makers to encourage decisions that result in underutilization. UPMC Health Plan provides access for members to obtain information about the utilization process and authorization decisions. The utilization management staff is available to provide information on how a decision was made. Members may obtain a copy of the criteria on which the decision was based. If you are a current UPMC for Life member, inquiries can be made by calling Member Services at the phone number listed on page 1 of this booklet. Information about behavioral health utilization matters can be obtained by calling TTY users should call Utilization Review Process Our role as a financial and medical steward of your health care requires that UPMC Health Plan reviews and approves certain medical procedures and services before these procedures and services are provided. This review process is referred to as a pre-service review or prior authorization process, and is conducted by clinical staff in our Clinical Operations/Medical Management and Pharmacy departments. These staff members conduct Utilization Reviews (UR) to promote the appropriate use of health care resources. Their aim is to assess whether the proposed services, care, or medication requests meet medical necessity criteria and, consequently, whether the request for payment will be covered under your health benefits. In addition to the prior authorization process, the utilization review process includes other types of reviews to determine reimbursement for medical services. These include concurrent reviews, retrospective (post-service) reviews, and discharge planning reviews. Concurrent reviews are performed when you or your provider request an extension of an ongoing course of treatment that has previously been approved. The request may be for an extended period of time or an increase in the number of treatments. Retrospective reviews assess appropriateness of medical services after services have been provided. A discharge planning review includes a comprehensive evaluation of your health needs to assist in the planning of care following discharge from an inpatient setting. UPMC Health Plan s clinical staff will communicate with your health care providers about these review processes. 7
10 Copyright 2015 UPMC Health Plan Inc. All rights reserved. 2016_INDGRPMNDYDC_15MCID0451
Y0069_15_3006 Approved
2015 Privacy Information Services Not Covered by UPMC for You Advantage (HMO SNP), UPMC for Life Options (HMO SNP), and UPMC Community Care (HMO SNP) Review and Approval of Medical Procedures Y0069_15_3006
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