Please note: Members are entitled to vision benefits only under this separate vision service program.

Transcription

1 Member Benefits The Health Plan Member Handbook is the primary source of information regarding The Health Plan member benefits. The Health Plan Member Handbook is available upon request. Office Copayments Members with a $0, $5, $10, $15, $20 copayment will have the same handbook, with the exception of the office copay amounts. Office copayments will be listed on the member s ID card, in order to assist in identifying the different benefit designs. Prescription Riders The Health Plan provides a separate card to identify prescription benefits to members. Those without prescription coverage will have NO or N on their cards. Vision Benefits The Health Plan offers benefit riders for vision benefits administered through Vision Service Plan (VSP). Providers must be a participating provider with VSP to be eligible to offer covered vision services. You will need to verify vision coverage through VSP at Please note: Members are entitled to vision benefits only under this separate vision service program. Members may require ophthalmologic medical services in conjunction with a medical condition. These medical services must be offered through The Health Plan contracted ophthalmologist or optometrist. A referral from the primary care physician (PCP) is required, in order for the member to obtain medical services from an ophthalmologist or optometrist. Product Matrix The Product Matrix lists all of the products offered by The Health Plan. This matrix identifies the basic plan design of each product and includes a sample ID card.

2 Fully-Insured HMO Plans Fully-insured Health Maintenance Organizations (HMO) Plans are plans that are fully insured by a Health Insuring Corporation (HIC). Employer groups with a minimum size of two employees contract with The Health Plan to provide a health insurance benefit plan and pay a monthly premium to cover eligible employees. The Plan assumes the responsibility for providing the benefit package, administering all aspects of the plan and the risk for paying for all covered services. These plans require a member to choose a primary care physician (PCP), and although The Health Plan has eliminated the need for the PCP to call in a referral for specialty physician services, the member must be referred by their PCP and to follow precertification guidelines for procedures, diagnostic testing, outpatient surgical procedures, and inpatient admissions. Members do not have out-of-network benefits unless authorized by the plan. HMO benefit plans generally have copays for: Primary and specialty care physician office visits Emergency room services Urgent care Outpatient mental health Physical, occupational, and speech therapy Durable medical equipment BioTech drugs Members may have a deductible and coinsurance associated with their benefit plan, as well as medical copayments for laboratory and X-rays, not associated with preventive services, depending on the plan.

3 SecureCare HMO Medicare Advantage Plan The Health Plan has entered into a contract with the Centers for Medicare and Medicaid Services (CMS), the federal agency that administers the Medicare program. Under this contract, CMS makes a monthly payment to The Health Plan for each Medicare beneficiary who enrolls in our Plan. This contract requires The Health Plan to provide comprehensive health services to persons who are entitled to Medicare benefits and who choose to enroll in The Health Plan. The Health Plan receives a set rate for each member plus any enrollee premium. Medicare Advantage benefit plans generally have copays for: Primary and specialty care physician office visits Inpatient admissions Skilled nursing home services Emergency room services Urgent care Outpatient mental health visits Physical, occupational, and speech therapy Biological drugs Durable medical equipment In keeping with our mission, we have identified members rights, along with their responsibilities, that are clearly indicated in the member's handbook. It is imperative that you be aware of these rights and responsibilities as a participating provider with The Health Plan. You are expected to assist our members by making them aware of their rights and by supporting these within your practice. Please refer to this section of the manual for important information regarding CMS quality standards that you are required to meet when caring for Medicare Advantage enrollees. The following Member Services Department is available to assist with any member issues that may arise at or

4 Appeals Overview When an enrollee requests coverage for a particular service, the decision on whether to provide such coverage is considered an ORGANIZATION DETERMINATION. Enrollees have a right within 60 days of a denial to request either a standard (30-day) or expedited (72 hours) reconsideration whenever a Medicare Advantage organization has denied an enrollee s request for services (denied claim/referral). Where the Medicare Advantage organization affirms its advice Organization Determination in whole or in part, the Medicare Advantage organization must automatically forward the case file to CMS independent review entity so that it may make a final reconsidered determination. CMS contracts with MAXIMUS Federal Service, Inc. Appeals may be made by an enrollee, a provider, or by a person authorized to act on behalf of an enrollee, including the Social Security Administration office and the Railroad Retirement Beneficiary. A provider may be appointed, as an enrollee s representative, either by signing a written statement or by completing a standard form. When a provider acts as the representative of a beneficiary, both the beneficiary and the provider should sign a written appointment of representative statement. This form is provided for your use. The detailed appeals policy is available upon request. Provision of Non-Covered Services CMS views contracted providers as extensions of the MA plan and CMS no longer recognizes the traditional ABN for MA plans (they still recognize it for Traditional Medicare). If a member wants to receive a non-covered service, then either the member needs to call customer service or the provider needs to call the pre-auth department prior to services being rendered and request an Organizational Determination (OD). Through the OD process, both the member and provider will then receive a letter indicating the member can be billed for these non-covered services. The only other option would be for the contracted MA provider to NOT BILL The Health Plan for the noncovered services. Then they could bill the member directly. However, the member may request the MA plan be billed prior to the member paying, and in that instance, the claim would be denied as not covered, do not bill patient.

5 Appointment of Representative Statement Beneficiary Name Medicare Number Provider Dates of Service The Health Plan I do hereby swear that I am the above mentioned beneficiary or an authorized representative of the above mentioned beneficiary. I do hereby appoint the following individual to act as my representative in requesting a reconsideration from The Health Plan and/or the Healthcare Financing Administration, or its designee regarding the services for which the health plan has denied payment or authorization. Signature Date

6 SecureChoice PPO Medicare Advantage Plan SecureChoice PPO is The Health Plan s Medicare Advantage Preferred Provider Organization (PPO) option. SecureChoice PPO members are not required to select a primary care physician (PCP) and referrals to specialists are not required. All Health Plan preauthorization requirements apply. The SecureChoice PPO plan provides benefits at an In-Network level from The Health Plan s extensive network of participating providers. The SecureChoice PPO plan also provides benefits to SecureChoice PPO members at an Out-of- Network level from any Medicare provider of choice at an additional out-of-pocket expense to the member. The benefits for SecureChoice PPO members are identical to traditional Medicare benefits, in addition to enhanced benefits that are offered by The Health Plan. It is imperative that you are aware of these rights and responsibilities as a participating provider with The Health Plan. You are expected to assist our members by making them aware of their rights and by supporting these within your practice. Please refer to this section of the manual for important information regarding Centers for Medicare and Medicaid Services (CMS) quality standards you are required to meet when caring for Medicare Advantage enrollees. The following Member Services Department is available to assist with any member issues that may arise at or Appeals Overview When an enrollee requests coverage for a particular service, the decision on whether to provide such coverage is considered an ORGANIZATION DETERMINATION. Enrollees have a right within 60 days of a denial to request either a standard (30-day) or expedited (72 hours) reconsideration whenever a Medicare Advantage organization has denied an enrollee s request for services (denied claim/referral). Where the Medicare Advantage organization affirms its advice Organization Determination in whole or in part, the Medicare Advantage organization must automatically forward the case file to CMS independent review entity so that it may make a final reconsidered determination. CMS contracts with MAXIMUS Federal Service, Inc. Appeals may be made by an enrollee, a provider, or by a person authorized to act on behalf of an enrollee, including the Social Security Administration office and the Railroad Retirement Beneficiary. A provider may be appointed, as an enrollee s representative, either by signing a written statement or by completing a standard form. When a provider acts as the representative of a beneficiary, both the beneficiary and the provider should sign a written appointment of representative statement. This form is provided for your use. The detailed appeals policy is available upon request.

7 Appointment of Representative Statement Beneficiary Name Medicare Number Provider Dates of Service The Health Plan I do hereby swear that I am the above mentioned beneficiary or an authorized representative of the above mentioned beneficiary. I do hereby appoint the following individual to act as my representative in requesting a reconsideration from The Health Plan and/or the Healthcare Financing Administration, or its designee regarding the services for which the health plan has denied payment or authorization. Signature Date

8 D-SNP Program Medicare Advantage Special Needs Plan Effective January 1, 2014, The Health Plan will administer a Medicare Special Needs Plan (SNP) for those members who have a chronic condition. The special needs population are those recipients who qualify for both Medicare and Medicaid. These dual eligibles are individuals who are entitled to Medicare and are also eligible for some level of assistance from their state Medicaid program. The Health Plan received approval as a contracted MA-PD plan that is offering a new SNP program by completing a Model of Care (MOC) for Centers for Medicare and Medicaid Services (CMS). This approval applied to the dual-eligible Special Needs Plan (D-SNP). The Health Plan has developed the MOC to provide comprehensive care management to members enrolled in the D-SNP. The Health Plan s MOC is a written document describing measureable goals of the program, along with The Health Plan staff structure and care management roles, the Interdisciplinary Care Team (ICT), and the use of clinical practice guidelines and protocols, training for personnel and our providers, a health risk assessment tool to collect information, the development of an individualized care plan, communication efforts, care management for the most vulnerable sub-populations, and performance and health outcome measures. MEASUREABLE GOALS Improve access to essential services including medical, behavioral health, and social services by providing a comprehensive network. Every SNP member will be assigned a case manager with social services readily available. SNP members will select a primary care physician (PCP) and a THP case manager will be assigned to the member. Streamline the process of transition of care across health care settings, providers, and health services coordinated by the physician/provider and the care manager. Improve access to preventive care. Improve member health outcomes through participating annual Healthcare Effectiveness Data and Information Set (HEDIS ) data collection, as well as member surveys. The above list is just a brief description of some of our measureable goals. PROVIDER REIMBURSEMENT AND BILLING The provider will bill The Health Plan for medically appropriate covered services provided to the D-SNP member. The Health Plan will reimburse the provider for services rendered according to the member s

9 benefit plan, less any copays, coinsurance, or deductible amounts. The provider will then be eligible to submit any balance associated with the copays, coinsurance, and deductible directly to West Virginia or Ohio Medicaid program. PROVIDER EDUCATION Provider education will be conducted by several approaches: face-to-face, web-based training, seminars and ProviderFocus newsletter articles. Additional information regarding the SNP program will be forthcoming. To access our MOC and the D-SNP MOC Annual Training presentations, visit our website under Providers/Knowledge/Resources. To obtain referrals or eligibility information please call our Customer Service Department at or Appeals Overview When an enrollee requests coverage for a particular service, the decision on whether to provide such coverage is considered an ORGANIZATION DETERMINATION. Enrollees have a right within 60 days of a denial to request either a standard (30-day) or expedited (72 hours) reconsideration whenever a Medicare Advantage organization has denied an enrollee s request for services (denied claim/referral). Where the Medicare Advantage organization affirms its advice Organization Determination in whole or in part, the Medicare Advantage organization must automatically forward the case file to CMS independent review entity so that it may make a final reconsidered determination. CMS contracts with MAXIMUS Federal Service, Inc. Appeals may be made by an enrollee, a provider, or by a person authorized to act on behalf of an enrollee, including the Social Security Administration office and the Railroad Retirement Beneficiary. A provider may be appointed, as an enrollee s representative, either by signing a written statement or by completing a standard form. When a provider acts as the representative of a beneficiary, both the beneficiary and the provider should sign a written appointment of representative statement. This form is provided for your use. The detailed appeals policy is available upon request.

10 Appointment of Representative Statement Beneficiary Name Medicare Number Provider Dates of Service The Health Plan I do hereby swear that I am the above mentioned beneficiary or an authorized representative of the above mentioned beneficiary. I do hereby appoint the following individual to act as my representative in requesting a reconsideration from The Health Plan and/or the Healthcare Financing Administration, or its designee regarding the services for which the health plan has denied payment or authorization. Signature Date

11 Notice of Medicare Noncoverage (NOMNC) When The Health Plan has, for a Medicare Advantage member, authorized coverage of an inpatient admission or the admission was an emergency or urgently needed care, the member remains entitled to inpatient hospital care until he/she receives a Notice of Discharge and Medical Appeal Rights, formerly known as the Notice of Noncoverage (NOMNC). Physician s concurrence with the notice is required. A member who wishes to appeal the determination made by The Health Plan that inpatient care is no longer medically necessary must request an immediate review by the Peer Review Organization (PRO) of the determination. The member must request the immediate PRO review by noon of the first working day after receipt of the notice. The member will not be financially responsible for the hospital care until the PRO makes its decision. If the admission was not authorized by The Health Plan or the admission did not constitute emergency or urgently needed care and the PRO upholds The Health Plan s determination, the member is financially responsible for the hospital costs. A member who fails to request an immediate PRO review may request expedited reconsideration by The Health Plan through the appeal process.

12 Coordination of Benefits Medicare Advantage Secondary Payer Medicare Advantage is not always the primary payer for health insurance claims. The Health Plan will comply with the Centers for Medicare and Medicaid Services (CMS) requirement to provide information pertaining to claims in which Medicare Advantage is secondary. Medicare Advantage is the secondary payer where the beneficiary is entitled to veteran s benefits, workers compensation, black lung benefits, or employer group coverage based on the Medicare Secondary Payer Guidelines.

13 THP Insurance Company Medicare Supplemental Plans Medicare beneficiaries who have Medicare as their primary insurance pay a monthly premium to The Health Plan to cover their Medicare deductibles and coinsurance. The Plan provides benefit packages that are designed by Medicare and administer all aspects of the plan in accordance with Medicare guidelines. These plans DO NOT require a member to choose a primary care physician (PCP) or obtain a referral for specialty physician services.

14 Administrative Services Only (ASO) Self-Funded Employer Groups Many employers choose to pay claims as they are incurred, rather than pay a prepaid monthly premium for their employee s medical benefits. The Health Plan offers Administrative Services Only (ASO) to assist these employers with administering their benefit plan. The Plan offers them a contracted network of providers, utilization management services, and claims processing. These plans are most often designed by the employer group and administered by The Health Plan. These plans benefits, copays, deductibles, and ID cards may vary from the standard insured plans offered by The Health Plan.

15 Mountain Health Trust West Virginia Health Bridge (WV Medicaid Program) Mountain Health Trust (MHT) and WV Health Bridge are fully insured managed care plans offered to Medicaid-eligible residents of West Virginia. The plan requires a member to select a primary care physician (PCP), obtain a referral for specialty physician services, and follow precertification guidelines for procedures, diagnostic testing, outpatient surgical procedures, and inpatient admissions. Members do not have out-of network benefits unless prior authorized by the Plan. Under the Medicaid programs, the state of West Virginia determines eligibility and enrollment through a broker hired by the state of West Virginia for enrollment services. Once the member selects The Health Plan, we are notified electronically of enrollment. At that time, a packet of information is sent to the member, along with The Health Plan ID card. The MHT and WVHB member will have two cards. The Health Plan ID card, as well as the West Virginia Medicaid card, issued annually, showing eligibility. The Health Plan will not reissue their ID card each month with the exception of a replacement ID card for a lost or misplaced ID card. The date appearing on The Health Plan ID card is the actual date the card printed and not the effective date of coverage. The effective date of coverage is always the first of the month, except for a newborn. You may contact The Health Plan Customer Service Department at or to check eligibility or if you have any question regarding MHT and WVHB programs. Eligibility, benefits, and claims status is available through our provider secure portal.

16 Fully-Insured Point-of-Service (POS) Plans Fully-insured Point-of-Service (POS) Plans are fully insured by a Health Insuring Corporation (HIC). Employer groups with a minimum size of two employees contract with The Health Plan to provide a health insurance benefit plan and pay a monthly premium to cover eligible employees. POS plans are designed to allow members the freedom to choose between having their health care managed or arranged by their primary care physician (PCP) as In-Plan Option or the member has the option to manage and arrange their care as an Out-of-Plan Option. The Plan provides the benefit package giving the employer the option to choose from a variety of deductibles and copay plans. These plans require a member to choose a PCP, obtain a referral for specialty physician services, and follow precertification guidelines for procedures, diagnostic testing, outpatient surgical procedures, and inpatient admissions. Members have out-of-plan option benefits and may choose to access services outside The Health Plan network at an increase in their out-of-pocket expense for deductibles, copays, and coinsurance amounts. POS benefit plans generally have copays for: Primary and specialty care physician office visits Emergency room services Urgent care Outpatient mental health Physical, occupational, and speech therapy Durable medical equipment BioTech drugs Additionally, members are responsible for deductibles and coinsurance amounts associated with their plan benefit.

17 Noncovered Service Guidelines Occasionally, you and your patient may decide a service or treatment is the best course of care, even though it is not a covered item/service by Medicare or The Health Plan for Medicare Advantage SecureCare (HMO), SecureChoice (PPO), or SecureCare SNP (HMO SNP). If you believe the service may not be covered by Medicare or The Health Plan, you must inform the member before referring or performing the service. The Health Plan requires a written acknowledgment from the member or their authorized representative in the event a service or item will not be covered by The Health Plan and the member agrees to be solely responsible for paying the noncovered item and/or service. The Health Plan s intent is to provide the member with sufficient information, including cost, in order for the member or their authorized representative to make an informed decision about whether or not to obtain the item/service for which they will pay out-of-pocket for the service. This written acknowledgement is maintained in the member s medical record. Once the member agrees that they will be responsible for paying for the service, the service may be performed and the member may be billed for the noncovered services. Fully-Insured Preferred Provider Organization (PPO) Plans Fully-insured Preferred Provider Organization (PPO) Plans are fully insured by a Health Insuring Corporation (HIC). Employers contract with The Health Plan to provide a health insurance benefit plan and pre-pay a monthly premium to cover eligible employees. Members who are covered under the PPO Plan generally are not required to select a primary care physician (PCP) or obtain a referral for specialty physician services. All preauthorization guidelines for procedures, diagnostic testing, outpatient surgical procedures, and inpatient admission apply. By utilizing The Health Plan in-plan or tertiary network, members receive a higher level of benefits. Members who utilize out-of-network providers or fail to preauthorize a service will have increased out-of-pocket expenses for deductibles, copays, and coinsurance amounts. PPO benefit plans generally have copays for: Primary and specialty care physician office visits Emergency room services Urgent care Outpatient mental health benefits Physical, occupational, and speech therapy Durable medical equipment

18 BioTech drugs Additionally, members are responsible for deductibles and coinsurance amounts associated with their benefit plan.

19 Prescription Drug Riders THP members may obtain their prescription drugs at any participating THP pharmacy. A list of THP pharmacies is provided to the member at the time of their enrollment or upon renewal of coverage. To fill prescriptions, members need only present The Health Plan ID card to the pharmacist showing prescription benefits. They will be required to pay a copay at the time of service, based on their prescription drug benefits. The members ID card will give the variation of their copay. A qualified generic prescription is an order for a drug that is available from multiple sources. A qualified brand prescription must be available only from a single source supplier of the particular drug. Prescriptions must not be subject to any exclusions or limitations, as outlined in the Exclusions and Limitations section below. What is Covered? The Health Plan covers "legend prescription drugs" and medications only if such drugs are purchased at a participating THP pharmacy and are prescribed by a participating THP physician. Each prescription may be dispensed up to a 31-day supply. Legend prescription drugs" are those drugs which by federal law can be dispensed only pursuant to a prescription and which are required to bear the legend, "Caution: Federal law prohibits dispensing without a prescription. Out-of-Area Emergencies In situations of emergency, if there is a need for a prescription outside The Health Plan service area, please contact Express Scripts for the location of a participating pharmacy in that area at Present The Health Plan ID card, with the emergency prescription, and pay your copay. If no pharmacy in the area participates, you must purchase the emergency prescription then send your receipt to The Health Plan. You will be reimbursed in full, less your applicable copay, for the prescription, provided the prescription meets the guidelines specified in this document. Exclusions and Limitations The following will not be covered or paid for by The Health Plan: 1. The charge for any prescription refill other than the number set by the prescriber. No refills dispensed more than one year from the date of the original prescription. 2. The charge for any prescription oral, topical, or injectable that is prescribed for cosmetic purposes.

20 3. The charge for any medications not FDA approved for use in the general population. Use of a FDA approved drug in the treatment of a non-fda approved indication. 4. The charge for a drug not prescribed by a THP participating provider, except in true emergencies/urgent situations. 5. The charge for any medication covered by any workers' compensation or occupational disease laws, or any other group policy or government program that is not The Health Plan's program. 6. Vitamins, nutritional products, or supplements. Prenatal vitamins are covered when related to a pregnancy only. 7. Dental related prescriptions such as, but not limited to, dental mouthwashes or devices used in dental therapy. Oral fluorides will be covered, provided they meet preventive medication guidelines. 8. Prescriptions or some over-the-counter products related to smoking cessation are covered, providing they meet preventive medication guidelines. 9. Prescriptions for drugs or devices used to promote weight loss. 10. Prescriptions used to treat sexual dysfunction (oral, topical, or injectable), or devices used for impotence. 11. Prescription drugs (oral, topical, or injectable) for fertility, unless medically necessary. 12. Appliances and therapeutic devices, which require a prescription, are not covered. These include, but are not limited to, garments, splints, bandages, or braces regardless of intended use. 13. Over-the-counter aspirin, iron supplements, and folic acid are covered, providing they meet preventive medication guidelines. Insurance Fraud Warning: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

21 Vision Service Benefit Members enrolled through The Health Plan Commercial and Medicare programs may also have vision benefits. Those benefits are administered through Vision Service Plan (VSP). Please refer to resources available through VSP for information on benefits and coverages under the Vision Plan. Vision Service Plan (vsp.com) Monday through Friday 8:00 a.m. to 11:00 p.m. Saturday 9:00 a.m. to 8:00 p.m For assistance with translation, hearing impaired callers may call Members enrolled through The Health Plan WV Medicaid programs may have vision benefits. Those benefits are administered through Block Vision. Billing for Medical Eye Exams with a Vision Screening In most situations, a vision screening (CPT Determination of Refractive State) is considered noncovered under a medical benefit plan, but is often covered by a vision benefit plan. When there is the need to provide a vision screening as part of a medical exam, the following billing guidelines will assist you in obtaining appropriate reimbursement for the vision screening if there is a benefit that is available through The Health Plan s vision benefit vendors, provided you are a participating provider. Billing Procedures The visit is billed to The Health Plan on the appropriate CMS 1500 form with the following codes: 92002, 92004, 92012, or Eye Exam, new or established patient vs Determination of Refractive State After The Health Plan has made payment for the exam and denied the refraction as noncovered, you can then submit the visit code and the Determination of Refraction State to The Health Plan s vision provider, as long as you are a contracted provider, for payment of the refraction. You must include our payment voucher (with the page that shows the explanation of the denial codes) when submitting to VSP for the remaining portion. Vision provider will coordinate benefits with The Health Plan and pay only the refraction which is still due when a benefit is available to cover the refraction. If the member has a vision benefit through some other plan that is not associated with The Health Plan, you may also submit a claim for the refraction to that plan in the same manner and they will adjudicate the claim according to their plan guidelines.

22 The Health Plan encourages our diabetic members to see an in-plan ophthalmologist or optometrist for an annual dilated retinal exam (excludes self-funded ASO participants.) If a Determination of Refractive State is also done during the visit, the following billing procedures apply (please include Diabetic Dilated Fundus Examination Form). Without a referral and with a waiver of the associated office copayment. Once The Health Plan has made payment, you can then submit the visit code and the Determination of Refraction State to Vision Plan, for payment of the refraction. You must include our payment voucher when submitting to VSP for the remaining portion. VSP will coordinate benefits with The Health Plan and pay only the refraction which is still due.

23 Managed Workers Compensation Program In 1993, the Ohio General Assembly passed House Bill 107. This reform legislation initiated many changes in the Ohio Bureau of Workers Compensation (BWC) Program and mandated that the BWC develop a managed care system. The Health Partnership Program (HPP) was developed and required that all state-funded employers utilize a Managed Care Organization (MCO) for the medical management of their workers' compensation claims. The Health Plan Managed Workers Compensation Program, an Ohio BWC-certified MCO and URAC Accredited Care Management Organization medically manages workers compensation claims for statefunded employer groups and six self-insured employers. MCO ensure that the claimant receives appropriate and timely medical treatment focusing on a safe return to work. We are responsible for assisting claimants in obtaining quality medical care, while assisting the employers in controlling workers compensation costs. The Health Plan employs full-time registered nurse (RN) case managers, who work in conjunction with support staff, to provide quality medical management services to claimants, employers, and provider offices. Compensability (allowance) determination rests solely with the Ohio BWC. Reporting Requirements The provider is responsible for reporting all injuries to the MCO, utilizing the Ohio BWC First Report of Injury (FROI) 1, accompanied by supporting medical documentation within 24 hours of treatment. Methods of reporting: Faxing: Mailing: The Health Plan Managed Workers Compensation Program PO Box 97 St. Clairsville, OH Online: ohiobwc.com Online: healthplan.org The Ohio BWC will assign a claim number. The Ohio BWC will notify the provider of the claim number. The Health Plan has distributed ID cards identifying The Health Plan as the MCO for the employer group.

24 Medical Management and Treatment 60-Day Presumptive Authorization Guidelines Effective January 1, 2001, BWC implemented a pilot program giving providers presumptive authorization to provide specific medical services without waiting for prior authorization from the MCO. For dates of injury on or after November 1, 2002, presumptive approval to provide services were extended from 45 days from the date of injury to 60 days. The MCO shall adhere to the presumptive approval guidelines. For a period not to exceed 60 days following the date of injury, physicians have presumptive approval to provide certain services when treating soft tissue and musculoskeletal injuries that are allowed conditions in a claim. Following are the services you can provide: Up to 10 physical medicine visits, including osteopathic, chiropractic, physical therapy, and occupational therapy performed by a provider, licensed to provide such services. Diagnostic studies, including X-rays, CAT scans, MRI scans, and EMG/NCV. Up to three soft tissue or joint injections involving the joints of the extremities (shoulder including AC joint, elbow, wrist, finger, hip, knee, ankle, and foot, including toes) and up to three trigger point injections. Injections of the paraspinal region including ESI facet and SI are not included. E/M services and consultation services. You must complete the following before you initiate any or all of the aforementioned services: File the FROI with the MCO. MCO may use disclaimer language when the claim is not yet in allowed status. Complete and file the Physician s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) form with the MCO. Notify the MCO within 24 hours of treatment, if the injured worker will be off work for more than two calendar days. You will still report injuries and provide written medical treatment plans to the MCO for medical management. In addition, you agree to notify the MCO within 24 hours if the injured worker will be off work for more than two calendar days. Except for emergency services, the services listed in the MCO Standardized Prior Authorization Table that do not fall within the presumptive approval parameters still require prior authorization. You must submit a C-9 to request formal authorization. Why has the BWC adopted the presumptive authorization policy? This change allows you to aggressively treat injured workers who suffer the most common work-related injuries soft tissue and musculoskeletal injuries. This new policy supports BWC Health Partnership

25 Program goals of early and safe return to work with new emphasis on remain at work and transitional work initiatives. What are soft tissue and musculoskeletal injuries? They are injuries, such as sprains, strains, superficial injuries, and contusions, per the International Classification of Diseases (ICD-9-CM) book. Are there any limitations or noncovered procedures for diagnostic studies under presumptive authorization? Medical necessity for the allowed conditions is always the driver for services. Surgical diagnostics, such as arthroscopic procedures, are not included, unless it is an emergency. What are the benefits of the presumptive authorization program? By eliminating wait time for authorizations, you can immediately schedule diagnostic testing and other procedures covered under the presumptive authorization policy at the time of the office visit. Quicker treatment means faster recovery, lower disability costs, and injured workers returning to gainful employment. Will MCO case managers advise providers when they identify procedures that do not appear to be medically necessary? Yes, but as long as providers follow commonly accepted treatment guidelines when treating the allowed conditions in a claim, the bill will be paid. Does presumptive authorization apply to treatments provided within the first 60 days or requested within the first 60 days and provided later? The presumptive approval guidelines apply to services provided within 60 days from the date of injury. Where can I get more information on presumptive authorization? For more information on presumptive authorization, call OHIOBWC or the local customer service office. Standardized Prior Authorization Table The MCO and Ohio BWC collaborated in the development and implementation of a Standardized Prior Authorization Table. The procedures included in the Standardized Prior Authorization Table require prior authorization that can be obtained by submitting a BWC form C-9, Physician s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease to the assigned MCO. Please refer to the attached updated Standardized Prior Authorization Table. The claimant may only have one physician of record (POR). The POR must be Ohio BWC certified if providing ongoing treatment to claimants with dates of injury and beyond. A non-bwc certified provider can provide initial treatment to any claimant; however, an Ohio BWC certified

26 provider must provide subsequent treatment. If the claimant chooses to receive treatment from a noncertified provider, the Ohio BWC will not reimburse for the services. Treatment Guidelines The Health Plan Managed Workers Compensation Program utilizes Official Disability Guidelines 10 th Edition integrated with ODG Treatment Guidelines in Workers Comp 3 rd edition and Guidelines for Chiropractic Quality Assurance and Practice Guidelines to determine medical appropriateness of services and/or testing and return to work guidelines. Official Disability Guidelines Effective April 1, 2004, MCO staff began using the Official Disability Guidelines (ODG) in making their treatment authorization decisions. BWC staff will have access to ODG at the same time, but will not begin using them in the Alternative Dispute Resolution (ADR) process until this year when the guidelines have been added to our ADR rule. The ODG are evidence-based treatment guidelines that BWC and the MCO will be using extensively to assist in medical and claims case management. ODG is a web-based tool available to BWC and MCO staff on their desktops. BWC and MCO staff will be able to easily search and find pertinent information necessary to every day issues in claims and medical case management. Ohio providers can take advantage of the BWC negotiated price if they order on the web worklossdata.com or call the toll-free number at

27 Ohio BWC/MCO Standardized Prior Authorization Treatment is limited to the allowed conditions in your claim SERVICE Physical Medicine Services, including chiropractic/osteopathic manipulative treatment and acupuncture Consultations psychological/chronic pain program only Chronic pain program including preadmission evaluation and treatment Dental Diagnostic testing DME Home/auto/van modifications Home Health Agency Services Hospital inpatient treatment, including surgery and outpatient/asc surgery Injections (excludes IM) Non-emergency Ambulance Services Orthotic and prosthetic devices and/or repair Skilled Nursing Facility (SNF)/ Extended Care Facility (ECF) TENS and NME units TENS and NME monthly supplies REQUIREMENT Prior Authorization (PA) PA PA PA PA (except basic X-rays which do not require PA) PA if purchase price is > $250 PA for all DME rental PA from the Ohio BWC PA PA for surgery from date of injury, if not emergency PA PA PA > $250 PA PA for both rentals and purchases (rental payment not to exceed purchase price) PA for a maximum of six months per authorization Vision and Hearing Services PA > $100

28 Vocational Rehabilitation All vocational rehabilitation services, including remain at work and in- or out-of plan PA Note: PA not required for transitional work onsite therapy services provided by an OT or PT that fall under the 60-day presumptive authorization guidelines. Occupational Rehabilitation (Work Hastening) requires CAG accreditation

29 Request for Medical Services Approval Guidelines Request for medical services must be submitted by the physician of record (POR) or treating physician to the appropriate MCO prior to initiating any non-emergency treatment. The preferred method of submission is the BWC Physician s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) form; however, any other physiciangenerated document may be used, provided that the substitute document contains, at a minimum, the data elements on the C-9 form. POR should identify additional conditions to be allowed in the claims on item 6 of the C-9 form and should spell out additional conditions with supporting documentation. The MCO must respond to the physician within three business days with a decision regarding the proposed treatment request. The MCO must return fax of the authorized, denied, or pended medical services request back to the physician within the required three business days. If faxing is not feasible, the MCO is required to call the physician in order to communicate the decision and follow-up in writing via mail. If the MCO is unable to make a decision within three business days due to the need for additional information, the MCO will send a request for a C-9 form (C-9-A) to the provider. The provider must return the form and any additional supporting documentation to the MCO. The MCO has 10 business days from the date additional information is received to make a subsequent decision. The MCO must render a decision to allow or deny the medical services request if the physician does not provide the MCO with any requested documentation within 10 business days, as required by the Provider Agreement. The physician must be notified by fax or phone of the subsequent decision. If the MCO is unable to make a decision within three business days due to the need for a medical review and the physician is notified, the medical review must take place and a decision granted within the five business day period. Again, the physician must be notified by fax or phone of the subsequent decision. The MCO must consider and communicate with POR possible alternative treatments that may be eligible for reimbursement if requested by the provider, based on nationally accepted guidelines. Such alternative treatment proposals or suggestions must be communicated in the denial letter to provider. Effective November 1, 2004, the Ohio BWC is responsible for treatment decisions on inactive claims. An inactive claim is defined as a claim with no claim or medical activity in greater than 13 months. A medical service request will be considered approved and the provider may initiate treatments when all of the following criteria are met: The MCO fails to communicate a decision to the physician within three business days of receipt of an original medical services request or five business days if the request was pended; The physician has documented the medical services request completely and correctly on a C-9 or other acceptable document;

30 The physician has proof of submission to the appropriate MCO; Medical services are for the allowed conditions; The claim is in a payable status. In instances when a C-9 is not responded to within three business days and the provider initiates treatment, the MCO will provide concurrent and retrospective review of that treatment. If it is found before, after, or during delivery, that any treatment, approved, or not approved within three business days, is not medically indicated or necessary, not producing the desired outcomes, or patient is not responding, the MCO will notify the parties of decision to discontinue payment of said treatment. Only charges for treatments already rendered will be paid. If the provider, IW, or employer, wish to dispute the decision, they may do so via the ADR process. The MCO may reject a C-9 when there is no evidence that the provider has seen and examined the injured worker within the previous 30 days from the date of the C-9 submission, unless there is proof that the injured worker requested a visit with the provider. A C-9 rejected in this manner shall not be appeal able through the ADR process. Retroactive Medical Service Request The MCO shall authorize, deny, or pend a provider s proposed retroactive medical service request (submitted on a C-9 or other appropriate form) within 30 calendar days from the MCO medical service request receipt date. A medical service request will be considered approved if the MCO does not take action on the request within the 30 calendar days. The MCO shall not automatically pend a retroactive medical service request on day 30 after receipt and then take the additional five days to make a decision on the pended medical service request. The MCO shall perform all the research necessary, and obtain information within the 30-day period from the MCO medical service request receipt date. Billing and Reimbursement Bills are to be submitted to The Health Plan. In accordance with the Ohio BWC guidelines, reimbursement will be the lower of the BWC scheduled fee, The Health Plan's contractual rate, or the billed charges. The provider will submit bills according to the Ohio BWC Billing and Reimbursement Manual guidelines. These guidelines are updated quarterly by the Ohio BWC. The Health Plan will include the Ohio BWC explanation of benefits codes on the payment voucher. The claims in process section of the payment voucher will include additional codes to inform you of the status of the bills and/or if additional information is needed in order to process the bill.

31 Miscellaneous Please utilize the forms from the Ohio BWC website. If you have any questions regarding an injury or workers' compensation claim, please direct your calls to or Additional references: Ohio BWC Provider Billing and Reimbursement Manual Ohio BWC website at ohiobwc.com