Please remember any vision problems, which are medical in nature (i.e. cataracts) are handled as medical referrals.

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2 A. VISION PROGRAMS January 1, 2005, Cole Managed Vision was selected by HealthAmerica, HealthAssurance, and Advantra to administer our vision care benefits and can be reached by calling Effective January 1, 2008, Cole Managed Vision Care has a name change to EyeMed Vision Care. EyeMed Vision Care phone number is: Website: Below is a description of our vision programs. HealthAmerica Optometry Rider These members may have a co-payment for an annual routine eye exam and also may have an allowance towards the purchase of eyewear. Members must use a participating provider. Vision benefits and services did not change as a result of the name change. It is the same vendor but with a larger network. HealthAssurance Optometry Rider Members with this rider may have a co-payment for their annual exam and may have an allowance towards the purchase of eyewear. In order to utilize the full benefit the members must see a participating provider. We recognize that PPO, POS, and PHCS PPO members might choose to use out-of-network benefits for examinations and/or corrective materials. These members will pay more for using out-ofnetwork providers. To obtain out-of-network benefits, eligible members will need to submit an itemized bill with the non-par claim form to the address listed on the claim form: The claim form can be obtained by visiting our website, at and using the link. If you have any questions regarding the routine vision benefits for a HealthAmerica and HealthAssurance members, please call the Customer Service Organization. Please remember any vision problems, which are medical in nature (i.e. cataracts) are handled as medical referrals. EyeMed s One Eyecare Program is a value-added service that is offered to all members of HealthAmerica and HealthAssurance for no additional charge. Members are able to receive a discount on vision services if the services are rendered by a participating EyeMed provider. EyeMed s One Eyecare Program offers immediate savings on eye care needs including discounts on frames, lenses, conventional contacts, and even LASIK surgery at participating providers through the Eyemed network. The EyeMed Vision Care network includes Sears Optical, participating Pearle Vision locations, LensCrafters (effective 1/1/08) Target Optical, JCPenney Optical, and many independent doctors of optometry. Members don t need a Cole s Discount ID card to receive the benefit but, if they would like a copy please refer them to our website to print one out. All that a member needs to do to receive the program discounts is to show his/her HealthAmerica or HealthAssurance ID card to the participating EyeMed provider. Refer to Advantra Section for Vision Guidelines for Advantra Members. 2

3 B. CHIROPRACTIC SERVICES Effective January 1, 2006 No longer affiliated with ASHN. No treatment plans required. Members may self-refer. No referral or pre-authorization is required for Chiropractic Services. Pre-authorization is required for Physical Therapy Services for HMO members. (Please use the Therapy Progress Summary Worksheet found on page 8 of this section) Contact the Customer Service Department to confirm members benefit. Refer to Chiropractors contract for appropriate CPT codes. Advantra coverage limited to Chiropractic Manipulative Treatment using CPT codes 98940, and Claim editing software may apply.

4 C. Physical Therapy Coverages: HMO: 15 visits per condition, per contract year or an unlimited number of visits provided within 60 consecutive days per condition, per contract year. Contact the Authorizations Department for Preauthorization. CCPPO and PPO: Benefits will vary according to plan. Pre-authorization is not required with the exception of Central PA Teamsters and GEHA. Contact the Customer Service Department to determine eligibility. Subject to Benefit limits/exclusions. Surgery is considered a new condition and constitutes a new benefit period. **Therapy services for HMO and Advantra members must be pre-authorized. The ordering physician or therapy office can request the authorization. Services must be administered by a participating provider. Please complete the Therapy Progress Summary Worksheet when requesting services. This form can be found on page 8 of this section.

5 New Therapy Progress Summary Worksheet In order to better serve our therapy providers with obtaining continued authorization of visits, we have created a standardized form to submit these requests. The form can be utilized for physical, occupational, and vestibular therapies. Since all of the necessary information required to review the request is addressed on the form, we are able to evaluate the member s treatment more efficiently. While use of the form is not mandatory, it is suggested to ensure accurate and timely processing. Attached, you will find the worksheet along with an instructional guide that explains the proper use for each field. If you have any questions regarding the form, please contact your Provider Relations representative for assistance.

6 Therapy Progress Summary Worksheet General: This section provides general information as it relates to the requested service. HA Referral Number Date Type of therapy Please provide the Health America referral number if request is for an extension of services Date form is completed Please indicate the type of therapy(ies) that are being requested. Check appropriate boxes Demographic Information: This section provides demographic information on the member. Member Name Member ID Date of Birth Provider/ Facility Phone/Fax Number Tax ID of Facility Physician Telephone Number Referring Physician Name of member receiving treatment Health America ID number of member receiving treatment Date of birth of member receiving treatment Telephone and fax numbers of provider/facility rendering care Tax ID of provider/facility rendering care Telephone number of physician overseeing care of member Name of physician overseeing care. Please indicate if provider is a DO or a MD Treatment Plan Information: This section provides information on the treatment being rendered for the member. Date of initial evaluation Date of original injury/onset Diagnosis Description Provide the date of the initial evaluation NOTE: If the request is for continuation of services, please submit a copy of the initial evaluation Provide the date of injury (if appropriate) and/or date of onset of symptoms Provide the diagnosis code associated with the injury/symptoms Provide the description for the diagnosis Completed visit total Date of surgery Diagnosis Description Therapy to affected area/body part Is treatment being given for condition related to autism Is treatment being given for condition related to a learning disability: Is treatment related to sports activity Is treatment related to workers comp/mva injury Number of visits completed (this is a cumulative total) Date surgery was performed (if appropriate) Provide the diagnosis code associated with the injury/symptoms Provide the description for the diagnosis Please indicate if right or left side (e.g. right hip, right side of neck, etc.) Select the appropriate box Select the appropriate box Select the appropriate box Select the appropriate box

7 Assessment This section provides information as it relates to current status of member s condition. Please document objective/measurable findings regarding range of motion, strength, gait, assistance required, pain, balance, motor findings/motor coordination, assistive devices, transfers and ADL S, as applicable. Please provide the following information for each section: prior value with associated date current value with associated date short term goal with target date long term goal with target date Range of motion Strength Pain ADL Ambulation Transfer Other Home exercise program Treatment plan Progress Comments Provide values (prior and current) for abduction, adduction, extension, etc. Document the member s assessment (subjective) of pain on a scale of 1-10 Document the member s ability to conduct activities of daily living Document the number of feet the member is able to ambulate. Also indicate if the ambulation is accomplished via assistive devices (e.g. walker, etc.) Document the member s ability to transfer to and from bed/wheelchair, etc. Indicate other important data (e.g. side bends, etc.) Select the appropriate box to indicate the status of the home exercise program. Initiating new, just begun; progressing adding components, progressing; independent all components have been added, member understands and is independent. Outline the specifics of the treatment plan to include the frequency of treatment and the expected duration that modalities are to be provided (e.g. 3x/week for 4 weeks Select the appropriate box that indicates how much progress the member has made towards stated goals (e.g %, 25-50%, 50-75% or %) Provide any additional comments that would be helpful to understand request being submitted

8 HA Referral Number: Therapy Progress Summary Worksheet Date: Type of Therapy being requested: Physical Occupational Vestibular Member Name: Member ID Number: Date of Birth: Provider /Facility Name: Provider/Facility Phone Number: Provider/Facility Fax Number: Tax ID of Facility: Physician Telephone Number: Referring Physician (name): DO MD Treatment Plan Information: Note: If this is a treatment plan for additional visits please include a copy of the initial evaluation Date of Initial Evaluation: Date of Original Injury Diagnosis (ICD 9): Description: /Onset: # of completed visits from Date of Surgery: Diagnosis (ICD 9): Description: start date: Therapy to affected area/body part: (specify): Right 1. Is treatment being given for condition related to autism: 2. Is treatment being given for condition related to a learning disability: 3. Is treatment related to sports activity: 4. Is treatment related to workers comp/mva injury: YES YES YES YES ASSESSMENT: Note: Please document objective/measurable findings regarding range of motion, strength, gait, assistance required, pain, balance, motor findings/motor coordination, assistive devices, transfers and ADL S, as applicable. Updates: Prior Value: Current value: Short term goal: Long term goal: Date: Date: Target Date: Target Date: Range of motion: Left NO NO NO NO Strength Pain (1-10) ADL Ambulation Other: Side Bends Home Exercise Program: Initiating Progressing Independent Treatment Plan including frequency of treatment, expected duration for the goals to be achieved. 3x/week for 4 weeks. Progress (continuation of care plan only) Patient improved: Comments: HealthAmerica/HealthAssurance Utilization Management: Preauthorization Department FAX TO: (717) or (888) Revised: 08/18/09

9 Please read the information about MH Net Behavioral Health on the next page.

10 Effective September 1, 2008 D. BEHAVIORAL HEALTH SERVICES / MENTAL HEALTH / SUBSTANCE ABUSE MHNet Behavioral Health (MHNet) is managing the mental health / substance abuse benefits for all products. Have the member contact MHNet prior to initiating behavioral health services to discuss pre-authorization, provider selection and benefit information. Physicians may contact MHNet with treatment or referral recommendations. The Mental Health Provider (MHP) is responsible for obtaining a release of information from the member, after which, the physician will be kept apprised of the member s status and progress during treatment. MHNet will assist the physician in obtaining consultation regarding behavioral health issues. MHNet is available 24 hours a day, seven (7) days a week for emergencies by calling or during normal business hours, Monday through Friday, 8:00 AM to 5:00 PM EST, for routine referrals to a provider. MHNet Mailing Address MHNet Mailing Address For Clinical Operations: For Claims Submissions: MHNet - HAPA MHNet 1211 State Road 436, Suite 355 P.O. Box Casselberry, FL Austin, TX Phone: Phone:

11 E. LABORATORY SERVICES HEALTHAMERICA LABORATORY POLICY 1. Effective March 1, 2009 HealthAmerica (Southeastern PA) expanded the number of lab tests for which physicians will be reimbursed when performed in the provider office. Please reference the attached list of codes below. 2. Reimbursement will not be made for any lab test not listed below when performed in a physician s office and the member will be held harmless, in accordance with existing provider contracts. 3. Labs not listed below should be referred to Quest Diagnostics or LabCorp. Please note Coventry Health Care of Delaware labs or members can only be referred to LabCorp. 4. If you do not perform these specific lab tests in your office, or if you collect specimens in your office, all members, specimens and collected samples should be referred to Quest Diagnostics or LabCorp. Please note Coventry Health Care of Delaware labs or members can only be referred to LabCorp. 5. Labs in bold face currently are reimbursed according to the existing lab policy when performed in a physician s office.

12 HealthAmerica Updated Stat Lab Codes Southeastern PA Effective 3/1/2009 Code Description Electrolyte panel Lipid panel Drug screen, single Assay of lithium Urinalysis, nonauto w/scope Urinalysis, auto w/scope Urinalysis nonauto w/o scope Urinalysis, auto, w/o scope Urine screen for bacteria Microscopic exam of urine Urine pregnancy test Acetone assay Microalbumin, semiquant Assay of ethanol Occult blood, other sources Occult blood, feces, single Blood occult peroxidase Assay test for blood, fecal Assay, bld/serum cholesterol Collagen crosslinks Assay of creatinine Assay of urine creatinine Assay of estrone Assay, glucose, blood quant Reagent strip/blood glucose Glucose test Glucose tolerance test (GTT) GTT-added samples Glucose blood test Glycated protein Gonadotropin (FSH) Gonadotropin (LH) Helicobacter pylori breath test Helicobacter pylori drug test Hemoglobin, copper sulfate Glycosylated hemoglobin test Glycosylated hb, home device Immunoassay, dipstick Assay of lactic acid Assay of lipoprotein Assay of blood lipoprotein Natriuretic peptide Assay of body fluid acidity Assay thyroid stim hormone Transferase (AST) (SGOT) Alanine amino (ALT) (SGPT) Assay of triglycerides Assay of urea nitrogen Chorionic gonadotropin assay

13 Code Ovulation tests Description Automated diff wbc count Bl smear w/diff wbc count Spun microhematocrit Hematocrit Hemoglobin Complete cbc w/auto diff wbc Complete cbc, automated Manual cell count, each Blood smear, peripheral, interpretation Bone Marrow, smear interpretation Blood platelet aggregation Prothrombin time Prothrombin time, sub, plasma fractions Rbc sed rate, nonautomated Thromboplastin time, partial Immunoassay, tumor, qual Heterophile antibodies Immunoassay,infectious agent Particle agglutination test Skin test, tuberculosis, intradermal Lyme disease antibody HIV HIV-1/HIV-2, single assay Culture aerobic identify Culture screen only Smear, gram stain Smear, wet mount, saline/ink Tissue exam for fungi Strep a ag, eia Ag detect nos, eia, mult Candida, dna, dir probe Garnerella vaginalis, amplified probe Infectious agent detection by DNA RNA Influenza assay w/optic Rsv assay w/optic Strep a assay w/optic Cytopathology, evaluation of fin needle aspirate Cytopathology, evaluation of fin needle aspirate interpretation Complex prep Semen analysis w/huhner Evaluation, cervical mucus F. RADIOLOGY The following four (4) categories of imaging services listed below will require preauthorization by calling or faxing a request to Utilization Management: 1. CT all examinations

14 2. MRI all examinations 3. MRA all examinations 4. PET -all examinations Ordering physician can give the member a Rx script to order all diagnostic imaging. Include authorization number when appropriate. Please provide the following information when calling for pre-authorization as follows: Ordering physician Patient Name Patient ID number Subscriber s ID number Requested imaging procedure Radiological procedures associated with Emergency Department and Inpatient Admissions do not require pre-authorization. If an emergency clinical situation exists, other than in a hospital emergency room, requiring CT, MRI or MRA studies, you should proceed with the examination and contact HealthAmerica and HealthAssurance the next business day. The toll free pre-authorization phone number is The toll free pre-authorization fax number is Please use the CT Scan and/or MRI worksheets when faxing an MRI or CT request to Utilization Management. These forms can be found in Section III, Utilization Management, page 26 and 27.