Provider Manual. Coventry Health Care of Kansas Coventry Health and Life Insurance Company KS (7/15)

Transcription

1 2015 Provider Manual Coventry Health Care of Kansas Coventry Health and Life Insurance Company KS (7/15)

2 Dear Provider: Coventry Health Care, an Aetna company, values our relationships with local providers. Since we are based on the communities we serve, we share your goal of keeping our communities healthy. Thank you for collaborating with us to give your patients access to high-quality health care at an affordable price. The health care industry has recently experienced unprecedented changes related to the Affordable Care Act (ACA). It is important for Coventry Health Care to maintain an open line of communication with our providers. Should you have any questions about the ACA, you can refer to the health care reform section of our Coventry Health Care website at at any hour, 24/7. As always, at Coventry Health Care we remain committed to providing accessible, high-quality service to our members, and we appreciate your efforts in helping us to achieve that goal. To ensure that we communicate effectively with you, we have revised this Provider Manual to assist you and your staff. These policies and procedures are designed to guide you through Coventry Health Care s administrative processes. We hope you find this manual informative and helpful. We will continue to provide you with updates via the web, our provider newsletter and through your provider relations representative as changes occur. Thank you for your participation and interest in caring for our members. Sincerely, Brad Clothier Kansas Market President, Mid America Region 9401 Indian Creek Parkway, Suite 1300 Overland Park, KS Toll Free: Coventry is the brand name used for products and services underwritten or administered by one or more of the Coventry group of subsidiary companies, including Coventry Health Care of Florida, Inc. and Coventry Health and Life Insurance Company, each of which is an affiliate of Aetna.

3 Administrative Office: Coventry Health Care 9401 Indian Creek Parkway, Suite 1300 Overland Park, KS Coventry Health Care 8535 W. 21st Street N Wichita, KS Important Telephone Numbers Website ( Phone Fax (Overland Park) (Toll free) (Wichita) (Overland Park) (Wichita) Pre-certification (Commercial and Medicare Advantage) (Overland Park) Pre-certification (Wichita) (Wichita) (Wichita, Toll-free) (Wichita) Pharmacy (Commercial and Medicare Advantage) Prior Authorization Medicare Advantage Rx HMO PPO Medical Management 8:00 a.m. 5:00 p.m. (CST), Monday Friday N/A N/A N/A Call number on the back of member ID card Coventry Health Care Dental cvty.dental.com , Opt #1 N/A TDD/TTY 711 Relay 8:00 a.m. 8:00 p.m. (CST), Monday Friday N/A N/A Customer Service (CHCKS commercial products) directprovider.com (Overland Park) (HMO, POS and PPO) chckansas.com (Wichita) N/A Customer Service (Medicare Products - Houston) Medicare Advantage HMO, Medicare Advantage PPO kc.chcadvantra.com N/A Pharmacy Department N/A EyeMed eyemedvisioncare.com N/A Coventry Health Care National - Mail Handlers Benefit mhbp.com N/A First Health firsthealth.com , Opt #3 N/A Carpenters Claim Issues N/A N/A Quest Diagnostic Labs N/A N/A Emdeon emdeon.com N/A Accredo (Express Scripts Specialty Pharmacy) N/A N/A Express Scripts Express-Scripts.com N/A Mental Health Network (MHNet) mhnet.com N/A Deaf Interlink deafinterlink.com N/A N/A Med Solutions Inc. medsolutionsonline.com NIA RadMD.com (Opt #6) N/A TRIAD N/A 1

4 Coventry Health Care of Kansas Service Area Coventry Health Care of Kansas and Coventry Health and Life Insurance Company serves all of Kansas and the western half of Missouri and Northwest Arkansas. A map of our service area is provided below. Our management team is headquartered in Overland Park, Kansas supported by additional staff in Wichita, Kansas and Springfield, Missouri. As a regionally managed plan, our senior management staff including medical directors and case managers are available and familiar with the markets we serve. In addition to our regionally-based health services staff and medical directors, we maintain sales, broker relations, and underwriting personnel as well as experienced provider relations and contracting teams to assist you with our products, policies and procedures. Customer Service Operations (CSO) Coventry Health Care maintains centralized expertise in our CSO department. CSO is responsible for: Call center services Claims processing services Enrollment Premium billing Actuarial services Information technology services KANSAS MISSOURI Wichita Provider Relations Overland Park Provider Relations ARKANSAS Overland Park Provider Relations (Medicare Advantage Network) Coventry Health Care Offices 2

5 Territory Listing of Counties (Kansas, Missouri and Arkansas) WICHITA OVERLAND PARK ARKANSAS CHC MO Barber Allen - Kansas Baxter Medicare only Adair Barton Anderson Benton Audrain Butler Atchison Boone Bollinger Chase Bourbon Carroll Boone Cheyenne Brown Cleburne Medicare only Butler Clark Cherokee Conway Medicare only Callaway Clay Crawford Crawford Camden Cloud Doniphan Faulkner Medicare only Cape Girardeau Comanche Douglas Franklin Carter Cowley Franklin Fulton Medicare only Clark Decatur Jefferson Garland Medicare only Cole Dickinson Johnson Izard Medicare only Cooper Edwards Labette Johnson Medicare only Crawford Ellis Leavenworth Logan Dent Ellsworth Linn Lonoke Medicare only Dunklin Finney Miami Madison Franklin Ford Neosho Marion Medicare only Gasconade Geary Wyandotte Montgomery Medicare only Howard Gove Andrew - Missouri Newton Medicare only Howell Graham Atchison Perry Medicare only Iron Grant Barry Pope Medicare only Jefferson Gray Barton Pulaski Medicare only Knox Greeley Bates Saline Medicare only Lewis Hamilton Benton Scott Lincoln Harper Buchanan Searcy Medicare only Macon Harvery Caldwell Sebastian Madison Haskell Carroll Stone Medicare only Maries Hodgeman Cass Van Buren Medicare only Marion Jewell Cedar Washington Miller Kearny Chariton White Medicare only Moniteau Kingman Christian Yell Monroe Kiowa Clay Montgomery Lane Clinton Morgan Lincoln Dade New Madrid Logan Dallas Oregon Marion Daviess Osage McPherson Dekalb Pemiscot Meade Douglas Perry Mitchell Gentry Phelps Morris Greene Pike Morton Grundy Pulaski Ness Harrison Ralls Norton Henry Randolph Osborne Hickory Reynolds 3

6 Territory Listing of Counties (Kansas, Missouri and Arkansas), cont. WICHITA OVERLAND PARK ARKANSAS CHC MO Ottawa Holt Ripley Pawnee Jackson Schuyle Phillips Jasper Scotland Pratt Johnson Scott Rawlins Laclede Shannon Reno Lafayette Shelby Republic Lawrence St. Charles Rice Linn St. Francois Riley Livingston St. Genevieve Rooks McDonald St. Louis Rush Mercer St. Louis City Russell Newton Stoddard Saline Nodaway Warren Scott Ozark Washington Sedgwick Pettis Wayne Seward Platte Sheridan Polk Sherman Putnam Smith Ray Stafford Saline Stanton Shawnee Stevens St. Clair Sumner Stone Thomas Sullivan Trego Taney Wallace Texas Washington Vernon Wichita Webster Chautauqua Worth Coffey Wright Elk Greenwood Jackson Lyon Marshall Montgomery Nemaha Osage Pottawatomie Wabaunsee Wilson Woodson 4

7 General Information...6 Appointment Scheduling and Waiting Time Guidelines...7 Requirements for Participation...7 Provider Accessibility Standards...8 Practitioner Office Site Quality...9 Cultural, Ethnic, Racial and Linguistic Needs of Members...9 PCP On-Call Requirements...9 Changes to Tax Identification Number or Demographics...9 Health Insurance Portability and Accountability Act (HIPAA)...10 Coventry Health Care Commercial Member Rights and Responsibilities...10 Coventry Health Care s Medicare Advantage Member Rights and Responsibilities...10 Member ID Cards...11 Copayments...11 Provider-Specific Communications...11 Coventry Health Care Interactive Voice Response (IVR) System...11 Emdeon...12 Directprovider.com...12 Coventry Health Care Commercial Products...13 Fully Insured Commercial Products...13 Self-Funded/ASO Commercial Products...16 Coventry Health Care s Medicare Products...16 Coventry Health Care s Medicare Provisions...18 Prescription Drugs...19 Medicare Provider Training & Education...21 Reciprocal Arrangements With Other Coventry Health Care Affiliates...22 Coventry Health Care National Network...22 Coventry Health Care Payor Guide...23 Quick Reference Guide-Contact List...24 Workers Compensation...25 Coventry Health Care Auto Product...25 Medical Management...25 Prior Authorization...26 Case Management...27 Disease Management...28 Medicare Advantage Condition Management Program...28 Group-Specific Prior Authorization Lists...28 Specialty Referrals...29 In-Office and Outpatient Procedures...29 OB/Gyn Care: HMO/POS, Coventry Health Care ASO Network, PPO, and Medicare Advantage...29 Other Medical Management Processes...30 Ancillary Services...32 Lab Services...32 Outpatient Imaging Program...33 Triad-Outpatient Pain Management Services...34 Behavioral Health/Chemical Dependency...34 Table of Contents Oncology Drug Program...34 Pharmacy Prescription Benefits...36 Emergency Care...39 Claims Information...39 Member Billing...39 Submission of Claims...40 Claims Payment Procedures...42 Claim Submission Guidelines...42 Claim Forms...42 Sample RAs...47 Administrative Guidelines...51 Wrong Site/Person/Procedure (WSPP) and Hospital-Acquired Condition (HAC) Claim Denial Process...51 Attachment A...53 Collection Advice...54 Payments from HRA, FSA or HSA Plans...54 Department of Labor Guidelines...54 Medicare Advantage Risk Adjustment...55 Medical Record Review Guidelines...61 Claims/Reimbursement Issues...61 Coventry Health Care s Anti-Fraud and Abuse Policy...63 Policy for Financial Incentives...64 Hold Harmless...64 Capitation Payments...64 Reporting Patient Encounters...64 Medicare Reporting...65 Workers Compensation Claims...65 Motor Vehicle Accidents/Personal Injury Claims...65 Coordination of Benefits...65 High-Dollar Review of Outpatient and Inpatient Claims...65 Recoveries...66 Health Improvement Services...66 Quality Management...66 HEDIS Measures...66 Preventive Health and Wellness Programs...71 Preventive Health Guidelines...71 Other Provider Concerns...71 Provider Communication...71 Panel Closings...72 Facility/Provider Authorization Review Procedure...72 Delegated Contracting...72 Request to Terminate Your Relationship With a Member...73 Failure to Pay Copays/Co-insurance and Deductible...73 Provider Sanctions...73 Corrective Action Plan...73 New Provider Orientation...75 Council for Affordable Quality Health Care (CAQH)...75 Transfer of Information Between Providers...75 Recredentialing

8 General Information The purpose of this manual is to provide information regarding the administration of health care services to Coventry Health Care members. Coventry Health Care of Kansas and Coventry Health and Life Insurance Company are wholly owned by Aetna, Inc. This manual is specific to providers contracted with the Kansas plan. The content of this manual can be found online at chckansas.com > Providers > Document Library > (your region). It defines policies and procedures concerning clinical and administrative issues as applicable to participating providers. The provider manual for workers compensation and auto can be found at coventrywcs.com>provider-services>document-library>index, incorporated herein by reference. Throughout this manual you will see references made to Coventry, Coventry Health Care or Plan. These terms refer to Aetna affiliate companies, Coventry Health Care of Kansas and Coventry Health and Life Insurance Company. This manual is a global document addressing operational requirements of the HMO plans administered by Coventry Health Care of Kansas, and the PPO plans administered by Coventry Health and Life Insurance Company in Kansas, Western Missouri, and Oklahoma. The Purpose of the Contracting Provider Manual The Manual was developed to share important policies and procedures as well as other useful administrative and clinical information. As Plan policies and procedures are updated, you will receive notifications via our provider newsletters, direct mail or fax announcements on the web. Provider newsletters are also available on our website at As a contracting provider, you and your team are encouraged to become familiar with this document and the other resources available on our website. This document does not replace the terms stated in your Provider Agreement. In the event any conflict between the terms stated in this document and your Agreement, the terms of your Agreement will control. Coventry has several products in our portfolio combined with several networks of providers to service each product s members, which includes: HMO and Point of Service (POS) products Administered by Coventry Health Care; self funded options are availble. Other options include Qualified High Deductible Health Plans, Healthcare Savings Accounts, and Healthcare Reimbursement Accounts PPO Administered by Coventry Health and Life Insurance Company; self-funded options are available. Other options include Qualified High Deductible Health Plans, Health Care Savings Accounts and Health Care Reimbursement Accounts CoventryOne Individual PPO Traditional PPO plans; Qualified High Deductible Health Plans and Health Care Savings Accounts are also available Health Insurance Exchange Coventry Health Care National PPO Administered by Coventry Health and Life Insurance Company; PPO plans purchased by regional and national self-funded employer groups Medicare Advantage HMO, PPO Generally extra benefits and lower copayments than original Medicare for individuals, employer groups, and retirees. Provides Part A and Part B Medicarecovered health care services and includes Part D prescription drug plan. Total Care Workers Comp Coventry Workers Comp website: Auto Includes network access to auto insurance carriers, third party administrators and other entities and corporations for member injuries resulting from auto accidents for which coverage is provided under relevant member contracts. The networks of providers that service the above products are as follows: About Coventry Health Care Commercial HMO/PPO Network Connector Medicare Advantage Medicare HMO/PPO Network Coventry Health Care Total Care High Performance Network PPO Network CHC ASO Network Select Network Coventry Health Care National Network national PPO network First Health Network national rental PPO network PPO Preferred PPO network POS Preferred Via Christi Employees Plan PPO network Coventry Health Care Workers Comp Network provides clients to the largest national provider network offering in the workers compensation industry. Coventry Health Care Auto Solutions includes network access to auto insurance carriers, third party administrators and other entities and corporations for member injuries resulting from auto accidents for which coverage is provided under relevant member contracts. For your convenience, frequently called numbers are provided in the front of this manual. The Provider Hotline is your contact point for any questions you may have about claims or member eligibility. When you require an authorization, call the Medical Management number on the back of the member ID card. When you have questions about or need an authorization for a Coventry ASO Network member, refer to the number on the back of the member ID card. Our Interactive Voice Response (IVR) system is another easy way to check member eligibility, claim status and benefits. Simply call and follow the prompts. You can also access a wide variety of helpful information through the Emdeon Office internet site. For more information or to enroll in Emdeon Office, call Emdeon at Or, for an in-depth preview of the online product, visit webmd.com and click on Emdeon Office Tour. The Provider Relations department is ready to serve your office. Provider Relations administers the contracts of in-network providers, ancillary services and hospitals, and orientates providers on Coventry Health Care s policies and procedures. If your office would like a refresher course on our policies and procedures, or if you have questions about your network agreement, your provider relations representative will be happy to assist. Providers are required by the Americans with Disabilities Act of 1990 to provide an interpreter for individuals with hearing impairments who request the service. You can contact an interpreter by calling TDD/TTY 711 Relay

9 Administrative Office Coventry Health Care 9401 Indian Creek Parkway, Suite 1300 Overland Park, Kansas To assure the best service possible for our members, we ask you to adhere to the following standards for appointment scheduling and waiting time: Guidelines: Appointment Scheduling and Waiting Time Guidelines Obstetrical care appointments during the first or second trimester should be scheduled within one week. Appointments for patients in the third trimester should be scheduled within three days. Routine care should be scheduled within 7 days for both adults and children. Appointments for urgent care should be scheduled within 24 hours. Emergencies must be seen immediately. Visits with specialists or consultants should be scheduled within three weeks unless the primary care provider (PCP) requests an earlier time. Patients with scheduled appointments should be seen within 30 minutes of their scheduled appointment times. Providers and emergency care facilities are to be available or provide phone coverage 24 hours a day, 7 days a week for emergency care For after hours care each primary care physician must have a reliable 24 hour a day/7 days a week answering service or machine with a beeper or paging system. A recorded service that refers members to emergency rooms is not acceptable. The Plan performs surveys to ensure providers meet the above standards. If the above standards are not met, we send a letter to the provider asking him/her to develop an action plan. Requirements for Participation Coventry Health Care and Coventry Health and Life Insurance Company providers are partners in the health care of Coventry s members. Because of this mutual responsibility, we require our providers to adhere to the following standards for all lines of business: 1. We expect our providers to give the U.S. Department of Health and Human Services (HHS) and U.S. General Accounting Office (GAO), and their authorized designees, the right to audit, evaluate and inspect all books, contracts, medical records, patient care documentation and other records relating to your participation and services furnished to members, for 10 years following termination or expiration of your agreement for any reason, or until completion of an audit, whichever is later, unless the timeframe is extended. 2. We expect our providers to safeguard the privacy of any information that identifies a particular member in accordance with federal and state laws and to maintain the member records in an accurate and timely manner. We recommend that providers request identification from our members in addition to the Coventry member ID card, such as a valid drivers license. 3. Our providers will not deny, limit or condition the furnishing of covered health care services to members based on health factors including, but not limited to: mental or physical illness, claims experience, receipt of health care, medical history, genetic information, evidence of insurability or disability. 4. Providers will ensure members are not discriminated against in the delivery of healthcare services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. 5. Our providers will provide covered benefits and health care services to members in a manner consistent with professionally recognized standards of health care. Providers must render or order only medically appropriate services. 6. Our providers will cooperate with the Plan s medical management and quality improvement activities and procedures. This includes returning phone calls, answering correspondence, providing medical records and responding to our staff as needed so they can perform their duties. 7. Our providers will cooperate with the Plan by participating in Centers for Medicare and Medicaid Services (CMS) and HHS quality improvement initiatives. 8. Our providers must obtain authorizations for all hospitalizations as well as the services specified in this manual as requiring prior authorization. 9. We expect our providers to fully comply with the terms of their agreement and maintain an acceptable professional image in the community. 10. We expect our providers to keep their licenses and certifications current and in good standing and to cooperate with our recredentialing program. Coventry Health Care must be notified of any material change in provider qualifications affecting the continued accuracy of the credentialing information submitted to Coventry Health Care. 11. Providers must obtain and maintain professional liability coverage as is deemed acceptable by Coventry Health Care through the credentialing process. Providers must furnish Coventry Health Care with evidence of coverage upon request and must provide the plan with at least 15 days notice prior to the cancellation, loss, termination or transfer of coverage. 12. Providers look solely to Coventry Health Care for payment of services furnished to members, and will not bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have claim or recourse against a member, or anyone acting on behalf of a member, under any circumstance unless explicitly approved for reason of coordination of benefits or subrogation. This will not prohibit collection of copays on Coventry Health Care s behalf made in accordance with the terms of the agreement between Coventry Health Care and the member. 13. Providers will ensure the completeness, truthfulness and accuracy of all claims and encounter data submitted to Coventry Health Care including medical records data required and ensuring that information is submitted on the prescribed form. 14. In the event that the provider or Coventry Health Care seeks to terminate the agreement, it must be done in accordance with the contract. 7

10 15. Providers can collect from members charges for services that are not covered services as defined in the agreement between Coventry Health Care and the member, provided that the patient has been informed in advance of delivery of services that the services are not covered. Members must agree in writing, in a form substantially similar to the ones found at The member must sign the Authorization To Perform Non-Covered Services form and include specific information listing the non-covered services and the date of service specific to the non-covered services. The above-mentioned form cannot be a generic form used upon registration and will not be accepted in lieu of obtaining a prior authorization for covered services. The provider must submit the claim along with any member-written acknowledgment to accept responsibility for non-covered services to the plan. Use of this form does not supersede your contract obligations. 16. Providers may not advertise their participation in Coventry Health Care s Medicare Advantage networks without written consent of Coventry Health Care. Our Medicare contract with CMS stipulates that we must obtain CMS s approval before releasing any information about our Medicare products. This obligation extends to our contracted providers who wish to publicly announce their Medicare Advantage affiliation. Non-compliance with this regulation would place us in violation of our agreement with CMS. 17. If Coventry Health Care s contract with CMS terminates, expires, or becomes insolvent, providers will continue to provide covered services to Coventry Health Care members who are hospitalized on that date through the date of each member s discharge or for the remainder of the period the premium has been paid. Continuation of services shall be made in accordance with the terms and conditions of the provider contract. 18. Providers will furnish covered benefits to Medicare Advantage members consistent with CMS requirements and Coventry Health Care s policy. 19. Providers will cooperate with Coventry Health Care in furnishing a health assessment of all new Medicare Advantage members within 90 days of the effective date of enrollment. 20. Providers will send in changes to their demographic or payment information 30 days prior to the effective date of change. 21. Notices of termination must be sent within the terms of your agreement. If you fail to notify Coventry Health Care of your desire to terminate your agreement within the term and timeframe, as outlined in your contract, you must arrange for a Coventry Health Care in-network provider to cover your Coventry Health Care members. 22. Providers will ensure Medicare Advantage members have direct access to Pap smears, mammograms, influenza vaccines, pneumococcal vaccines and diabetic retinal eye exams. 23. Providers will be familiar with Coventry Health Care member rights as outlined in the Member Rights and Responsibilities section of this manual. Providers will ensure that they honor all Coventry Health Care member rights, including but not limited to, treatment with dignity and respect, confidential treatment of all communications and records pertaining to their care and to actively participate in decisions regarding health and treatment options. Providers will freely communicate with patients about their treatment, regardless of benefit coverage. 24. Providers will be available to Coventry Health Care members as outlined in the Appointment Scheduling and Waiting Time Guidelines section of this manual. Providers also will arrange 24-hour on-call coverage for his/her patients by providers that participate with Coventry Health Care, as outlined below. 25. Providers will ensure timely and confidential transfer of records between providers as outlined in the Transfer of Information Between Providers section of this manual. Providers may not bill or charge members or Coventry Health Care for the copying or transferring of medical records, x-rays or other information (needed to diagnose and/or treat the member) to another Coventry Health Care in-network provider. 26. Provider will allow the plan access to medical records as needed to process claims, make benefit determination, complete medical management and QM activities. 27. Our Providers must keep our members information confidential and stored securely. They must also ensure their staff members receive periodic training on member information confidentiality. Only authorized personnel should have access to medical records. We encourage our providers to contact their provider relations representative any time they require further details regarding the above. Failure to comply with these standards may result in financial penalties and/or the termination of the contract. Provider Accessibility Standards To assure the best service possible for our members, we ask you to adhere to the following standards for appointment scheduling, availability and waiting time. Although there may be exceptional circumstances, every effort must be made to adhere to these standards. Access Standard Description Standard Hours of Operation 20 regularly scheduled hours per week for a one-physician practice 30 hours per week for a two-physician practice (or more) Medically Necessary Services 24 hours per day, 7 days per week If unavailable, coverage should be arranged through a Coventry Health Care provider Routine Office Visit Non-Symptomatic Within 7 days Routine Physical Within 30 days Urgent Care Visit Symptomatic Same day or within 24 hours Emergency Care Visit Immediate OB Access 1st and 2nd trimester: one week 3rd trimester: 3 days Provision of After-hours Services Each primary care physician must have a reliable 24 hours a day/7 days a week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not acceptable. Telephone On-hold Time During Office Hours (waiting to speak Less than 5 minutes to a receptionist) Response Time to Urgent Telephone Call From Member Within 20 minutes of notification Waiting Time in Office Reasonable for scheduled appointment, e.g., 30 minutes Coventry Health Care utilizes the various methods to monitor and verify the above requirements are being met on an ongoing basis: on-site office review; member complaints; random telephone surveys; and customer satisfaction surveys (CAHPS). 8

11 Office site visits are made to network practitioners after receiving a member s complaint to evaluate the physical accessibility, physical appearance, adequacy of waiting and exam room space related to the settings in which member care is delivered. Standards are set for office site criteria and medical record keeping practices. If a site visit is required for member complaints to evaluate the physical accessibility, physical appearance, adequacy of waiting and examining room space, the medical record keeping practices are also evaluated to assess methods used to maintain confidentiality of member information and for keeping information in a consistent, organized manner for ready accessibility. No site visit is required for complaints regarding availability or medical records keeping. The Coventry Health Care Office Assessment criteria are stated in the practitioner agreements and business criteria of the practitioner agreements. The medical record keeping practice standards are stated in the Coventry Health Care Medical Record Criteria that are distributed to practitioners. A structured, documented review of a practitioner s office to determine compliance with selected business criteria and Coventry Health Care medical record keeping practice policies in response to member complaints regarding the physical appearance, physical accessibility including handicapped access, and adequacy of waiting and examining room space. The results of the review are documented on an office assessment checklist. Cultural, Ethnic, Racial and Linguistic Needs of Members To ensure the Coventry Health Care s health delivery system meets the cultural, ethnic, racial and linguistic needs of its members and providers, Coventry Health Care performs, at a minimum, annual assessment of the following to engage the availability of providers: Annual review of membership demographics (preferred language, ethnicity, race) Local and national geographic population demographics and trends derived from publicly available sources Network assessment Health status measures such as those measured by HEDIS (as available) Comparison with selected measures, such as Healthy People 2010 Evaluation of member satisfaction survey Member provider preference You can assist us by providing information when a language, other than English, is spoken in your office. PCP On-Call Requirements You, or the provider on-call for you, must be available and accessible 24 hours a day, 7 days a week. You must arrange coverage when you are unavailable, and the covering provider must be a Coventry Health Care in-network provider. Coventry Health Care will not pay for services that have been capitated to the member s PCP. The capitated PCP is financially responsible for the covering provider for his/her practice. If a fee-for-service PCP arranges for on-call coverage of his/her practice and wants to ensure payment for the on-call provider, the fee-for-service PCP must contact Coventry Health Care Provider Relations to update their on-call coverage record. Coventry Health Care pays the provider for the services provided to the member on a fee-for-service basis. Taped telephone messages that direct patients to the emergency departments are not acceptable as an alternative to arranging coverage by another provider. Changes to Tax Identification Number or Demographics Please notify Coventry Health Care s Provider Relations department in writing with any additions, deletions or changes to the following: Tax identification number Office or billing address Telephone or fax number address Specialty Board certification information New providers added to the practice (please allow time for credentialing) Licensure (DEA, DPS, state licensure or malpractice insurance) Group affiliation Hospital privileges Adverse actions taken by a hospital, Board of Medical Examiners, managed care organization, or other entity that is responsible for the National Practitioner Data Bank. If a provider leaves a practice or plans to change locations, open new locations, or leave the current practice, written notification should be provided as far in advance as possible to Coventry Health Care s Provider Relations department prior to the change. By providing information prior to the change, the following is ensured: The provider and practice information is properly listed in Coventry Health Care s provider directory. All payments made to the provider practice are properly reported to the IRS. Practitioner Office Site Quality There is no disruption in claims payments and claims are processed correctly according to the provider s contract. 9

12 Health Insurance Portability and Accountability Act (HIPAA) HIPAA guidelines require that providers be asked certain identifying questions when they are accessing protected health information (PHI). Please have the following information available when contacting Coventry Health Care: 1. Tax identification number 2. Provider ID number 3. Name and address 4. NPI number Coventry Health Care Commercial Member Rights and Responsibilities As a member of Coventry Health Care, you have certain rights and responsibilities. Knowing your rights and responsibilities helps ensure that you get the covered services and care that you need. You have the right to: Receive information about the organization, its services, its practitioners and providers, and member rights and responsibilities Be treated with respect and recognition of your dignity and your right to privacy Participate with practitioners in making decisions about your health care A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage Voice complaints or appeals about the organization or the care it provides Make recommendations regarding the organization s member rights and responsibilities policy You have the responsibility to: Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care Follow plans and instructions for care that you have agreed to with your practitioners Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible Coventry Health Care s Medicare Advantage Member Rights and Responsibilities Upon enrollment, Coventry Health Care presents Medicare members with an Evidence of Coverage that sets forth their rights and responsibilities. The member rights and responsibilities as set forth in the Evidence of Coverage are reproduced below for your information. Your right as a Medicare Advantage member: We must treat you with fairness and respect at all times. We must ensure that you get timely access to your covered services and drugs. We must protect the privacy of your personal health information. We must give you information about the plan, its network of providers, and your covered services. We must support your right to make decisions about your care. You have the right to know your treatment options and participate in decisions about your health care. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself. You have the right to make complaints and to ask us to reconsider decisions we have made. Your responsibility as a member of Medicare Advantage plans: Get familiar with your covered services and the rules you must follow to get these covered services If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Tell your doctor and other health care providers that you are enrolled in our plan. Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor s office, hospitals, and other offices. Pay what you owe. Tell us if you move. Call Customer Service for help if you have questions or concerns. 10

13 Member ID Cards Each Coventry Health Care member, including the subscriber and eligible dependents, is provided with an ID card. The ID card must be presented by a member each time services are requested at the physician s office, hospital or other setting. The card is for identification purposes only and is not a guarantee of current membership. If a member does not have his or her ID card, please contact Customer Service to verify membership or obtain an image of the ID card on directprovider.com. Cards will vary between plans and networks. Member ID card reference guides are located on our website at chckansas.com in the Provider Document Library. Specific member ID cards can be viewed and printed on directprovider.com. Auto and Workers Comp clients do not provide ID cards to insureds/injured parties. Providers will need to access the client/payor list on directprovider.com in order to determine whether they are participating in the Auto or Workers Comp network for that member. Copayments Members are advised that the appropriate copayment is to be paid at the time the services are rendered. The member s ID card reflects the standard office copayments for PCPs, specialists, Rx, emergency room (ER) and urgent care (UC). Patients pay differing copayment amounts based on the benefits a group may have selected. To determine a correct copayment for a Coventry Health Care member, please contact our CSO or go online to directprovider.com. Auto and Workers Compensation clients do not provide ID cards to insureds/injured parties. Providers will need to access the Client/Payor list on directprovider.com in order to determine whether they are participating in the Auto or Workers Compensation network for that member. The Workers Compensation and Auto provider manuals can be found at: The copayments, as they appear on the member s ID card, are explained below: PCP or OV (Office visit) The dollar amount paid by the member every time he/she has a professional encounter in the PCP s office SPEC (Specialist office visit) The dollar amount paid by the member every time he or she has a professional encounter at the specialist s office RX (Pharmacy) The dollar amount paid by the member every time he/she fills a prescription at a participating pharmacy ER (Emergency Room) The dollar amount paid by the member every time he/she receives services at an emergency room UC (Urgent Care) The dollar amount paid by the member every time he/she receives services at an urgent care facility Provider-Specific Communications Coventry Health Care utilizes various communication methods to inform providers regarding policies and procedures. Many of those listed below may also be found on the Provider page on our website, chckansas.com. Provider Manual May be found on chckansas.com or on directprovider.com Directprovider.com Coventry Health Care s provider portal offers real-time access to information on authorizations, claims, benefits, eligibility, technology assessments, and messaging, and policies and procedures Provider newsletters The provider newsletter, is provided quarterly to provide timely information on relevant issues, such as Coventry Health Care policies, new products, new employer groups and other helpful administrative information Blast s and faxes These communications will target a specific subject. Coventry Health Care prefers to communicate by . Providers may opt in and register at bit.ly/provider- . Provider contract Many significant financial and administrative policies and procedures are found in the contract Coventry Health Care Interactive Voice Response (IVR) System The IVR system offers automated information on eligibility, benefits and claim status to our providers 24 hours a day, 7 days a week. You will receive an immediate response to your request, a hard copy fax of information for your records and reduced hold time to acquire information. Simply call and follow the prompts to access Coventry Health Care s IVR system. To check eligibility, benefits and claims, you will need: Member ID Fax number, if appropriate Provider TIN Date of service 11

14 Main Menu Provider Menu Selection Options Result Required Entry Must enter Tax ID to proceed to Menu Selections Claim status Remain in IVR Member ID Date of service Eligibility information Authorization information None of these Summary Dates of service Billed amount Claim status Paid amount Paid date Claim number Remain in IVR Member ID Member effective date Member termination date PCP office visit copay PCP name Remain in IVR Go to plan specific menu and prompts Member ID Date of service Referral number Referred by Referred to From and to dates Type of referral Total days Information Provided Detail Member responsibility Member copay Amount applied to deductible Amount rejected Reason for denial (if denied) Member s group name Member s group number Effective date with PCP PCP telephone number PCP fax number Member deductible met Member deductible remaining Rider type (10 maximum) Rider effective date Emdeon Coventry Health Care partners with Emdeon to give our providers access to helpful information for administration services. The Coventry Health Care site allows providers to check eligibility, submit claims, obtain authorizations, check claim status and receive remittance advises and payments through electronic fund transfers for Coventry Health Care members. In addition, there is functionality to allow claims disputes to be processed electronically. This feature allows for a more convenient and timely method of handling disputed claim payments. If you are interested in obtaining a username and password to access this site, please contact your provider relations representative or call Emdeon at Directprovider.com Directprovider.com is a one-stop, self-service secure tool offering our providers a direct connection, faster service and lower costs. It is easy-to-use and contains the tools and information providers need to get the job done. By directly connecting to our organizations through the website, providers realize a better response for payments, a simplified work flow process, content and tools that address the needs of all providers, and lower costs. The website currently offers: - Claim inquiry - Eligibility inquiries including benefit information - Claim history, receipt, processing and adjudication of a claim - EFT and payment inquiry - Secure messaging - Viewable Member ID cards - Claim level rejection, claim editing and resubmission - Viewable remittances - Sensitive policy documents and forms - Authorization/Referral requests In addition to the HIPAA-compliant business transactions, the website contains enhanced content and expansive information. Through the security of the website, providers have access to news, industrystandard information about benefit plans, various reports, user guides, prescription tools and resources, downloadable forms, Member ID cards, enhanced reporting for providers, direct connectivity capability and more. Go to to register. How to Find the Correct Coventry Health Care Plan on directprovider.com When checking eligibly, authorizations or claims you need to select the appropriate drop down box for your member. Below is a key to the Coventry Health Care plans you may need to access: - Coventry Health Care of Kansas - MODOT - Coventry Health Care of Missouri - University of Missouri - Coventry One National - Rural Carrier Benefit Plan - Mail Handlers Benefit Plan - Foreign Service Benefit Plan 12

15 Fully Insured Commercial Products Coventry Health Care Commercial Products Fully Insured Commercial Products Coventry Health Care offers a wide variety of products for our members, which include both Group and Individual plans. Coventry Health Care s HMO, POS, PPO and ASO products are available as Deductible, Coinsurance and Copay benefit plans. For Deductible benefit plan designs, members may be responsible for meeting their in-network and/or out-of-network deductible before coinsurance or copays are applied by Coventry Health Care when processing the claim. Some of these benefit plans also qualify as high deductible health plans that require member deductibles to be met before Coventry Health Care makes payment, unless such services qualify as a preventive service. Consequently, in-network providers should always collect applicable copays at the point of service and submit claims to Coventry Health Care for adjudication. For benefit plans that have coinsurance established for the service being provided, submit the claim to Coventry Health Care for adjudication prior to collecting funds from the member. In all instances Coventry Health Care s remittance establishes the contractual allowance and provide direction regarding member liability. You are always allowed to bill members directly for charges determined to be member responsibility. HMO and POS Products A Health Maintenance Organization (HMO) is a type of managed Care Organization (MCO) that provides a form of health insurance coverage that if fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. Unlike traditional indemnity insurance, care provided in an HMO generally follows a set of care guidelines provided through the HMO s network of providers. Under this model, providers contract with an HMO to receive more patients and in return usually agree to provide services a discount. This arrangement allows the HMO to charge a lower monthly premium, which is an advantage over indemnity insurance, provided that its members willing to abide by the additional restrictions. Members of Coventry Health Care s Commercial primary care provider (PCP) products enjoy comprehensive HMO and POS coverage. In addition to using their contracts with providers for services at a lower price, HMOs hope to gain an advantage over traditional insurance plans by managing their patients health care and reducing unnecessary services. Some of Coventry Health Care s HMO and POS benefit plans require the member to select a PCP. The difference between HMO and POS is an out-of-network benefit, or POS option, that is available to POS members. HMO and POS members both use the HMO/ POS network. If a PCP is required, HMO/POS members may choose any internist, general practitioner, family practitioner or pediatrician listed in the HMO/POS Provider Directory as their PCP, given the PCP of choice has an open panel or he/she does not have age restrictions for patients. Coventry Health Care has no OB/GYNs designated as PCPs. The PCP is the gatekeeper of the HMO member s health care. Whenever a PCP wishes to refer an HMO or POS member to a specialist, he/she must refer the member to a provider that participates in the HMO/POS network. POS members have the option to see out-of-network providers; however, certain services still require prior authorization. As an in-network provider, you are required to call Coventry Health Care s Medical Management Department to obtain prior authorization for services as necessary on behalf of Open Access HMO and Open Access POS members. Emergency medical care does not require prior authorization from a PCP, and plans allow women to select an OB/GYN in addition to a PCP, whom they may see without a referral (for obstetrical and gynecological care only). In some cases a chronically ill patient may be allowed to select a specialist in the field of the illness as a PCP. HMOs may manage care through utilization review. The amount of utilization is usually expressed as a number of visits or services or a dollar amount per member per month (PMPM). Utilization review is intended to identify providers providing an unusually high amount of services in which case some services may not be medically necessary, or an appropriate care and are in danger of worsening a condition. HMOs often provide preventive care for a lower copayment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services such as immunizations, well-baby checkups, mammograms or physicals. It is this inclusion of services intended to maintain a member s health that gave the HMO its name. some services, such as outpatient mental health care, are often provided on a limited basis, and more costly forms of care, diagnosis, or treatment may not be covered. Other methods for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient s care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving the appropriate treatment, so that the condition does not worsen beyond what can be helped. HMOs may shift some financial risk to providers through a system called capitation, where certain providers (usually PCPS) receive a fixed payment per member per month and in return provide certain services for free. Under this arrangement, the provider does not have the incentive to provide unnecessary care, as he will receive any additional payment for the care. A variation of the HMO, is a point-of-service (POS) plan. The POS plan is a combination of HMO and preferred provider organization. In a POS plan, the member chooses a PCP to manage and coordinate his/her care. These plans are known as point-of-service because each time the member needs care he/she decides whether to stay in the network allowing the PCP to manage his/her care or the member may choose to go outside the network on his/her own without a referral form his/her PCP. If the member chooses to seek care without PCP approval or go outside the network, the member will have more out-of-pocket expense. Gatekeeper HMO Membership Eligibility The PCP gatekeeper HMO Plan generates a monthly Provider Member Listing Report for each PCP. This report includes all Coventry Health Care HMO Plan members assigned to that PCP. When a member presents for treatment, PCP offices are advised to Request the Coventry Health Care HMO Plan ID card from the member. The designated PCP will be listed on the ID card. If the card is not available, you may verify eligibility by either calling the Customer Service department at , or by visiting Verify the member s PCP prior to rendering the service, in order to avoid Claim denials and patient misunderstanding. Please do not assume that a POS member who has a self-referral benefit option is accessing his/her self referral benefit. 13

16 Member Assignments and Changes to the Primary Care Physician Generally, the PCP change will be effective on the first day of the month following the change request. In certain circumstances, it may be necessary to approve a change effective immediately or even retroactively. The plan makes every effort to avoid changes that are mid-month or retroactive. If an immediate or retroactive change appears appropriate, the plan will consider whether the member has seen their former PCP during the current month, has outstanding referrals and if services were received by someone other than their PCP. In the event the plan made an error in assigning the member s PCP and the member is not at fault, their request to change PCPs will be effective on the date requested by the member. Newborns are typically assigned to their mother s PCP. If the HMO plan receives a PCP Change Form requesting a different PCP within 30 days of the newborn s birth, then the newborn will be assigned to that PCP from their effective date. If the change form is received more than thirty (30) days after birth, the newborn will be effective with the requested PCP on the first day of the following month. If a member requests to change his or her PCP to a provider that is designated as EPO ( established patients only status ) or to another PCP in the same office, the plan will call the office to verify the EPO status and confirm that the member should not be assigned to their practice. Practice Parameters Participation Status A PCP-based program is one in which a Referral Authorization is required, the PCP acts as a gatekeeper of member information and treatment and lack of a Referral Authorization results in reduced benefits to the member. Contracting providers are required to designate their practicing status with Coventry Health Care s HMO Plan as PCP or Specialist Physician at the time the Contracting Provider Agreement is executed. If the contracting provider chooses to change the practicing status, a written notification must be sent to the Provider Relations representative as outlined below in the guidelines for requesting a change in participation or practicing status. PCPs may define their practice by identifying patient age limitations, however, those limitations must apply to all managed care programs with which the PCP participates, including other health maintenance organizations and point of service programs. PCPs may not limit or exclude any members assigned to their practices due to the member s health status, diagnosis, health care needs or health insurance coverage. PCPs may not have their immediate family members assigned to their individual practice. Immediate family members include themselves, spouse, mother, father, brother, sister, or child. If this inadvertently occurs during the enrollment process, please contact the Coventry Health Care Customer Service department to request a PCP change for the family member. PCPs are not obligated to accept new HMO Plan Members who have previously been dismissed from their practice. However, Coventry Health Care has no way to determine that a member was dismissed from the practice under a prior health plan. Participation Status Designation PCPs may designate their participation status according to the following: Open Status PCP is accepting new member enrollment. A PCP with an open practice must accept all new members assigned by Coventry Health Care s HMO Plan Established Patient Only Status An established patient is defined as a member who has been previously treated by the PCP and for whom records have been established within the past three years. PCPs who have elected EPO status with Coventry Health Care s HMO Plan are required to have that same status with all PCP-based programs with which the PCP participates, including other health maintenance organizations and point of service plans Request for Participation Status Change A PCP who wishes to change status must notify Coventry Health Care s HMO plan according to the following guidelines. Exceptions can be made to expedite the process due to unusual circumstances where immediate action is necessary. Requests for temporary status changes will be considered on a case-by-case basis. Written notification of a change request must be sent to the Provider Relations department at least 90 days prior to the requested date of change. Requests to expedite the process should be indicated in the notification and include a summary of the unusual circumstances. Providers practicing in primary care specialty classifications must have active or provisional staff privileges or the equivalent of unrestricted admitting staff privileges at a contracting hospital, where one is available. In the event a hospital has exclusive arrangements with a category of provider that would prohibit the provider from being on the medical staff, Coventry Health Care has the ability to waive the privileging requirement. Member enrollment applications submitted prior to the effective date of change in status will be assigned to the PCP except when the contracting provider is changing the status from PCP to specialist physician. A confirmation letter indicating the effective date of the change will be sent to the contracting provider. Member Dismissal There may be times when a PCP finds it impractical to continue to maintain an effective Physician-Patient relationship with a member. In some instances, it may be necessary to dismiss a member from the PCP s practice. The PCP is obligated to provide services for as long as the member requires medical care or until the relationship is terminated appropriately. A member may not be terminated or denied care due to diagnosis or health status/needs. Language barriers are not criteria for patient dismissal. Federal law requires translation/interpretive services be provided. When determining approval for member dismissal, Coventry Health Care s HMO Plan may consider the following reasons: Non-compliance with recommended treatment plans Abusive behavior toward the PCP or the office staff Refusal of or failure by the member to meet financial obligations A history of missed appointments Attempts to fraudulently obtain health care services 14

17 Please follow the process indicated below: 1. Counsel the member about the conflict or problem prior to requesting dismissal. This may include written education advising a member of specific, detailed information placing responsibility for compliance directly on the Member. Coventry Health Care encourages PCPs to provide written education to convey a clear set of instructions. The consequences, if any, for not following instructions should always be included. 2. Request authorization to dismiss the Member from the PCP s practice by faxing a completed Coventry Health Care HMO Plan PCP Member Dismissal Form, attention Provider Relations at This request should be completed in full and include, but not be limited to, supportive documentation* detailing the situation. Supporting documentation may be in the form of copies of medical records, office notes, etc and may include: Pertinent dates (missed appointments) Documentation of conversations (verbal abuse) Documentation of billing statement, including amount, letters advising Member to pay their bill (financial) Documentation of previous attempts to educate Member regarding noncompliance with recommended treatment plans or office practices Coventry Health Care s HMO Plan will request additional documentation if necessary. Failure to provide documentation to support the dismissal request within five (5) working days of Coventry Health Care HMO Plan s request will result in the request for dismissal being denied. 3. The PCP will receive written authorization to dismiss the member. 4. After the PCP receives authorization from Coventry Health Care s HMO Plan to dismiss the member, the PCP has five working days to provide written notification to the member and send a copy of such notice to Coventry Health Care s HMO plan. The PCP s notification must include the reason for the dismissal and must not occur before notification to Coventry Health Care s HMO Plan. Coventry Health Care will not contact the member for reassignment until the plan has received the PCP dismissal letter. If Coventry Health Care does not receive a copy of the PCP s dismissal letter to the member within ten business days following plan approval to dismiss, the dismissal becomes invalid. The provider is required to initiate the process again if they wish to pursue the dismissal. 5. The PCP is required to provide treatment and access to services until the member selects a new PCP, a new PCP is assigned, or for a maximum of 30 days as required by state laws. When a PCP dismisses a member, all Referral Authorizations for that member become null and void. The member must contact the new PCP to obtain new Referral Authorizations. If a physicians group wishes to dismiss a HMO member from all their office locations, they should contact the health plan and the request will be reviewed on a case-by-case basis. Member Reinstatement The PCP must notify Coventry Health Care in writing if the PCP wishes to reinstate a member that has been previously dismissed or is in the process of being dismissed. Physician Assistants (PAs) and Advanced Registered Nurse Practitioners (APRNs) Practicing in a PCP s Office PAs and APRNs are required to complete the credentialing process to be deemed Contracting Providers. Each PA/APRN must bill the health plan directly for the services they render and the PA s/aprn s name and credentials must appear in Box 31 of the CMS-1500 Claim form. If a PA/APRN is practicing under the supervision of a capitated PCP, any capitated services directly provided by the PA/APRN will be considered capitated and no additional reimbursement will be allowed. If the PA/APRN renders non-capitated services, claims will be adjudicated based on the appropriate fee schedule referenced in the PA/APRN s Contracting Provider Agreement. If a PA/ARNP is practicing under the supervision of a non-capitated PCP, claims will be adjudicated based on the fee schedule as referenced in the PA/ARNP s Contracting Provider Agreement. Coventry Health Care HMO/POS Members The PCP is the gatekeeper of the HMO member s health care. Whenever a PCP wishes to refer an HMO or POS member to a specialist, he/she must refer the member to a provider that participates in the HMO/POS network. POS members have the option to see out-of-network providers; however, certain services still require prior authorization. As an in-network provider, you are required to call Coventry Health Care s Medical Management department to obtain prior authorization for services as necessary on behalf of Open Access HMO and Open Access POS members. Some HMO and POS members are not required to select a PCP, but are urged to establish and maintain a professional relationship with a PCP. Like our traditional PCP product, Coventry Health Care offers a POS benefit plan option. The difference between HMO and POS is the out-of-network benefit, (POS option) which is only available to POS members. POS members receive in-network HMO benefits as long as they stay within the HMO/POS network. If POS members use out of network providers, they receive benefits according to the POS (out-of-network) benefit plan option. Coventry Health Care pays its portion of member coinsurance after members meet their deductibles, with the members assuming financial responsibility for billed charges above Coventry Health Care s out-of-network allowable, and for the coinsurance percentage of the out-of-network allowable as designated in their benefit design. Please encourage members to utilize in-network providers whenever possible in order to improve your ability to coordinate the delivery of quality health care and to limit their out-of-pocket expenses. PPO PPO members utilize the PPO network. PPO members have a strong financial incentive through lower copays, deductibles and coinsurance to utilize PPO in-network providers. Members may choose to utilize out-of-network providers but they ll face higher out-of-pocket costs. Therefore, Coventry Health Care asks all in-network PPO providers to refer PPO patients to other PPO in-network providers. PPO in-network providers are responsible to obtain prior authorization for certain services as presented in the Medical Management section of this Provider Manual. Failure to obtain prior authorization will result in holding the member harmless for the service. Providers are required to call Coventry Health Care s Medical Management Department to obtain prior authorization for services on behalf of PPO members. Select The network utilized by Select members is smaller than the PPO network. Select members have a strong financial incentive through lower copays, deductibles and coinsurance to utilize Select in-network providers. Members may choose to utilize out-of-network providers but they face higher out-of-pocket costs. Therefore, Coventry Health Care asks all network Select providers to refer Select members to other Select in-network providers. Select in-network providers are responsible to obtain prior authorization for certain services as presented in the Medical Management section of this Provider Manual. Failure to obtain prior authorization will result in holding the member harmless for the service. Providers are required to call Coventry Health Care s Medical Management Department to obtain prior authorization for services on behalf of Select members. 15

18 Qualified High Deductible Health Plans (QHDHP) Hospital agrees that in no event, including, but not limited to, nonpayment by Health Plan, Health Plan insolvency or Health Plan breach of the Agreement shall Hospital bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Member or persons other than Health Plan or a Payor acting on their behalf, for Covered Services rendered under the Agreement. This section shall not prohibit collection of copayments, coinsurance or deductibles in accordance with the Member s benefit plan, nor shall it prohibit collection of payment for Non-Covered Services from the Member. Hospital may seek to collect such Member Payments at any time before, during or after its provision of the health care services in question, in accordance with Hospital s customary policies and procedures regarding the collection of patient accounts. Coventry Health Care Marketplace/Exchange Products Coventry Health Care s Marketplace (Exchange) products are available to individuals selecting coverage through the Illinois and Missouri Federal Marketplace. Coventry Health Care offers its broad traditional CoventryOne PPO network throughout eastern and central Missouri and select counties in southern Illinois. All providers currently participating in Coventry Health Care s PPO are participating in the CoventryOne PPO that is available on themarketplace (Exchange). For more information on participating providers please visit Self-Funded/ASO Commercial Products Coventry Health Care acts as the third party administrator for Self-Funded/Administrative Services Only (ASO) products for employers. Coventry Health Care administers Self-Funded/ASO products directly for full-service ASO accounts, which is known as Coventry Health Care ASO Network. All Self-Funded/ASO products are administered on a fee-for-service basis. All claims are processed using your underlying fee-for-service contracted fee schedule. ASO/Self-funded Contact List Some groups contract with Coventry Health Care of Kansas to use our network and our medical management services. We do not pay claims for these groups and they have their own customer service departments to pay/process all of their claims. For information regarding how claims were paid/processed or for benefit information, please contact the group s Customer Service department listed on plan participants ID cards. Coventry Health Care ASO Network The Coventry Health Care ASO Network benefits are unique to each group benefit plan. Some plans have a design that is similar to a gatekeeper PCP model with copays, while others have an open-access POS style with deductibles and coinsurance. Self-funded plans have the flexibility of varying benefit designs to suit the needs of their individual group. Coventry Health Care ASO Network Member ID Card Coventry Health Care ASO Network Member ID cards may be customized based on the employer group s specification. Coventry Health Care ASO Network administered benefit plans can be identified by the Coventry Health Care ASO Network logo on the front or back of the Member ID card, or the group s logo will be present indicating as administered by Coventry Health Care. Coventry Health Care ASO Network Coventry Health Care ASO Network members utilize the Coventry Health Care ASO network. The Coventry Health Care ASO network encompasses the majority of Coventry Health Care s HMO/POS network providers, hospitals and ancillary providers. Coventry Health Care ASO network providers are responsible to obtain prior authorization for certain services as presented in the Medical Management section of this Provider Manual. Failure to obtain prior authorization will result in holding Coventry Health Care ASO Network members harmless for the service. General Referral Information-Coventry Health Care ASO Network Coventry Health Care ASO Network administers the benefit plans for its ASO clients. If a particular plan requires that its members designate a PCP, then the PCP should refer the member to a Coventry Health Care ASO Network in-network provider for any necessary specialty care. If you send your Coventry Health Care ASO Network members to out-of-network providers, the member may incur additional out-of-pocket expenses or, in some cases, receive no coverage at all. When providing Coventry Health Care ASO Network members with specialty care, list the referring provider s name on the submitted claim form to indicate the visit was authorized by the member s PCP. In cases where PCP referrals are required, members who schedule an appointment with a specialist without their PCP s authorization are responsible for the full cost of the specialist s services, and the visit will not be covered by Coventry Health Care ASO Network. If you are ever in doubt about the need for or method of referrals to specialists for CMR members, please call the number on the back of the Member ID card for information about the requirements. Coventry Health Care s Medicare Products Coventry Health Care s Medicare Advantage plans are Medicare Advantage (HMO/POS) and Gold Advantage (HMO), Medicare Advantage (PPO) and Coventry Health Care Total Care (HMO-POS). Coventry Health Care s Medicare Advantage products include all the standard benefits of Medicare coverage plus many extras that Medicare alone does not cover. What is a Medicare Advantage Plan? A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide Medicare beneficiaries with all their Part A and Part B benefits, including different additional benefits, and may also provide Medicare prescription drug coverage. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans and Medicare Medical Savings Account Plans for people 65 years of age and older, certain disabled people, and those of any age with End Stage Renal Disease (ESRD). The Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003 was enacted by President Bush on December 8, 2003, and is available to everyone who is Medicare eligible. Medicare prescription drug coverage (sometimes referred to as Medicare Part D ) works differently than Medicare Part A or Part B. To get this coverage, members choose a plan from a private company and may elect to pay the plan directly or have Part D premiums withheld by Social Security. Members may qualify for reduced premiums and increased cost sharing if they meet certain income requirements. To be eligible to join our Plan, Medicare beneficiaries must live in our service area and either be entitled to Medicare Part A and/or be enrolled in Medicare Part B and cannot have ESRD. If a Medicare beneficiary currently pays a premium for Medicare Part A and/or Medicare Part B, he/she must continue paying their premium in order to keep Medicare Part A and/or Medicare Part B and to remain a member of our Plan. 16

19 About Our Advantage Plan Coventry Health Care has entered into a Medicare Advantage Prescription Drug contract with the Centers for Medicare and Medicaid Services (CMS) that authorizes Coventry Health Care to provide comprehensive health services to persons who are entitled to Medicare benefits and who choose to enroll in Coventry Health Care s Medicare Advantage Prescription Drug Plan (MA-PD), Health Maintenance Organization (HMO), Health Maintenance Organization - Point of Service (HMO-POS) Preferred Provider Organization (PPO). HMO members must obtain all of their medical care through Coventry Health Care contracted providers. The exception to this requirement includes emergency services within the service area and emergency or urgently needed services outside the service area. PPO members have coverage for out-of-network services. Coventry Health Care Medicare Advantage Plans are not a Medigap policy or a Medicare Supplement Plan. Medicare Advantage Plans include Medicare Part A and B benefits and enhanced benefits not covered by traditional Fee for Service Medicare, such as preventive services, fitness benefits, and worldwide emergency care. Some Coventry Health Care Medicare Advantage Plans do not include prescription drug coverage. However, there are opportunities for members to purchase a seperate prescription plan. Members who enroll in a stand alone Part D plan will be automatically terminated from their Medicare Advantage coverage. CMS regulations specifically prohibit a Medicare beneficiary from having a separate Part D plan and coverage under a Medicare Advantage plan at the same time. Medicare Advantage HMO and POS plans Coventry Health Care Total Care is a High Performance Network product with a limited network. Coventry Health Care Total Care members utilize the Coventry Health Care Total Care network. The PCP is the gate keeper of the Coventry Health Care Total Care member s health care. Whenever a PCP wishes to refer a Coventry Health Care Total Care member to a specialist, he/she must refer the member to an in-network Coventry Health Care Total Care provider in order for the member to receive covered benefits. These plans have no out of network benefits. Medicare Advantage HMO Plans Medicare Advantage Plan - Health Maintenance Organization HMO is for people with Medicare offered by Coventry Health Care of Kansas. Benefits include original Medicare coverage, plus extra benefits offered to HMO members, such as a fitness benefit. These plans have no out of network benefits. How Does the Program Work? The HMO member selects a Primary Care Provider (PCP) who coordinates their care. Members can use network physicians and specialists who have agreed to accept our payment to them as payment in full and members are responsible for only a copayment or coinsurance for covered services. The exception to this requirement includes emergency services within the service area and emergency or urgently needed services outside the service area unless otherwise indicated in their HMO Evidence of Coverage. Members must be eligible for Medicare Part A and Part B and are required to continue paying their Medicare Part B premium. Medicare Advantage PPO Plans Medicare Advantage PPO plan is a Preferred Provider Organization (PPO) Program offered by Coventry Health and Life Insurance Company and administered by Coventry Health and Life Insurance Company. This plan includes all the benefits of original Medicare coverage, plus many benefits offered to PPO members, such as a fitness benefit. How Does the Program Work? The PPO plan offers greater flexibility, freedom and savings. Members are not required to select a primary care physician. They can choose to visit any Medicare participating doctor, any specialist or any hospital at any time. Members can use network physicians and specialists who have agreed to accept our payment to them as payment in full and members are responsible for only a copayment or coinsurance for a doctor or specialist visit. If members choose providers outside the network, they are still eligible for benefits, but their cost share will be higher. Members must be eligible for Medicare Part A and Part B and are required to continue paying their Medicare Part B premium. What is the Prescription Drug Plan? Coventry Health Care s Part D benefit is a Medicare approved national prescription drug plan underwritten and administered by Coventry Health Care plans (Coventry Health and Life Insurance Company, Cambridge Life Insurance Company, and First Health Life & Health Insurance Company). How Does the Program Work? The prescription drug prgram Is a stand-alone Medicare prescription drug plan. This plan is for those who do not already have prescription drug coverage through a Medicare Advantage Plan or another Medicare Health Plan that offers drug coverage. The Part D plan will help members by covering generic and brand-name medications at pharmacies on our network. We have participating pharmacies nationwide. If members need a new prescription while they are traveling (or leave an important medication behind), they are covered across the Untied States. The plans vary in cost and coverage. 17

20 The following provisions apply to each of Coventry Health Care s Medicare products. Treatment for Serious or Complex Medical Conditions The Balanced Budget Act of 1997 requires Coventry Health Care to identify all of Coventry Health Care s Medicare members with complex or serious medical conditions, establish assessment of the condition, monitor each case on an ongoing basis and establish and implement treatment plans appropriate to the condition. Home Assessment Program-Medicare Advantage Members Only As part of our ongoing quality improvement efforts, Coventry Health Care periodically offers in-home health assessments with our Medicare Advantage members. It is possible that patients from your panel will be asked to participate in this free, comprehensive assessment. The assessment is strictly voluntary and will be performed in the patient s residence by a licensed provider. If one of your patients is selected to participate in this program, the completed assessment will be mailed to you. Coventry Health Care will use information from the assessment to identify medical management/disease management programs which may benefit the member. If you have any questions about the home assessment program, please contact your local Provider Relations representative for more information. Health Risk Appraisals Health risk appraisals (HRA) are sent to each member upon confirmation of effective date from CMS. HRAs are analyzed in order to determine if those members have complex or serious medical conditions. Post-Stabilization Care Coventry Health Care provides coverage for members requiring medically necessary, post-emergency services that are needed to ensure stabilization from the time that an in-network or out-of-network provider or facility requests authorization from Coventry Health Care until one of the following occurs: The patient is discharged An in-network provider arrives and assumes responsibility for care An out-of-network provider and Coventry Health Care agree to other arrangements Coventry Health Care s Medicare Provisions Plan Member grievance or Medicare Appeal Process The provider shall cooperate and comply with all Coventry Health Care and Medicare requirements regarding the processing of plan member appeals and grievances, including the obligation to provide information within a reasonable timeframe. Coventry Health Care has established a separate Customer Service Department dedicated to Medicare Advantage plan members. The first step of the plan member appeal process begins after Coventry Health Care processes an organization determination on behalf of one of its plan members. An organization determination is any determination made by a health care provider or by the Plan regarding the receipt of treatment or payment of services. A plan member must receive this determination, whether favorable or a denial, within 14 days of a service request, or within 60 days of a claim payment request, unless an expedited determination is necessary. Please refer to our website for a listing of Medicare Advantage policies. Coventry Health Care Total Care In the Wichita market, Coventry Health Care Total Care is a High Performance Network product. Coventry Health Care Total Care members utilize the Coventry Health Care Total Care network. The PCP is the gate keeper of the Coventry Health Care Total Care member s health care. Whenever a PCP wishes to refer a Coventry Health Care Total Care member to a specialist, he/she must refer the member to an in-network Coventry Health Care Total Care provider in order for the member to receive cover benefits. Coventry Health Care of Kansas Star Rating Coventry Health Care of Kansas (Coventry Health Care) HMO/HMO-POS and PPO plans are awarded star ratings by CMS. CMS rates Medicare Advantage plans on a 1 5 star scale, with 5 stars representing the highest quality. Stars score provide an overall measure of a plan s quality. Stars score provide an overall measure of a plan s quality. It is a cumulative indicator of the quality of care, access to care, responsiveness, and benefi ciary satisfaction provided by the plan and its network providers. We thank you for your commitment to quality and service, as well as for your support to our programs which helps our Medicare members to achieve their treatment goals. 18