HARBOR CHOICE HEALTH PLAN PROVIDER OFFICE MANUAL

Transcription

1 HARBOR CHOICE HEALTH PLAN PROVIDER OFFICE MANUAL This manual is prepared for use by HARBOR CHOICE HEALTH PLAN contracted physician and ancillary providers for Harbor Choice HMO products. These products are offered to the public both directly and through the Affordable Care Act Health Insurance Marketplaces (also known as Exchanges). Providers should ensure that the information in this manual is made available to all appropriate staff, including any off-site billing departments and/or billing services utilized by the provider. If needed, additional copies may be obtained from your HARBOR CHOICE HEALTH PLAN Provider Relations representative. This manual attempts to follow Insurance laws and regulations in effect, however, we urge you to consult statutory and regulatory provisions regarding prompt payment, which from time to time change. An address and telephone guide is included in the INTRODUCTION section for your reference. We welcome your suggestions for future editions of our manual. Please send any comments or suggestions to the following address: HARBOR CHOICE HEALTH PLAN Attention: Provider Relations 3663 Woodward Ste 120 Detroit, MI FAX: (313) When writing to us about the manual, please include your name, phone number with area code and your return address. Thank you. The Staff of HARBOR CHOICE HEALTH PLAN 1

2 HARBOR CHOICE HEALTH PLAN PROVIDER OFFICE MANUAL TABLE OF CONTENTS SECTION Page Number 1 INTRODUCTION About the Manual Confidentiality of Information How to Reach HARBOR CHOICE HEALTH PLAN Address and Telephone Guide Provider Information Update Form PROVIDER ID NUMBERS AND AUTOMATED SERVICES HARBOR CHOICE HEALTH PLAN Provider ID Numbers Automated Services Accessing the Services CUSTOMER SERVICE Customer Service Member Identification (ID) card Sample Member ID Card Member Rights and Responsibilities QUALITY IMPROVEMENT PROGRAM Overview Summary of the Credentialing Process Practitioner Office Site Visit MEDICAL SERVICES Standards of Care Access to Care Utilization Management Program Mission Statement Purpose. 5.2 Goals and Objective. 5.2 Utilization Management Decision Making

3 SECTION Page Number 5 MEDICAL SERVICES (continued) Roles and Responsibilities of a PCP Responsibilities Member Assignments Roles and Responsibilities of a Specialist Physician Responsibilities Specialists Acting as a PCP Designated OB/GYN for Female Members Maternity Care Referral Procedures Approval Requirements Referral Processing Referral Time Frame, Visits and Scope of Care Pre-Authorization Program and Requirements Services Requiring Pre-Authorization 5.11 Admitting Physician Responsibilities How to Obtain a Pre-Authorization Information Required for Pre-Authorization Elective Service Pre-Authorization Lead Time Requirements Emergency Admissions and Direct Admissions Inpatient Admission and Length of Stay Authorization Concurrent Review of Inpatient Admissions Requesting Extensions to the Authorized Length of Stay Chief Medical Officer Role Technical Denials Adverse Determinations Lab Testing and Radiology Services Durable Medical Equipment, Orthotics, Prosthetics and Medical Supplies Emergency Care Verification Prescribing Medications Prescription Drug Coverage Drug Formulary Exception/Pre-Certification Process Generic Drug Policy BEHAVIORAL HEALTH CARE

4 SECTION Page Number 7 CLAIMS Filing a Claim Do s and Don ts of a Paper Claim National Provider Identifier (NPI) Requirements Electronic Claims Submission Paper Claims Submission Coding Service Location Codes Modifiers Claims Filing Deadlines Copayments Special Billing Situations OB/GYN Services Allergy Services Anesthesia Services Notice of Pending Claims to Providers Claims Editing System Claim Audit Procedures Changes in Physician Status or Practice Information HARBOR CHOICE HEALTH PLAN Explanation of Payment (EOP) Customer Service Unit Checking the Status of a Claim Appeal Guidelines Overpayments Coordination of Benefits Medicare Reimbursement Methodology Matrix Subrogation Motor Vehicle Accidents Work Related Injuries Fraud, Waste and Abuse COMPLAINT AND MEDICAL APPEAL PROCEDURES Overview Complaint Procedure Complaint Appeal Procedure Adverse Determinations Appeal Procedure Filing Complaints with the Texas Department of Insurance Appeals to an Independent Review Organization (IRO)

5 SECTION Page Number 9 GLOSSARY OF TERMS ATTACHMENTS AND FORM SAMPLES CMS 1500 UB04 CMS 1450 Elements of a Clean Claim Modifier Requirements Table Sample Explanation of Payment (EOP) EFT-Direct Deposit Form Texas Referral/Authorization Form Notice of Financial Responsibility Provider Information Update Form CLINICAL PRACTICE GUIDELINES For information regarding current Vaccine/Immunization Schedules Childhood and Adolescent Immunization Schedule Children and Adolescents Who Start Late Catch-Up Schedule for Children age 7-18 Adult Immunization Schedule Please visit the Centers for Disease Control (CDC) website at 5

6 INTRODUCTION Welcome to the HARBOR CHOICE HEALTH PLAN network of providers a network of hospitals, physicians and ancillary health care providers that have agreed to work together to provide a complete network of services to HARBOR CHOICE HEALTH PLAN Members. We are sincerely pleased that you have agreed to participate in the HARBOR CHOICE HEALTH PLAN network. We look forward to working with you to offer quality health care to your patients who participate with HARBOR CHOICE HEALTH PLAN. About the Manual This manual has been prepared to help you understand the HARBOR CHOICE HEALTH PLAN program and its procedures. The information in this manual offers guidelines that will apply to most patients that are enrolled with HARBOR CHOICE HEALTH PLAN. In the event any discrepancies arise between this manual and a provider agreement, the language in the more current of the two documents will prevail, only with respect to HARBOR CHOICE HEALTH PLAN policies and procedures. In all other cases of discrepancies, the provider agreement shall prevail, unless the differences are caused by the actions of state or federal regulatory bodies or any of the health benefit programs operated by these entities. This manual is for the benefit of in-plan physician and ancillary providers. HARBOR CHOICE HEALTH PLAN policies include, but are not limited to what is identified in the manual. The policies described in this manual are accurate at the time of printing and may be subject to modification, addition, and/or deletion. Updates may occur at intervals and may be communicated in the form of provider newsletters, direct mail or by fax from HARBOR CHOICE HEALTH PLAN, and provider manual revisions. Providers should maintain their manuals by incorporating any updates into the existing manual. This provider manual is subject to periodic updates, with the most recent version found on our website at Confidentiality of Information Confidentiality is the responsibility of every HARBOR CHOICE HEALTH PLAN employee and HARBOR CHOICE HEALTH PLAN provider. We are both "Covered Entities" under the Privacy Regulations in the 1996 Health Insurance Affordability and Accountability Act (HIPAA), even if you submit paper claims. Fortunately, all of the normal transfers of confidential patient information between us are allowed under HIPAA, within the prescribed Security limits of the Act. There is an HARBOR CHOICE HEALTH PLAN Corporate Policy of zero-tolerance for any infraction of the policy by HARBOR CHOICE HEALTH PLAN 4

7 employees. All new HARBOR CHOICE HEALTH PLAN employees are informed in the Orientation Process that they can be immediately fired for any breach of confidentiality. This policy is also highlighted in the employee handbook. Additionally, access to all files (manual and computerized) is provided with security clearance at the time of employment with HARBOR CHOICE HEALTH PLAN and revoked formally at the time of termination. Providers should comply with HARBOR CHOICE HEALTH PLAN policies regarding confidentiality to the extent that confidential treatment is provided for under state and federal laws and regulations. All records and all other documents deemed confidential by law, and disclosure or transfer of confidential information will be in accordance with applicable law. 5

8 HOW TO REACH HARBOR CHOICE HEALTH PLAN Address and Telephone Guide Customer Service Department (M-F 8:00am 5:00pm, Eastern) Member Eligibility, Benefit Questions, Claims Inquiries, and Complaints & Appeals Pre-Authorization Department Provider Relations Medical/Case Management Pharmacy Provider NAVITUS Phone Number: (866) TTY: (877) Phone Number: (844) Fax Number: (313) Phone Number: (844) Fax Number: (313) Phone Number: (844) Fax Number: (313) Phone Number: (866) Fax Number: (855) Claims Mailing Address Claims Electronic Clearinghouse Emdeon Payer ID ( HARBOR CHOICE HEALTH PLAN P.O. Box El Paso, Texas Phone Number:

9 HARBOR CHOICE HEALTH PLAN Provider Information Update Please make copies of this form and use to advise your Provider Relations representative of changes in information relative to your practice. Provider Name: City, State: The following information needs to be updated in HARBOR CHOICE HEALTH PLAN provider records: Change of Address/Phone Billing Office Primary Office Secondary Office Third Office Previous Address: New Address/Effective Date: Phone: Phone: Change of Tax ID Number Please include updated W-9 with this sheet. Previous Tax ID #: New Tax ID #/Effective Date: Other Changes Effective Date: Signature and Title Date of Signature Please mail or fax to your Regional Provider Relations Department. HARBOR CHOICE HEALTH PLAN 3663 Woodward Ste 120 Detroit, MI Fax: (313)

10 PROVIDER ID NUMBERS AND AUTOMATED SERVICES HARBOR CHOICE HEALTH PLAN Provider ID Numbers The provider s National Provider Identifier (NPI) number is used by HARBOR CHOICE HEALTH PLAN to identify providers in all areas of interaction between the provider and HARBOR CHOICE HEALTH PLAN, from claims submission and payments to access of HARBOR CHOICE HEALTH PLAN automated services such Provider Services Web Portal. Providers are reminded that these numbers should be made available by the contracted provider to all appropriate office staff and billing services at the discretion of the provider in order that they may also access the convenient automated services made available by HARBOR CHOICE HEALTH PLAN. Automated Service HARBOR CHOICE HEALTH PLAN automated service consists of the HARBOR CHOICE HEALTH PLAN Provider Services Web Portal. This automated system gives HARBOR CHOICE HEALTH PLAN participating providers confidential, 24-hour access to information and services such as: Member Eligibility and Benefits including quick access to copay information Status checks on previously submitted Claims, Authorization Requests and access to Explanation of Payments (EOP S) The provider s Tax ID number is used to access the online Provider Services Web Portal. A provider who is having problems accessing the Provider portal through the website should contact Customer Service at or TTY Accessing the Service To access the Provider Services Web Portal, go to the HARBOR CHOICE HEALTH PLAN homepage at click on the Physicians link and then click on the Provider Portal link. A unique login is needed to access the Provider Portal. Since use of the automated systems may have some limitations and will not be appropriate for all services please contact customer service at the number listed in the "How to Reach Us" in the INTRODUCTION section of this manual Section: Provider ID Numbers and Automated Services

11 CUSTOMER SERVICE Customer Service Customer Service Representatives are available between the hours of 8 a.m. - 5 p.m. Monday through Friday, Central time. Our website can be accessed 24 hours a day, seven days a week at: Providers should call Customer Service or visit our web portal with questions regarding: Eligibility Benefits questions Claims inquiries Appeals Please refer to the phone numbers shown on the "How to Reach Us" in the INTRODUCTION section at the beginning of this manual for the correct numbers to call. IMPORTANT Each physician or provider is responsible for verifying eligibility when services are rendered. Copayments are to be paid by the Member at the time of service. Notify HARBOR CHOICE HEALTH PLAN immediately if an ID card has been used fraudulently. For specific plan design or coverage information, please contact the Customer Service Department. Copy the Member's ID card on the first visit and place a copy in the Member's file. Note the effective date of eligibility and remember to update this information. Member Identification (ID) Card Members enrolled in HARBOR CHOICE HEALTH PLAN products are issued a member identification card by HARBOR CHOICE HEALTH PLAN. Members should present these ID cards when they are seeking services from HARBOR CHOICE HEALTH PLAN network providers. If the patient does not have his/her member card or enrollment form for new enrollees, the provider's office can call Customer Service or access the Provider Portal on the website ( to verify member eligibility. Remember that possession of an ID card does not guarantee eligibility. Providers are encouraged to verify the effective date of benefit coverage as well as Member identity prior to rendering services to the Member. A sample Member Identification Card is found on the following page. This ID card will contain the following information: Member Name including eligible dependents - The name that should be used for claims filing and preauthorization requests Section: Customer Service

12 Member Number - The HARBOR CHOICE HEALTH PLAN member ID number. Effective Date - The initial date of eligibility. Group Number - The number assigned to the Member's employer or payer. Coverage Type- Individual + Spouse or Family Important notices to plan Members and Providers are indicated on the back of the card, as well as emergency phone numbers Section: Customer Service

13 Sample ID Card Front Sample ID Card Back 3. 3 Section: Customer Service

14 All Members have a Right to: Member Rights and Responsibilities Receive information about the managed care organization, its services, its practitioners and providers, and members rights and responsibilities. To be treated with respect and recognition of their dignity and right to privacy. To participate with practitioners in decision making regarding their health care. A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. To refuse treatment to the extent permitted by law, and to be made aware of the potential medical consequences of such action. To voice complaints or appeals about the managed care organization or the care provided. To make recommendations regarding the organization s members rights and responsibilities policies. To request to see his/her medical record and the ability to request an amendment to the medical record. All Members have a Responsibility to: Provide to the extent possible, information that HARBOR CHOICE HEALTH PLAN and physicians need in order to provide their health care. Follow HARBOR CHOICE HEALTH PLAN Evidence of Coverage. The Evidence of Coverage is the document used to determine and define their benefits. Follow instructions for care that they have agreed on with their physicians. Carry their HARBOR CHOICE HEALTH PLAN member ID card with them at all times. Present it to each provider (physician, hospital, laboratory, etc.) before every appointment. Provide proof of insurance to all providers rendering services (HARBOR CHOICE HEALTH PLAN member ID card) in a timely fashion allowing time for provider to submit claims for payment before the one year claims filing deadline. If a copy is not provided within this time frame all charges may be billed to member by the provider of service. Obtain a referral from their Primary Care Physician or designated OB/GYN before making an appointment with a plan specialist, if required by member's health plan design. Be on time for appointments. Notify their physician s office at least 24 hours in advance if they need to cancel or reschedule an appointment. Make the lifestyle changes their physician recommends to help the member be healthier. Understand the medications they take; know what they are, what they are for and how to take them properly. Notify HARBOR CHOICE HEALTH PLAN and their PCP within 24 hours after receiving emergency care Section: Customer Service

15 QUALITY IMPROVEMENT PROGRAM Overview The Quality Improvement (QI) Program is designed to objectively and systematically monitor and evaluate the quality and appropriateness of the medical care that members receive. The program is also designed to pursue opportunities to improve member care and resolve identified problems. This program provides the foundation by which members issues regarding care or service will be evaluated and improved for the benefit of the member, practitioner and health plan in order to meet or exceed both the internal and external customers expectations. This is accomplished through the implementation of a comprehensive organization-wide work plan with an on-going assessment to identify opportunities for improvement. The scope of the Quality Improvement (QI) program encompasses the activities that have direct or indirect influence on the quality of the medical care and service the members receive from the affiliated practitioners of the health plan, as well as the measurements of those activities. HARBOR CHOICE HEALTH PLAN QI program: Evaluates and verifies the credentials of the practitioners/providers providing care to its members, Monitors practitioner availability, practitioner and health plan accessibility of services provided, and the acceptability of services provided as perceived by members. Monitors activities, including medical record review that access appropriateness, as well as continuity and coordination of care. Utilizes drug utilization, quality care and/or service complaints and other QI/UM reports to target high risk, high volume, problem-prone issues and potential problem areas. Tracks and trends key organizational and quality indicators. Monitors and evaluates the clinical care and services provided by practitioners and institutional providers of both primary care and major specialty services, including mental health. Develops and implements practice guidelines for preventive health and other important aspects of care. Develops and implements system-wide preventive health and health education programs. Develops and implements programs to meet the needs of members identified as potential high risk and who suffer from acute and/or chronic diseases. Monitors the effectiveness of the oversight process for delegated activities. Monitors and evaluates services issues by using provider and member satisfaction surveys and complaints received. The Board of Directors has approved the QI program and has assigned the responsibility for developing, implementing, monitoring, and evaluating the program to HARBOR CHOICE HEALTH PLAN Executive Director. Quality Improvement program activities are developed and monitored by the Quality Management Council (QMC), which is composed of HARBOR CHOICE HEALTH PLAN 4. 1 Section: Quality Improvement/Management

16 Executive Director, Chief Medical Officer, Director Medical Management and Plan participating physicians. This committee provides the mechanism for comprehensive review of all healthcare issues affecting members, oversight of quality improvement initiatives, and peer review activities. All Quality Improvement and protected healthcare information is maintained in strict confidence. To request further information or a copy of the Quality Improvement Program, please call 1 (844) Section: Quality Improvement/Management

17 CREDENTIALING PROCESS CREDENTIALING AND RECREDENTIALING Harbor Health Plan is committed to offering its' members quality health care by carefully selecting providers to participate in our Harbor Choice network. In accordance with state, federal and national accreditation standards, all providers are recredentialed every three years. Harbor Health Plan is working diligently to make the recredentialing process seamless. Participation Criteria Harbor Choice welcomes applications from the following types of providers: o Physicians (MD or DO) o Physician Assistant o Nurse Practitioner o Psychologist o Psychiatrist o Audiologist o Physical Therapist o Speech Therapist o Social Worker o Hospital o Urgent Care Center o Durable Medical Equipment Supplier o Home Health Agency o Skilled Nursing Facility o Laboratory o Specialty Pharmacy o Hospice o Physical Therapy o Radiology Centers o Dialysis Centers o Federally Qualified Health Centers o Behavioral Health Centers o Pain Management Clinics o Vision Providers o Free Standing Surgery Centers Harbor Choice requires each provider or practitioner wishing to participate in its' network to complete an application for credentialing. The provider must complete an online application via the CAQH at or the Michigan Association of Health Plan (MAHP) Standard Practitioner Application for Credentialing or any other Harbor Choice approved application with signed Attestation and Consent from the provider. Harbor Choice credentials and recredentials providers according to state, federal and national accreditation standards. The Harbor Choice credentialing program determines whether or not a provider or practitioner is qualified to perform their respective services while meeting the minimum criteria as defined. Primary source verification is conducted on various components within 4. 3 Section: Quality Improvement/Management

18 the provider/practitioner application. All applicants must hold a current, unrestricted license to practice in the State of Michigan. Applications must be completed in its entirety and contain all requesting supporting documentation. Practitioner Credentialing Process To begin the credentialing process, the provider or practitioner application must contain the following: Completed Application and Signed Attestation/Consent to Release Ability to Participate in Medicare/Medicaid Board certification or proof of board eligibility and exam date Hospital privileges in good standing, if applicable Current malpractice/general liability insurance Current, valid DEA or Controlled Dangerous Substances (CDS) certification Current, valid, unrestricted license Work history for five years with documented gaps (over 30 days) Provider Ethnicity Form History of professional liability claims that resulted in settlements or judgments paid by or on behalf of the practitioner within last five years Harbor Health Plan Addendum to Credentialing/Recredentialing Form ECFMG Certificate (if applicable) Recredentialing Process It is essential that all providers are credentialed prior to their three year anniversary date to Harbor Health Plan. All providers and practitioners are required to be recredentialed. If the provider or practitioner does not submit or chooses not to be recredentialed within the allotted time frame, their application will be terminated at the end of the current appointment period. The recredentialing process will include a re-verification of the provider or practitioner application as well as quality data assessed through member concerns, grievances, appeals and quality of care concerns. Policies Harbor Choice has policies and procedures in place for both the initial and recredentialing process. These policies are subject to change and should be used as a guideline only. Final determination of the credentialing decision is the granted by the Harbor Choice Credentialing Committee. Providers that are not credentialed cannot provide covered services to Harbor Choice members in an office or outpatient setting until the credentialing and contracting process has been completed Section: Quality Improvement/Management

19 PRACTITIONER OFFICE SITE VISITS Harbor Choice may conduct an office site visit to any primary care. high-volume or ancillary provider at any time for cause. The office site visits are designed to gather data to assure our network providers are meeting the Harbor Health Plan standards for Quality. When Harbor Choice detects or suspects deficiencies at a provider s office, the Credentialing and/or Provider Services departments will initiate a comprehensive investigation that may include a site visit. The methods by which the deficiencies are identified include, but are not limited to: monitoring member and provider complaints, adverse events, member complaints or valid concerns from Provider Relations, Medical Management and/or other internal departments. A scoring methodology is used to assess exterior, interior, exam rooms, laboratory equipment, record keeping practices, etc for a provider's office. Any deficiencies are noted and scored appropriately. Providers who receive less than 80% on a site visit will received a non-passing score and require a Corrective Action Plan. Providers are given 30 days to correct any deficiencies. The Credentialing Department can be reached at (313) Section: Quality Improvement/Management

20 MEDICAL SERVICES Standards of Care Access to Care HARBOR CHOICE HEALTH PLAN has established standards for all participating physicians in areas such as appointment scheduling and office wait time. In addition, HARBOR CHOICE HEALTH PLAN has established that all contracted hospitals provide qualified, consistent, and easily accessible coverage 7 days a week, 24 hours a day. In addition, HARBOR CHOICE HEALTH PLAN has established that all contracted urgent care centers provide qualified, consistent, and easily accessible coverage 7 days a week. As noted previously, a Primary Care Physician (PCP), or designated physician, is expected to be available to the members at all times or to arrange for coverage with another participating physician to meet the standard of immediate access. Appointment Availability Standards PCP Preventative Care Services PCP Routine Care Services Contracted Specialist/Specialty Care Services In-area Urgent Care Services from Contracted Provider Services during Normal Business Hours Appointment date must be within sixty (60) days of member s request, or sooner if necessary, for member to receive immunization(s) timely. Appointment date must be within fifteen (15) days of member s request, or sooner if medically necessary. Appointment date must be within sixty (60) days of member s request, or sooner if medically necessary. Seven days a week. Contracted ancillary providers, or sooner if medically necessary Section: Medical Services

21 UTILIZATION MANAGEMENT PROGRAM Mission Statement The mission of the Medical Services Division at HARBOR CHOICE HEALTH PLAN is to ensure that each member gets the right care and services by the right provider(s) in the right setting(s) at the right times, at the right cost, while being fully compliant with state and federal legal and ethical standards. Purpose The purpose of the Medical Management/Utilization Management (MM/UM) Program is to ensure that health care resources are used efficiently and effectively to provide the best value to individuals and organizations purchasing health care and services based on evidence-based national or community standards of care. UM involves the evaluation of requests for coverage by determining the medical necessity, appropriateness and efficiency of the health care services under the applicable health benefit plan. The MM/UM Program directs utilization management activities for all business products of the Health Plan. By adopting the program, HARBOR CHOICE HEALTH PLAN demonstrates a commitment to providing quality of care and quality of services to its members through effective continuous improvement activities. These activities use mechanisms that assess care delivery. Goals and Objectives The goal of HARBOR CHOICE HEALTH PLAN MM/UM Program is to implement a planned, systematic and organized program to assess, plan, implement, coordinate, monitor, evaluate, promote and improve high quality member care along a wellness continuum. The program addresses the needs of each member to assure high quality health care that is within achievable goals and resources. High quality care means the clinical management of members is efficacious and appropriate within the terms of their member benefits contract and that it is available and accessible when needed. Additionally, care should be delivered in a timely manner, respectful and caring from the member s perspective, as well as effective, safe, efficient and coordinated over time, culturally competent and across practitioners and settings. For further information about the Utilization Management Program, please call (844) Section: Medical Services

22 UTILIZATION MANAGEMENT DECISION MAKING HARBOR CHOICE HEALTH PLAN encourages its physicians to have patients actively participate in decisions regarding their health care and be part of candid discussions regarding appropriate or medically necessary treatment options for their condition(s), regardless of the cost or benefit coverage. Physicians are also encouraged to provide information to patients about an illness, the course of treatment, including medications and possible side effects, and prospects for recovery in terms that they can understand. HARBOR CHOICE HEALTH PLAN does not discriminate in any manner against any physician or other provider who openly discusses medically necessary treatment options, regardless of cost or benefit coverage, with their patients. HARBOR CHOICE HEALTH PLAN bases its decision-making only on appropriateness of care and/or service and existence of coverage. HARBOR CHOICE HEALTH PLAN does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service. There are no financial incentives for utilization management decision makers Section: Medical Services

23 Roles and Responsibilities of a PCP When required by the terms of a member s plan, a Primary Care Physician (PCP) with HARBOR CHOICE HEALTH PLAN is responsible for providing, arranging, and coordinating all aspects of the member s health care for those members assigned to the PCP.They are also responsible for directing and managing appropriate utilization of health care resources. The PCP is the focal point of all care management for HMO members. HARBOR CHOICE HEALTH PLAN recognizes General Practice, Family Practice, Internal Medicine, and Pediatric physicians as PCP. Female members may also designate an OB/GYN provider in addition to a PCP. When the member s plan requires a selection of a PCP, the member is asked to select or designate a PCP at the time of enrollment. If a selection is not made, a primary care physician will be assigned by HARBOR CHOICE HEALTH PLAN. Members may change PCPs upon providing HARBOR CHOICE HEALTH PLAN notice. Responsibilities A PCP is expected to provide all necessary care required by a member that is within the scope of his or her practice and expertise. The PCP should refer a member to a specialist or other provider only when he or she is not able to provide the specialty care. The PCP must advise HARBOR CHOICE HEALTH PLAN of all out-of-network referrals prior to the specialty visit. Prior notification does not apply in the case of an emergency situation if the delay would result in physical harm to the member. The PCP is expected to provide qualified, consistent, easily accessible on-call coverage seven (7) days a week, 24 hours a day, either personally or by a reasonable call coverage arrangement with other appropriate individuals. Members are instructed to contact their PCP FIRST when they need urgent or emergent care. The PCP is responsible for evaluating the patient's needs and directing their care, including working them into the schedule during normal office hours when at all practical. In urgent or emergent situations after office hours, the PCP, or his/her designee for qualified coverage, is expected to provide access to a health care provider to advise the patient on the course of care they should follow. After-hours coverage may not solely consist of directing members to a hospital emergency room. The PCP must refer members to in-plan providers unless approval is received in advance from HARBOR CHOICE HEALTH PLAN. Member Assignments The PCP will have access to their assigned member roster through the web portal at www/phxchoice.com, for which they are responsible to oversee delivery of health care services. If a member is not on the PCP's eligibility list, the PCP is required to contact the HARBOR CHOICE HEALTH PLAN Customer Service Department to determine eligibility when contacted by the member seeking care. Failure to verify assignment to the PCP may prevent the PCP from receiving reimbursement from HARBOR CHOICE HEALTH PLAN for services rendered Section: Medical Services

24 Roles and Responsibilities of a Specialist Physician The role of a HARBOR CHOICE HEALTH PLAN participating specialist is to provide consulting expertise, as well as specialty diagnostic, surgical and other medical care for HARBOR CHOICE HEALTH PLAN members. HARBOR CHOICE HEALTH PLAN expects a participating specialist to support the role of a PCP in coordinating and managing a member's health care by providing only those specific services for which a referral has been issued, and promptly returning the continued care of the member to the PCP as soon as medically appropriate. Open, prompt communication with the PCP concerning follow-up instructions, circumstances of further visit requirements, medications, lab work, x-rays, etc. are essential to the coordination of care. The specialist is expected to provide qualified, consistent, easily accessible on-call coverage seven days (7) a week, 24 hours a day, either personally or by a reasonable call coverage arrangement with other appropriate individuals. In urgent or emergent situations after office hours, the specialist, or his/her designee for qualified coverage, is expected to provide access to a health care provider to advise the patient on the course of care they should follow. After-hours coverage may not solely consist of directing members to a hospital emergency room. If the member desires to receive services from the specialist without a referral, the specialist should obtain a waiver from the member acknowledging their financial responsibility before services are rendered. Services rendered by specialists when there is not a valid referral, or which are beyond the scope of services specified in the referral, may be denied by HARBOR CHOICE HEALTH PLAN. Responsibilities The specialist must provide a report to the member s PCP within five (5) working days of rendering care, or as soon as possible in the event that legitimate delays result from lab tests, x-rays, pathology reports, etc. If further care is required beyond the scope of the original referral, the specialist must follow the HARBOR CHOICE HEALTH PLAN pre-certification requirements for additional treatment. If the specialist identifies the need for a physician of a different specialty, the member should be referred back to the PCP first. If a specialist is consulted during an emergency room visit, a referral is not required for providing that care; however, a referral is required for any follow-up care provided after the emergency room visit. (This does not apply to orthopedic referrals resulting from an emergency room visit, as these do not require a referral or HARBOR CHOICE HEALTH PLAN authorization for follow-up care). If a specialist is called in for consultation during an observation or inpatient hospital stay, no referral is required for providing that care in the hospital. Specialists should order all laboratory testing, radiology studies or other diagnostic testing through a contracted, in-plan facility, unless an emergency situation clearly indicates 5. 5 Section: Medical Services

25 emergency lab or radiology services are required. HARBOR CHOICE HEALTH PLAN has specific, contracted laboratory and radiology service providers Section: Medical Services

26 Specialists Acting as a PCP Members with chronic, disabling or life threatening illness have the opportunity to utilize a nonprimary care physician specialist that is in network, as their PCP. These members care is centered on the decisions made by the specialist due to the difficulty in controlling and/or stabilizing their disease process. To request this exception, apply to HARBOR CHOICE HEALTH PLAN Chief Medical Officer using a special consideration application with the specifics of the case for his/her approval. Upon receipt of the written application request, HARBOR CHOICE HEALTH PLAN will establish that the non-primary care in-plan physician specialist meets their requirements for PCP participation; including credentialing and that the contractual obligations of the non-pcp specialist are consistent with the contractual obligations of HARBOR CHOICE HEALTH PLAN PCPs. The Specialist must also agree to perform the responsibilities of a PCP for that member. HARBOR CHOICE HEALTH PLAN determination to approve or deny the request along with written notification to the member of that determination will occur within thirty days of HARBOR CHOICE HEALTH PLAN receipt of the request. The effective date of the designation of a non-primary care in-plan physician specialist as a member s primary care physician will not be retroactive. Designated OB/GYN for Female Members Female members of HARBOR CHOICE HEALTH PLAN, in addition to designating a PCP, may access OB/GYN physicians without a referral to provide for their needs relating to: One well-woman exam per year; Care related to pregnancy; Care for all active gynecological conditions; and Gender-related care within the OB/GYN scope of professional practice, including treatment of medical conditions concerning the breasts, genital tract, female endocrinology, reproductive physiology, infertility, and pregnancy Section: Medical Services

27 Maternity Care By policy, HARBOR CHOICE HEALTH PLAN will initially cover inpatient care for delivery, for both mother and newborn, for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by cesarean section. The member, in consultation with their physician may choose to be discharged from an inpatient setting prior to the initial length of stay authorized if medically appropriate. Maternity care requires pre-certification, as does any other inpatient or surgical procedure. Precertification should be obtained following the first prenatal visit. A global fee reimburses routine obstetric care including ante-partum care, delivery and postpartum care. Ante-partum care typically includes initial/subsequent history, physician exams, recording of weight, blood pressure checks, exam of fetal heart tones, routine urinalysis and monthly visits up to 28 weeks gestation, biweekly visits up to 36 weeks gestation, and weekly visits until delivery. The office should bill for the global fee after the delivery. Office visits conducted as a part of the global OB care should be submitted on a standard CMS 1500 delineating the office visit and any laboratory tests that may have been performed. While the office visit will be included in the global fee, the tracking of this encounter is vital for the proper reimbursement of the global fee after the delivery. Note: claims submitted for office visits are for tracking purposes only and are paid as part of the global fee. Global OB Fees include: Initial office visit and physical Prenatal profile and pregnancy test Prenatal visits for obstetrical related problems and routine prenatal care Labor and delivery charges Monitoring Induction of Labor Local and regional anesthesia Episiotomy and repair Hospital visits for follow-up Forceps at delivery In-hospital care for mother Post-partum care in hospital and following discharge up to 6 weeks; excludes surgical complications Any immunizations that are required with an OB diagnosis NOTE: Amniocentesis and related laboratory services are not included in any of the global fee packages listed above Section: Medical Services

28 Referral Procedures Most care done by an in network physician and/or specialist does not require a referral. However, there are certain procedures that will require a referral and preauthorization. Please refer to the pre-certification list on our website at ALL out of network referrals, regardless of procedure, require a pre-certification. Failure to obtain the required pre-certification will result in a denial of payment. Approval Requirements The referral request is for a service that has not already occurred (Back dated referrals are not accepted by HARBOR CHOICE HEALTH PLAN and will not be authorized.) Information is complete (i.e., enough clear, concise information is provided for a reasonable decision concerning the medical necessity of the referral) The member is currently eligible for benefits The service requested is a covered benefit of the member s plan The referring provider is verified as PCP or designee Documentation supports the need to refer to an out-of-plan provider The service requested is consistent with the Health Plan s clinical guidelines and protocols Referral Processing Routine referral requests will be answered within three (3) calendar days from receipt of request Urgent referral requests will be answered within 24 hours from the date of receipt of request. Referral requests can come in by phone or fax. When a phone request is received, the provider will be asked to submit the supporting clinical information. Once received, the answer will be within the time frame allowed Providers are asked to leave their Fax systems on at all times in order to allow HARBOR CHOICE HEALTH PLAN to return information back to the provider (i.e. approvals of pre-authorization requests via Auto fax) Referral Time Frame, Visits and Scope of Care Unless otherwise stated in the referral confirmation, standard referrals to out of plan specialists are valid for up to two (2) visits within ninety (90) days, whichever comes first. If it is known that care will be required beyond two visits in a 90-day period, an authorization should be requested by the PCP by calling the Pre-Authorization Department at the phone numbers shown on the "Address and Telephone Guide" in the INTRODUCTION section of this manual. Referrals are only valid for the scope of services specified on the referral or notice from HARBOR CHOICE HEALTH PLAN. Services rendered beyond the scope of services specified in the referral will be denied Section: Medical Services

29 Specialists shall refer back to the PCP for additional pre-authorization request if consultation by another specialty is needed. No referral is required for a consultation provided by a specialist during a member's authorized inpatient confinement or hospitalization, or for a consultation during an emergency. Such treatment is included in the scope of the Pre-authorization, if each inpatient day has been approved by HARBOR CHOICE HEALTH PLAN Section: Medical Services

30 Pre-Authorization Program and Requirements Services Requiring Pre-Authorization HARBOR CHOICE HEALTH PLAN defines pre-authorization as the provider s having received HARBOR CHOICE HEALTH PLAN agreement for a service to be delivered based on evaluation of medical necessity prior to the time the service is rendered. Please contact our Prior Authorization Department for a list of procedures requiring authorization. Admitting Physician Responsibilities It is ultimately the admitting physician's responsibility to obtain authorization for services specified in this section and to provide the necessary clinical and patient information to process authorization requests. Although any physician participating in an admission, either directly or through consultation, may supply pre-authorization information, ultimate accountability for this authorization falls to the admitting physician. Elective admissions require pre-authorization prior to the admission date. Emergent admissions require the authorization request be received the next business day. Failure to obtain pre-authorization for the specified services will result in denial of payment for services rendered. Providers may not bill members for denied services. A physician or designee should be prepared to provide clinical information regarding the requested admission (elective or emergency) when contacting HARBOR CHOICE HEALTH PLAN Pre-Authorization Department. How to Obtain Pre-authorization Pre-certification requests are accepted from either a PCP or specialist. Elective services require authorization before delivery of the service or admission. Contact HARBOR CHOICE HEALTH PLAN for pre-certification by either calling or faxing the Pre-Authorization Department at the phone number shown on the "Address and Telephone Guide" in the INTRODUCTION section of this manual. For after hour emergencies or weekend/holiday admissions, a physician or facility must call the Pre-Authorization Department the next business day. During the pre-authorization process the department will: Verify the current status of member eligibility and benefits; Verify what services will be performed, and if the services are to be performed by a participating, in-plan provider; For inpatient admissions, determine if the admitting diagnosis, clinical information and treatment plan are presented; For inpatient admissions, review admission request against medical appropriateness criteria and health management guidelines; and For inpatient admissions, assign an estimated length of stay (ELOS) Section: Medical Services

31 Provision of pre-authorization by HARBOR CHOICE HEALTH PLAN for a specific service is not a guarantee of payment. Payment is subject to continuing member eligibility at the time the service is rendered. Information Required for Pre-Authorization Member name, date of birth, Health Plan ID # Facility name to provide service Expected date of admission/procedure (if date changes, notify Health Plan) Diagnosis (or a clear statement of the problem) Procedure code number or description Pertinent clinical information (a clear, concise description of the work-up, pertinent lab, x-ray, or other test data, and any other pertinent information reasonably providing justification for the requested services) Expected length of stay Anticipated discharge needs Treatment plan Other carrier information If faxing a Pre-Authorization Request to HARBOR CHOICE HEALTH PLAN, complete the fax form and include any pertinent clinical information. Elective Service Pre-Authorization Lead Time Requirements For non-emergent elective admissions and procedures contact HARBOR CHOICE HEALTH PLAN at least three (3) calendar days before the planned service or admission. Maternity admissions are to be pre-authorized at the first prenatal visit and must include the expected date of delivery. HARBOR CHOICE HEALTH PLAN must be informed if the expected date of delivery is significantly changed. Failure to meet the lead times specified for elective admissions or procedures may result in HARBOR CHOICE HEALTH PLAN inability to approve the procedure or admission for the original scheduled date. Late requests for authorization for elective services that do not meet the lead time requirements will not be given priority, will not be treated as emergencies, and will not be approved on a priority basis. Emergency Admissions and Direct Admissions It is the responsibility of the admitting facility and/or provider to contact the HARBOR CHOICE HEALTH PLAN Pre-Authorization Department the next business day of any emergency or direct admission. Failure to contact HARBOR CHOICE HEALTH PLAN about an emergency or direct admission may result in delay of payment for services or denial of payment Section: Medical Services

32 Inpatient Admission and Length of Stay Authorization HARBOR CHOICE HEALTH PLAN uses the nationally recognized standards of MCG, Medicare and Texas Medical Foundation (TMF) as well as direct physician supervision for review of the clinical information to determine if an inpatient admission will be authorized. At the time of the authorization, HARBOR CHOICE HEALTH PLAN will assign an expected length of stay. Additional days may be authorized based on clinical information supplied by the physician. All potential denials related to medical necessity must be reviewed by the Medical Director. Technical denials are based on non-medical issues such as: member not eligible, non-covered services, benefit limits, failure to obtain pre-certification with the required time frame, insufficient information to review, and requests for out-of-plan services that are available inplan. Technical denials are issued by the Pre-Authorization Department and/or Medical Management Department. If an elective admission is denied during the pre-authorization process, the physician may request review of the case by HARBOR CHOICE HEALTH PLAN Medical Director. The Medical Director will consult with the requesting physician about the case prior to rendering his or her decision. Please note that many denials during the pre-authorization process are a result of incomplete, absent or inadequate medical information. Specific and accurate clinical information is necessary to process a request for authorization properly. Failure to supply this information may result in delay and/or an adverse determination of the requested authorization. These delays and adverse determinations can easily be avoided if the physician or physician s representative supplying the information has the information available at the time of pre-authorization. Concurrent Review of Inpatient Admissions HARBOR CHOICE HEALTH PLAN will monitor the course of inpatient care services received by a member. The Concurrent Review Nurse or Case Manager may conduct any of the following: On site or telephonic reviews Review of member's chart Communicate with the patient/guardian/parent Discuss the case with the hospital UM staff Speak directly to the admitting physician regarding the progress of the case Identify discharge or alternative care needs Assist the facility, physician, and/or member with post-facility care arrangements, coverage information, benefit information, etc. If, during the course of the review, the Concurrent Review Nurse or Case Manager determines based on established guidelines, that the available documentation indicates the patient can be transitioned to a lower level of care, the attending physician will be contacted to discuss the justification of any continued services and possible alternatives. The Concurrent Review Nurse or Case Manager, in collaboration with the HARBOR CHOICE HEALTH PLAN Chief Medical Section: Medical Services