PROVIDER MANUAL HRINY_XXXX

Transcription

1 PROVIDER MANUAL 2015 HRINY_XXXX 1

2 Table of Contents 1 of 2 CLICK TO RETURN TO TABLE OF CONTENTS SUMMARY OF CONTACT INFORMATION HEALTH PLAN INFORMATION About Health Republic Insurance of New York Product Overview Provider Network QUALITY IMPROVEMENT PLAN Mission and Goals The Population Health Program (PHP) Utilization Management Case Management Program Clinical Guidelines Medical Policy Member Satisfaction Investigation of Quality Care Complaints Utilization Grievances and Appeals Credentialing MEMBER RESOURCES Member Center Member ID Card Choosing a Primary Physician Member Complaints, Grievances and Appeals PROVIDER NETWORK AND RESOURCES MagnaCare/Health Republic Insurance of New York Provider Network Provider Contracting Updating Practice Information Credentialing - Delegation of Credentialing - MagnaCare Credentialing Policies Provider Resources Compliance Hotline Health Republic Provider Relations UTILIZATION MANAGEMENT Out-of-Network Benefits or Services Transition of Care Role of the Primary Physician Importance of Collaboration and Sharing of Patient Information Covered Services Utilization Review Determination of Medical Necessity Services Requiring Preauthorization Emergency Department Services Hospital Admissions Protocol Preauthorization Review Urgent Preauthorization Review Concurrent Reviews Urgent Concurrent Reviews Home Health Care Reviews Inpatient Substance Use Disorder Treatment Reviews Retrospective Reviews Retrospective Review of Preauthorized Services Reconsideration UTILIZATION REVIEW APPEALS Out-of-Network Service Denial Out-of-Network Referral Denial First Level Appeal - Standard Appeal - Expedited Appeal - Substance Use Appeal Second Level Appeal Submitting an Internal Appeal External Appeal - Member s Right to an External Appeal - External Appeal of a Medical Necessity Determination - External Appeal of a Determination that a Service is Experimental or Investigational - External Appeal of a Determination that a Service is Out-of-Network - External Appeal of an Out-of-Network Referral Denial - External Appeal Process POPULATION HEALTH PROGRAM AND CASE MANAGEMENT PROGRAM Population Health Program (PHP) - Member Engagement - PHP Member Engagement Approaches - Patient Education Materials - Role of the Wellness Coach - Role of StatDoctors for Telemedicine Services Case Management Reimbursement for Care Coordination Services PHARMACY Program and Covered Services Medication Formulary Pharmacy and Therapeutics Committee Process Quantity Limitations Step Therapy Age Limits Pharmacy Prior Authorization Process Specific Extensions 2

3 Table of Contents 2 of 2 CLICK TO RETURN TO TABLE OF CONTENTS PHARMACY (contiuned) Pharmacy Drug Tiers Diabetic Drug Benefit Working with US Script - Guidelines for Processing Prior Authorization Requests - Prior Authorization Contact Information - Exception Requests Working with our Specialty Pharmacy Provider, AccarialHealth Mail Order Option BILLING AND CLAIMS Verification of Eligibility Co-payments and Deductibles Claims Submission Claims Processing Overview Professional and Technical Components Assistant Surgeon Coordination of Benefits Request for Additional Information for Claims Review Claims Appeal Process Common Claim Remark Codes 3

4 SUMMARY OF CONTACT INFORMATION Key Contact Information for Providers CONTACT ISSUE NUMBER : prompt 3 then prompt 2 Utilization Management Case Management Preauthorization and Medical Necessity Refer Members to Case Management Fax (preauthorization only) In writing to: Health Republic Insurance of New York P.O. Box 6329 Syracuse, NY : prompt 3 then prompt 2 Fax Appeals & Grievances Fax Claims Status Inquiries : prompt 3 then prompt 1 - Electronic Submission Emdeon (WEB MD) Claims & Eligibility Payer ID# Paper Submission In writing to: Health Republic Insurance of New York P.O. Box 6329 Syracuse, NY Provider Relations Member Services General Provider and Contracting questions Verify Coverage and Benefits General Pharmacy Questions (US Script) Urgent or After Hour Pharmacy requests MagnaCare General Inquiries: Health Republic Contract Inquiries: : prompt 3 then prompt : prompt 2 then prompt Pharmacy Prior Authorization Mail Order Option (RXDirect) Fax In writing to: Health Republic Insurance of New York P.O. Box 6329 Syracuse, NY Compliance Hotline

5 HEALTH PLAN INFORMATION About Health Republic Insurance of New York Health Republic Insurance of New York (Health Republic) is a not-for-profit health insurance plan. Health Republic is one of 22 Consumer Operated and Oriented Plans (CO-OPs) nationally, which were established by the Affordable Care Act to expand affordable healthcare options. CO-OPs are member-governed health insurance companies, meaning members have the opportunity to be elected to our Board of Directors. Our high-quality plans are available in 43 New York counties, covering approximately 93% of the state s population. By year-end 2014, Health Republic enrolled more than 150,000 members, making us the largest health insurance CO-OP in the country. Our tremendous success is a testament to the way our values resonate with our members. Health Republic is licensed as a not-for-profit health insurance company under Article 43 of New York Insurance Law as Health Republic Insurance of New York, Corp. In addition, Health Republic is a qualified health plan that offers coverage in the NY State of Health Marketplace, New York state s official health plan marketplace. Product Overview Health Republic offers products to individuals and small groups both on and off the NY State of Health Marketplace. All products meet or exceed state and federal requirements for Essential Health Benefits. This means that emergency room visits, the birth of a child, preventive services and many other health services are all covered benefits. Our plans offer a variety of coverage options across competitively-priced tier groups so our members can choose the benefits they want to accommodate their individual healthcare needs. Essential Health Benefits across our products include: Outpatient care Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse services, including behavioral health treatment, counseling and therapy Prescription drugs Habilitative and rehabilitative services (e.g. physical and occupational therapy, speech-language pathology, psychiatric rehabilitation and more) Laboratory tests Preventive services, wellness services and chronic disease management 5

6 PLAN HIGHLIGHTS $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. HRINY_CM09_PO.EC_ HRINY_CM09_PO.TI_091614_REV PLAN HIGHLIGHTS The bronze and silver levels offer 2 free visits to a selected primary care physician, even before the deductible is met. The gold level offers 3 free visits to a selected primary care physician, even before the deductible is met. $0 co-pay for in-network preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. PLAN HIGHLIGHTS $0 co-pay for visits to a designated primary care physician, even before the deductible is met. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. HRINY_CM09_PO.PS_091614_REV PLAN HIGHLIGHTS Fixed co-insurance percentages for out-of-network services. $0 deductible for in-network services. $0 co-pay for in-network preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. HRINY_CM09_PO.TF_ HRINY_CM09_PO.PSPCMH_091614_REV PLAN HIGHLIGHTS $0 co-pay for visits to a designated PCMH primary care physician. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. Health Republic Insurance of New York Pediatric dental and vision care Additional wellness offerings available to all members: Free access to Stat Doctors, a telemedicine service that allows members to consult with board-certified emergency room physicians any time of day or night Discounted access to over 43,000 alternative and holistic medical providers, including acupuncture, chiropractic and massage therapy Up to $600 in gym membership reimbursement per year (including spouse) Free vaccines for flu, shingles, pneumonia and more through our vaccine network As designed by the Affordable Care Act, each individual and small group plan is offered in metal tiers that represent the approximate actuarial value of the plan: Bronze (60%), Silver (70%), Gold (80%) and Platinum (90%). Members who select a lower actuarial value pay a lower premium but are at risk of higher out-of-pocket costs until they reach the out-of-pocket maximum. Once members or their families reach the out-of-pocket maximum, they have no additional co-payments or co-insurance for the rest of the coverage year. Please see the following pages for more information on Health Republic products. EssentialCare. PrimarySelect. PrimarySelect PCMH. Available in the following counties: Bronx, Essex, Hamilton, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, Westchester. EssentialCare ESSENTIALCARE is our standard plan offering, aligning with state and federal requirements for deductibles, co-pays, and other benefits, allowing consumers to compare EssentialCare apples to apples with plans from other insurers. Highlights of the EssentialCare plan include set hospital co-pays and low co-pays for visits to specialists. PrimarySelect Health Republic s signature program, PRIMARYSELECT, emphasizes the role of a primary care physician in our members health. After selecting a primary care physician, visits to him or her are free of charge. With low deductibles and $0 copay for selected generics, PrimarySelect is a popular choice among many New Yorkers. Similar to PrimarySelect, PRIMARYSELECT PCMH focuses on comprehensive patient care with a specialized network of patient-centered medical homes certified by the National Committee for Quality Assurance (NCQA). Only available at the Silver level, PrimarySelect is a cost- PCMH friendly option for those looking to get the most out of their health plan. TotalIndependence. TotalFreedom. TOTALINDEPENDENCE, available to individuals on and off the exchange, is a simplified plan for TotalIndependence the next generation of healthcare. This plan offers members the comfort of high-quality healthcare when it s needed, and total independence to achieve their goals. TotalFreedom TOTALFREEDOM, available to small groups, offers all the benefits of a platinum level plan, with the added feature of out-of-network coverage. This plan is designed for small businesses who want total freedom to select any provider. 6

7 PLAN HIGHLIGHTS $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. HRINY_CM09_PO.EC_ EssentialCare Health Republic Insurance of New York Provider EssentialCare. Manual 2015 EssentialCare is our standard plan offering, aligning with state and federal requirements for deductibles, co-pays and other benefits, allowing consumers to compare EssentialCare apples to apples with plans from other insurers. Highlights of the EssentialCare plan include set hospital co-pays and low co-pays for visits to specialists. These plans are available on all metal levels. EssentialCare ESSENTIALCARE is our standard plan offering, aligning with state and federal requirements for deductibles, co-pays, and other benefits, allowing consumers to compare EssentialCare apples to apples with plans from other insurers. Highlights of the EssentialCare plan include set hospital co-pays and low co-pays for visits to specialists. Deductibles and Maximums Platinum Gold Silver Deductible (Single/Family) $0 $600/$1,200 $2,000/$4,000 Max Out-of-Pocket Limit (Single/Family) $2,000/$4,000 $4,000/$8,000 $5,500/$11,000 High Deductible Plans Bronze Catastrophic* HSA Qualified Yes No Deductible (Single/Family) $3,000/$6,000 $6,600/$13,200 Max Out-of-Pocket Limit (Single-Incl. Deductible) $6,350/$12,700 $6,600/$13,200 Cost Sharing (All Parameters) 50% 50% Prescription Drugs (After Deductible) $10/$35/$70 0% *Individual Only Cost Sharing-Medical Services After deductible is met Platinum Gold Silver PCP $15 $25 $30 Specialist $35 $40 $50 PT/OT/ST-rehabilitative and Habilitative Therapies $25 $30 $30 Inpatient/SNF/Hospice-Facility (Per Admission) $500 $1,000 $1,500 Outpatient-Facility $100 $100 $100 Surgeon (Inpatient, Outpatient) $100 $100 $100 ER $100 $150 $150 Ambulance $100 $150 $150 Urgent Care $55 $60 $70 DME/Medical Supplies 10% 20% 30% Outpatient Services After deductible is met Platinum Gold Silver Diagnostic and Routine Lab and Pathology $35 $40 $50 Diagnostic and Routine Imaging $35 $40 $50 Chemotherapy $15 $25 $30 Radiation Therapy $15 $25 $30 Dialysis $15 $25 $30 Mental/Behavioral Healthcare $15 $25 $30 Substance Abuse Disorder Services $15 $25 $30 Home Health Care $15 $25 $30 Hospice $15 $25 $30 Prescription Drugs Platinum Gold Silver Tier I (Selected Generics) $10 $10 $10 Tier II (Other Generics) $30 $35 $35 Tier III (Brand and Specialty) $60 $70 $70 7

8 PLAN HIGHLIGHTS $0 co-pay for visits to a designated primary care physician, even before the deductible is met. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. HRINY_CM09_PO.PS_091614_REV PrimarySelect Health Republic Insurance of New York PrimarySelect. PrimarySelect is Health Republic s signature program, emphasizing the role of the primary physician in our member s health. After selecting a primary physician, for most tiers, visits to that provider are free of charge. This promotes preventive care and wellness screenings, which leads to better health outcomes for patients and lower costs for everyone. These plans are available at the Bronze, Silver, Gold and Platinum levels for individuals. For small group members, these are available at the Silver, Gold and Platinum levels. Deductibles and Maximums Platinum Gold Silver Bronze* Deductible (Single/Family) $0 $250/$500 $2,000/$4,000 $5,500/$11,000 Max Out-of-Pocket (Single/Family) $1,400/$2,800 $3,500/$7,000 $6,350/$12,700 $6,350/$12,700 Cost Sharing (Co-Insurance) 20% 20% 20% 20% PrimarySelect Health Republic s signature program, PRIMARYSELECT, emphasizes the role of a primary care physician in our members health. After selecting a primary care physician, visits to him or her are free of charge. With low deductibles and $0 copay for selected generics, PrimarySelect is a popular choice among many New Yorkers. Cost Sharing-Medical Services Platinum Gold Silver Bronze* Primary Care (Member Selected) $0 $0 $0 $75 Specialist $75 $75 $75 $75 PT/OT/ST (Co-Pay after Deductible) $30 $30 $30 $75 Inpatient/SNF/Hospice-Facility (Per Admission) Physician/Surgeon Fee (Inpatient) (Co-Pay after Deductible) Outpatient-Facility Surgeon (Outpatient) $100 $150 20% After Deductible $150 Individual $100 Group 20% After Deductible 20% After Deductible $150 ER (Co-Pay after Deductible is Met) $250 $250 $250 $300 Ambulance (Co-Pay after Deductible is Met) $100 $150 $150 $150 Urgent Care (Co-Pay after Deductible is Met) $100 $100 $100 $100 Outpatient Services Platinum Gold Silver Bronze* Diagnostic and Routine Lab and Pathology $75 $75 $75 $75 Diagnostic and Routine Imaging $75 $75 $75 $75 Mental/Behavioral Healthcare (Selected) $0 $0 $0 $75 Diabetic Care and Supplies $0 $0 $0 $0 Chemotherapy $15 $25 $30 $75 Radiation Therapy $75 Individual $15 Group $75 Individual $25 Group $75 Individual $30 Group Dialysis $15 $25 $30 $75 Home Health Care (After Deductible) $15 $25 $30 $75 $75 Prescription Drugs Platinum Gold Silver Bronze* Tier I (Selected Generics) Tier II (Other Generics) (After Deductible) Tier III (Brand and Specialty) (After Deductible) $0 Individual $0 Group $30 Individual $35 Group $60 Individual $70 Group $10 Individual $0 Group $10 Individual $0 Group $10 $35 $35 $35 $70 $70 $70 *Individual Only 8

9 HRINY_CM09_PO.PSPCMH_091614_REV PLAN HIGHLIGHTS $0 co-pay for visits to a designated PCMH primary care physician. $0 co-pay for preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. PrimarySelect PCMH Health Republic Insurance of New York PrimarySelect PCMH. Available in the following counties: Bronx, Essex, Hamilton, Provider Manual Kings, Nassau, New York, Queens, 2015 Richmond, Rockland, Suffolk, Westchester. PrimarySelect PCMH focuses on comprehensive patient care with a specialized network of Patient-Centered Medical Homes (PCMH) certified by the National Committee for Quality Assurance (NCQA). Only available at the Silver level, this product is available in the following counties: Bronx, Essex, Hamilton, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk and Westchester. Similar to PrimarySelect, PRIMARYSELECT PCMH focuses on comprehensive patient care with a specialized network of patient-centered medical homes certified by the National Committee for Quality Assurance (NCQA). Only available at the Silver level, PrimarySelect is a cost- PCMH friendly option for those looking to get the most out of their health plan. Deductibles and Maximums Silver Deductible (Single/Family) $2,000/$4,000 Max Out-of-Pocket (Single/Family) $6,350/$12,700 Cost Sharing (Co-Insurance) 20% Cost Sharing-Medical Services Silver Primary Care (Member Selected) $0 Other Primary Care $30 Specialist $75 PT/OT/ST (Co-Pay after Deductible is Met) $30 Inpatient/SNF/Hospice-Facility (Per Admission) Physician/Surgeon Fee (Inpatient) (Co-Pay after Deductible) Outpatient-Facility Surgeon (Outpatient) 20% After Deductible $150 Individual/$100 Group 20% After Deductible 20% After Deductible ER (Co-Pay after Deductible is Met) $250 Ambulance (Co-Pay after Deductible is Met) $150 Urgent Care (Co-Pay after Deductible is Met) $100 Outpatient Services Silver Diagnostic and Routine Lab and Pathology $75 Diagnostic and Routine Imaging $75 Mental/Behavioral Healthcare (Selected) $0 Diabetic Care and Supplies $0 Chemotherapy $30 Radiation Therapy $75 Individual $30 Group Dialysis $30 Home Healthcare (After Deductible) $30 Prescription Drugs Tier I (Selected Generics) Silver $10 Individual $0 Group Tier II (Other Generics) (After Deductible) $35 Tier III (Brand and Specialty) (After Deductible) $70 9

10 HRINY_CM09_PO.TI_091614_REV PLAN HIGHLIGHTS The bronze and silver levels offer 2 free visits to a selected primary care physician, even before the deductible is met. The gold level offers 3 free visits to a selected primary care physician, even before the deductible is met. $0 co-pay for in-network preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. TotalIndependence Health Republic Insurance of New TotalIndependence. York TotalIndependence is available to individuals in the Bronze, Silver and Gold tiers. This higher deductible product provides an affordable option to our members while still offering valuable benefits such as 2 or 3 free primary care visits prior to the deductible as well as coverage for acupuncture, massage therapy and naturopathy. TOTALINDEPENDENCE, available to individuals on and off the exchange, is a simplified plan for TotalIndependence the next generation of healthcare. This plan offers members the comfort of high-quality healthcare when it s needed, and total independence to achieve their goals. Deductibles and Maximums Gold Silver Bronze Deductible (Single/Family) $1,950/$3,900 $3,800/$7,600 $6,000/$12,000 Max Out-of-Pocket Limit (Single/Family) $2,500/$5,000 $4,300/$8,600 $6,500/$13,000 Cost Sharing-Medical Services Gold Silver Bronze Primary Care (Member Selected) 3 Free 2 Free 2 Free Other Primary Care $0 after deductible $0 after deductible $0 after deductible Specialist $0 after deductible $0 after deductible $0 after deductible PT/OT/ST $0 after deductible $0 after deductible $0 after deductible Inpatient/SNF/Hospice-Facility (Per Admission) $0 after deductible $0 after deductible $0 after deductible Physician/Surgeon Fee (Inpatient) $0 after deductible $0 after deductible $0 after deductible Outpatient-Facility $0 after deductible $0 after deductible $0 after deductible Surgeon (Outpatient) $0 after deductible $0 after deductible $0 after deductible ER $250 $250 $0 after deductible Ambulance $250 $250 $0 after deductible Urgent Care $50 $75 $75 Outpatient Services Gold Silver Bronze Diagnostic and Routine Lab and Pathology $20 $20 $0 after deductible Diagnostic and Routine Imaging $0 after deductible $0 after deductible $0 after deductible Mental/Behavioral Healthcare (Selected) $0 after deductible $0 after deductible $0 after deductible Diabetic Care and Supplies $0 after deductible $0 after deductible $0 after deductible Chemotherapy $0 after deductible $0 after deductible $0 after deductible Radiation Therapy $0 after deductible $0 after deductible $0 after deductible Dialysis $0 after deductible $0 after deductible $0 after deductible Home Health Care $0 after deductible $0 after deductible $0 after deductible Prescription Drugs Gold Silver Bronze Tier I (Selected Generics) $20 $20 $30 Tier II (Other Generics) (After Deductible) $0 after deductible $0 after deductible $0 after deductible Tier III (Brand and Specialty) (After Deductible) $0 after deductible $0 after deductible $0 after deductible 10

11 PLAN HIGHLIGHTS Fixed co-insurance percentages for out-of-network services. $0 deductible for in-network services. $0 co-pay for in-network preventive care, screenings, and immunizations. No referral needed to see specialist. ADDITIONAL OFFERINGS Free access to Stat Doctors TM, a telemedicine service that connects you with board-certified emergency room physicians any time of day or night. Up to $200 gym membership reimbursement every 6 months. Discounted access to alternative and complementary medicine such as acupuncture, chiropractic, holistic and integrative physicians, dieticians, meditation therapy, yoga, and tai chi. HRINY_CM09_PO.TF_ TotalFreedom Health Republic Insurance of New York TotalFreedom. TotalFreedom, our first Preferred Provider Organization (PPO) product, is available to small groups in the Platinum tier. It offers similar in-network benefits as EssentialCare, while allowing small group members the flexibility to utilize out-of-network services at a reasonable cost. TotalFreedom TOTALFREEDOM, available to small groups, offers all the benefits of a platinum level plan, with the added feature of out-of-network coverage. This plan is designed for small businesses who want total freedom to select any provider. Deductibles and Maximums In-Network Platinum Out-of-Network Deductible (Single/Family) $0/$0 $4,000/$8,000 Max Out of Pocket (Single/Family) $2,000/$4,000 $5,000/$10,000 Cost Sharing (Co-Insurance) N/A 30% Cost Sharing-Medical Services In-Network Out-of-Network Primary Care $15 30% Specialist $35 30% PT/OT/ST $15 30% Inpatient/SNF/Hospice-Facility (Per Admission) $500 30% Physician/Surgeon Fee (Inpatient) $500 30% Outpatient-Facility $100 30% Surgeon (Outpatient) $100 30% ER $100 $100 Ambulance $100 $100 Urgent Care $55 $55 Outpatient Services In-Network Out-of-Network Diagnostic and Routine Lab and Pathology $35 30% Diagnostic and Routine Imaging $35 30% Mental/Behavioral Healthcare $15 30% Diabetic Care and Supplies $15 30% Chemotherapy $15 30% Radiation Therapy $35 30% Dialysis $15 30% Home Health Care $15 30% Prescription Drugs In-Network Out-of-Network Tier I (All Generics) $10 Not available Tier II (All Preferred Brands) $30 Not available Tier III (All Non-Preferred Brands) $60 Not available 11

12 Provider Network Health Republic contracts with MagnaCare and other providers to form the MagnaCare/ Health Republic Insurance of New York provider network. Our network consists of more than 70,000 physicians and providers in a variety of primary and specialty care across New York, New Jersey and select counties of Connecticut and Pennsylvania. The Health Republic provider directory includes providers, facilities, laboratories, radiology centers and urgent care centers. More information is available in the Provider Network and Resources section of this manual. QUALITY IMPROVEMENT PLAN Mission and Goals Health Republic and its partners are dedicated to promoting high-quality, costeffective care to our members. To achieve that goal, Health Republic has adopted a Quality Improvement Plan to specifically: encourage members to select and establish a relationship with a primary healthcare provider ensure that members have equal access to their benefits, regardless of personal characteristics such as race, ethnicity, gender, sexual orientation, geographic location, primary language or enrollment channel ensure that members have access to health promotion and educational resources so they can understand their health status and risks and learn how to utilize available services ensure that healthcare services are delivered safely, timely, efficiently, effectively, equitably and in a patient-centered manner meet or exceed all statewide average quality measures for preventive care, chronic care and patient access maximize member satisfaction with Health Republic The Quality Improvement Plan includes the following initiatives and activities: The Population Health Program (PHP) The Population Health Program (PHP) supports all quality program activities and objectives. The PHP helps members take charge of their health and healthcare and alters cost and quality trends through efficient and effective member interventions. The PHP offers members: the opportunity to complete an online or telephonic general health assessment 12

13 (GHA) in English or Spanish and receive a personalized summary of medical conditions that can be shared with their doctor health promotion educational materials access to StatDoctors, a free telemedicine service for Health Republic members, to receive immediate healthcare attention at all times access to a trained Wellness Coach who provides guidance on proactive health behaviors and more effective physician-patient communications Utilization Management Health Republic s Utilization Management program maintains compliance with local, state and federal regulatory requirements and accreditation standards. Health Republic provides effective monitoring and evaluation of patient care and services to ensure that care provided by the health plan delivery system meets the requirements of standard medical practice, meets the linguistic and cultural needs of the membership, is administered in the most appropriate setting and is perceived positively by health plan members and healthcare professionals. Health Republic monitors inpatient hospitalizations, the use of outpatient facilities and certain procedures and medications with the objective of ensuring that treatments are safe, appropriate and cost-effective. We work with a URAC accredited organization to implement these functions while maintaining oversight to ensure optimal performance and prompt identification of opportunities for improvement, including ongoing review of utilization management metrics. Case Management Program The Case Management Program at Health Republic serves to optimize the health and well-being of members with complex health issues or who are at high risk for adverse medical outcomes. To accomplish this, Health Republic implements a comprehensive program that is person-centered, facilitating collaboration between members and their healthcare team. This promotes self-management, active decision-making, and participation in healthcare interventions and outcomes. Health Republic utilizes specially-trained staff (including Registered Nurses and Licensed Social Workers) to advise members on treatment guidelines, adherence to clinical regimens, and assistance with social issues. We provide Case Management services to members with complex conditions such as cardiac disease, pediatric issues, behavioral health issues, medical psychiatric coordination, oncologic diseases, transplants, dialysis and catastrophic disease management. As part of the discharge planning process, we also provide Case Management services for members admitted to the hospital who are at risk of post-operative complications, and also those who may need to transition to lower levels of care; the goal is to optimize coordination of services and to prevent readmission. 13

14 Clinical Guidelines Clinical guidelines are systematically developed statements that assist providers and members in making appropriate healthcare decisions for a specific clinical circumstance. They are formed by a systematic review of clinical evidence, including an assessment of the benefits and harms of alternative care options. Evidence-based guidelines are known to be effective in improving health outcomes. The effectiveness of guidelines is determined by scientific evidence, by professional standards in the absence of scientific evidence or by expert opinion in the absence of professional standards. Health Republic has a process in place for the development, adoption, approval, dissemination and measurement of clinical guidelines in accordance with federal and state requirements, as well as the standards established by the National Committee for Quality Assurance (NCQA). Medical Policy Health Republic s medical policies provide guidelines for determining coverage criteria for specific medical and behavioral health technologies, including procedures, equipment and services. These policies, in combination with contractual benefits, are assessed for the sole purpose of coverage determination and should not dictate the care of the member. Medical policy decisions will be based upon evidence-based guidelines developed by nationally recognized organizations, peer-reviewed publications and generally accepted standards of practice. Practicing physician review and government approval status will also be considered. Health Republic reviews and approves all medical policies, including requests for new and/or updates to medical policies. Member Satisfaction Health Republic and its partners actively respond and seek resolution to member questions and problems. Complaint handling and their prompt resolution are tracked by the Member Experience Department. Ultimately, this information is aggregated and shared with the Membership Committee of the Board. Health Republic has delegated certain customer service activities to our vendors, POMCO (for utilization and case management, and claims administration issues) and Morneau-Shepell (for billing and enrollment issues), but Health Republic oversees those activities and provides customer service to members on escalated issues. Investigation of Quality Care Complaints The Quality Management Department oversees investigations of quality of care 14

15 complaints. Investigations may be triggered by members, providers or Health Republic staff. An investigation is conducted and a determination is made regarding whether the services under review deviated from the standard of care. Recommendations for corrective action are brought to Health Republic staff. Utilization Grievances and Appeals Health Republic provides a formal process for a member, a provider on behalf of a member or the member s representative to express dissatisfaction about the member s care and treatment. Any expression of dissatisfaction will be logged as a grievance, an appeal or both and will be addressed through the grievance and appeals process. We will monitor trends related to member and provider complaints, grievances and appeals and will implement action plans to address identified opportunities to improve performance. Credentialing Health Republic, in collaboration with MagnaCare, collects and confirms information on education, certifications, licensure and legal actions on the providers across our network to ensure there is appropriate access and availability of qualified providers in the service areas. MEMBER RESOURCES Health Republic is dedicated to ensuring that our members can access their wide range of benefits as quickly and as easily as possible. We have developed a variety of tools and resources for members to access health coverage information. Here are select resources that are available to all Health Republic members. Member Center Health Republic offers a secure and private Member Center that allows members to access their coverage information including premium billing, claims, primary physician selection, forms and guides and other important health information. Members may also access a health information library and an interactive education tool to look up disease symptoms, treatment and health issues by topic. Providers should encourage Health Republic members to create an online account through the Member Center, available at Member ID Card Health Republic members will receive their Health Republic welcome package as well as their member ID card after enrollment and, in most cases, prior to the effective date of coverage. Each member, including family members covered under our plans, will receive their own member ID card. 15

16 Members receive new ID cards in these situations: plan type change change in primary physician lost card reinstatement of coverage Card Front If a member needs to replace a lost or stolen member ID card, Member: please DREANNA ask the KAOmember to contact Health Republic Member Services at prompt 2 then prompt 3 to request a replacement. The member can also immediately Primary Physician request Co-Pay: a replacement $0.00 Primary Care Co-Pay: $30.00 ID card through their online Health Republic Member Center. Specialist The Co-Pay: ID card will $75.00 arrive in Deductible may apply the mail within ten (10) business days. For immediate access to a temporary ID card, the For precertification and coverage verification call: member can also print a copy of their ID card in their online Member Center. Member ID : Y Plan ID: 114 Primary Physician: JEAN-LOUISALINAS MD Provider Network: MagnaCare/Health Republic Insurance of New York MagnaCare/Health Republic Insurance of New York Sample Member ID Card Card Front Claims Mailing Address: PO Box 6329, Syracuse, NY Payer ID # healthrepublicny.org Card Back Primary Select PCMH Silver Member: DREANNA KAO Member ID : Y Plan ID: 114 Primary Physician: JEAN-LOUISALINAS MD Primary Physician Co-Pay: $0.00 Primary Care Co-Pay: $30.00 Specialist Co-Pay: $75.00 Deductible may apply For precertification and coverage verification call: Provider Network: MagnaCare/Health Republic Insurance of New York Claims Mailing Address: PO Box 6329, Syracuse, NY Payer ID # healthrepublicny.org Primary Select PCMH Silver RX Group #: RX BIN: Pharmacists, please call: Member Services: Card use and payment of benefits is subject to the terms of the Benefit Plan in effect at the time of service -- these are described in your member documents. If it is determined that you were not eligible when services were provided, you may be responsible for payment of services or any monies paid on your behalf. Pre-certification is required for certain services. Without pre-approval, you may pay more or even full price. To pre-certify, call the number on the front of this card, or if in an emergency, as soon as possible. Improper use of this card is a punishable offense and may result in termination of benefits. This card does not guarantee coverage. Card Back Choosing a Primary Physician All Health Republic members are encouraged to choose a primary physician RX Group #: RX BIN: (also Pharmacists, known please as call: a primary care physician or PCP) to coordinate their care. When a Member Services: PrimarySelect or PrimarySelect PCMH member chooses a primary physician, there is no co-payment for any visit. Card use and payment of benefits is subject to the terms of the Benefit Plan in effect at the time of service -- these are described in your member documents. Physicians If it is determined with that you training were not eligible in primary when services care were specialties provided, you are preferred as primary physicians. may be responsible for payment of services or any monies paid on your behalf. This Pre-certification includes is required Medical for certain Doctors services. Without (MD) pre-approval, or Doctors you may of Osteopathic Medicine (DO) trained pay more or even full price. To pre-certify, call the number on the front of this in card, Family or if in an Practice, emergency, as Internal soon as possible. Medicine, Improper Pediatrics, use of this card is or a Obstetrics and Gynecology. Specialists punishable offense and may result in termination of benefits. This card does not with guarantee training coverage. in the primary care specialties, such pulmonary medicine or infectious diseases, may also be primary physicians in some instances, if it is approved as being medically necessary. 16

17 Members can select or change their primary physician online in the Member Center and by telephone with assistance from a Health Republic Member Service representative at When selecting a primary physician for a PrimarySelect PCMH member through the Member Center, the member must look under the Patient Centered Medical Home column and be certain there is a checkmark indicator. Once a physician is selected, the name of the primary physician is printed on the member ID card to ensure the co-payment is not collected inappropriately during the office visit. Any changes to the primary physician go into effect the next business day. A new card will be sent to the member within ten (10) business days. Members can change primary physicians once a month, up to five times a year. Member Complaints, Grievances and Appeals All member complaints, grievances and appeals are handled through the Health Republic Member Services department. Members who have complaints are asked to call or write. A detailed investigation of any member complaint is conducted. Members will receive confirmation that the complaint was received, as well as notification of the outcome of the investigation. Members who are concerned that a claim may have been paid incorrectly can file a grievance. They will receive prompt confirmation that their grievance was received and a written response within 30 days. An appeal can be requested by a member, the ordering provider or an advocate formally designated by the member. The first step in the appeal process is reconsideration by the original physician issuing the denial. The medical reviewer may overturn the original determination or allow the case to proceed to appeal. The next step in the appeal process is a review by a physician not involved in the original determination. All information in the initial request, as well as any additional information that has become available, is reviewed. The physician issues a final determination that will result in an approval of the original outcome or an overturn. An appeal of an adverse decision (denial) regarding an urgent claim will be decided within 72 hours after the appeal request is filed. An appeal of an adverse decision regarding a pre-service claim will be decided within 30 days after the appeal request is filed. An appeal of an adverse decision regarding a post-service claim will be decided within 60 days after the appeal request is filed. Health Republic s appeal process complies with state and federal regulations. Appeals must be submitted in writing and mailed to the Health Republic appeals department within 60 days from the date of the written denial. Health Republic may reserve the right to maintain denial of benefits without further review for any appeals received more than 60 days after the initial notice of claim denial. Appeals should be submitted to the address listed at the beginning of this guide. An External Appeal can be requested by a member, the ordering provider or an advocate formally designated by the member. The request for an external appeal is 17

18 processed in accordance to guidelines developed by the New York State. Additional information is available in the Utilization Management, Utilization Review Appeals, and Billing and Claims sections of this manual. PROVIDER NETWORK AND RESOURCES MagnaCare/Health Republic Insurance of New York Provider Network Health Republic is committed to providing our members with access to a broad network of providers to meet their medical needs. To achieve this goal, Health Republic contracts with MagnaCare and directly with providers, including select Patient Centered Medical Homes (PCMH) and Federally Qualified Health Centers (FQHC), to form the MagnaCare/Health Republic Insurance of New York provider network. This vast network consists of more than 70,000 industry-leading healthcare providers in New York, New Jersey and select counties of Connecticut and Pennsylvania. The MagnaCare/Health Republic Insurance of New York network includes over 16,000 primary care locations, over 50,000 specialist locations and 155 hospitals. Our network has been reviewed and approved by the New York State Department of Health. All MagnaCare/Health Republic Insurance of New York providers are listed in the Provider Directory on the Health Republic website at Members and providers can search the MagnaCare/Health Republic Insurance of New York network by providers, facilities, laboratories, radiology centers and urgent care centers. A list of participating hospitals is also available on the Health Republic website for New York, New Jersey and Connecticut. When applicable, providers are encouraged to use the Provider Directory when searching for referrals, to other participating MagnaCare/Health Republic Insurance of New York providers and specialists. Provider Contracting Providers who want to participate in the MagnaCare/Health Republic Insurance of New York network and contract with other aspects of the MagnaCare network should contact the MagnaCare General Inquires at or Provider Service Line at FQHCs or other providers who would like to contract directly with Health Republic should contact Health Republic Provider Relations at , prompt 3 then prompt 4. Updating Practice Information It is the responsibility of the provider to update Health Republic with any changes in staff, addresses, locations, specialties or other information about their practice. This is critical for Health Republic members to access the most accurate and up-to-date information about providers in the MagnaCare/Health Republic Insurance of New York network. MagnaCare-contracted providers can update their practice information by contacting MagnaCare Provider Relations. Providers that contract directly with Health Republic should contact Health Republic Providers Relations. 18

19 Credentialing - Delegation of Credentialing MagnaCare handles all credentialing activities related to the MagnaCare/Health Republic Insurance of New York provider network, and Health Republic oversees the work of the MagnaCare Credentialing Committee (as it pertains to Health Republic) through the Health Republic Board of Director s Quality Committee. In some instances, MagnaCare may delegate its credentialing activity to an appropriately qualified delegate. - MagnaCare Credentialing Policies To become a participating provider in the MagnaCare/Health Republic Insurance of New York network, contact MagnaCare for an application. This application must be completed and forwarded to the Credentialing Department. Application requests can be sent via to HRIrecruitmentrequests@magnacare.com. MagnaCare has partnered with the Council for Affordable Quality Healthcare (CAQH) to access comprehensive provider information which optimizes the credentialing workflow, improves provider directories and iis more efficient. Therefore, providers who participate with CAQH need to only complete the information on page 5 of the application and sign the agreement. There is no need to fill out the remaining pages in the application. New Jersey Providers can choose to fill out the NJ Universal Physician Application instead of the MagnaCare credentialing application. The form can be found on the State website at Provider Resources Resources are available to providers through a dedicated Provider section of the Health Republic website. These resources assist providers in facilitating the provision of healthcare to Health Republic members. Resources include: Provider Directory Provider Manual Medical Procedure Prior Authorization List Medication Formulary Medication Prior Authorization Form Specialty Medication Prior Authorization Form Claims Submission 19

20 Health Republic s Reimbursement Philosophy Frequently Asked Questions Health Republic also offers a Provider Portal so that providers and their staff can access important information, news and tools to keep up to date on patients eligibility and claims. Providers can create an account at the For Providers section of the Health Republic website at The one-time registration will allow providers to have immediate access to claims look up, eligibility information and a secure messaging system. Please contact the Provider Relations team if there are any questions or technical issues. Health Republic contracts with Altegra Health to assist members in completing General Health Assessment (GHA) information, which will help providers deliver high-quality care to meet the health needs of their patients. Altegra Health also helps members select their primary physician through the MagnaCare/Health Republic Insurance of New York network and provide scheduling services to assist members in making appointments with the providers. As part of Health Republic s participation in the Centers for Medicare & Medicaid Services (CMS) premium risk adjustment program, Altegra Health also works with providers to collect data and conduct medical record reviews. For additional information on risk adjustment, please refer to the CMS website at CMS.gov > Private Insurance > Training Resources. Compliance Hotline Health Republic Insurance of New York has established a Compliance Hotline for anyone who knows of, or suspects, any unethical or improper practices including any illegal activities and inappropriate use of Personal Health Information. Information provided will be reviewed, investigated and treated as confidential. Inquiries may be submitted anonymously to Health Republic Provider Relations The Health Republic Provider Relations department is committed to collaborating effectively with our providers by offering ongoing support and education to providers. In addition, the Provider Relations department oversees the MagnaCare/Health Republic of Insurance Network provider activities, manages the relationships with directly -contracted providers, and creates resources for providers to assist them in the care of Health Republic members. The primary point of contact for MagnaCare/Health Republic Insurance of Network contracted providers is MagnaCare Provider Relations, which can be reached at their General Inquires line at or Provider Services line at For providers contracted directly with Health Republic, or for more information, contact Health Republic Provider Relations at prompt 3 then prompt 4. 20