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 [email protected]. 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

21 UTILIZATION MANAGEMENT Health Republic contracts with POMCO, a URAC accredited organization, for Utilization and Claims Management. Health Republic oversees and reviews all POMCO policies and procedures, as well as their ongoing activities to ensure they adhere to Health Republic standards. Out-of-Network Benefits or Services With the exception of the TotalFreedom product, Health Republic members do not have out-of-network benefits or services. An out-of-network benefit or service is defined as a benefit or service provided by a provider that does not participate in the MagnaCare/Health Republic Insurance of New York network. However, in the rare instance that a member requires a unique specialized service not offered by anyone in our network of providers, please contact our Utilization Management Department for assistance in obtaining a review of the request to see a specialized non-participating provider. The Utilization Management Department can be reached at prompt 3 then prompt 2. Transition of Care Transition of care provides a temporary bridge for current members when the provider leaves the MagnaCare/Health Republic Insurance of New York network during an ongoing course of treatment. The member may be able to continue to receive covered services for the ongoing treatment from the former participating provider for up to ninety (90) days from the termination date of the provider s contractual obligation to provide services to the member. If the member is in an ongoing course of treatment with a Non-Participating Provider when their initial coverage with Health Republic becomes effective, the member may be able to receive covered services for the ongoing treatment from the Non-Participating Provider for up to sixty (60) days from the effective date of their coverage with Health Republic. This course of treatment must be for a life-threatening disease or condition, or a degenerative and disabling condition or disease. The member may also continue care with a Non-Participating Provider if they are in the second or third trimester of a pregnancy when their coverage becomes effective; they may continue care through delivery and any post-partum services directly related to the delivery. In order for the member to continue to receive covered services for up to sixty (60) days or through pregnancy, the Non-Participating Provider must agree to accept as payment Health Republic s fees for such services. The Non-Participating Provider must also agree to provide Health Republic all necessary medical information related to the care of the member, and adhere to the Health Republic policies and procedures including those for assuring quality of care, obtaining preauthorization, referrals, and a treatment plan approved by Health Republic. 21

22 Role of the Primary Physician At the time of enrollment, members are advised to select a primary physician, also known as a primary care physician (PCP), to coordinate their care. Members are not required to have or use a PCP in any of the Health Republic products. However, we strongly encourage members to designate and coordinate their care with a PCP. Most members will select a doctor from one of the traditional primary care specialties such as Family Practice, Internal Medicine or Pediatrics. In some instances, members can select from other medical subspecialties such as Infectious Disease, Cardiology or Obstetrics and Gynecology. Other proposed specialties will be reviewed by the plan Medical Director on a case-by-case basis. Health Republic products do not require prior authorization for care provided by a participating PCP. Although a referral from a PCP is not required for a member to get care from a participating Specialty Physician, a referral can serve as the first step in coordination of care for the member. Importance of Collaboration and Sharing of Patient Information Health Republic seeks to improve coordination and collaboration between providers in the treatment of care for Health Republic members. The increased focus on patient safety, treatment compliance and improved outcomes highlights the critical nature of improving collaboration between treatment providers. In addition, the quality of communication is considered as an important factor by PCPs when choosing a specialist to whom they can refer their patients. Therefore, we strongly encourage providers to send progress notes and discharge summaries to their patients other treating practitioners. This will help facilitate ongoing care between physicians and is critical in the coordination of care for Health Republic members. Covered Services The following is a list of covered services. Please note that stipulations and limits apply to some of the services covered by Health Republic. Preventive Care: (a) Well Baby and Well Child Care, (b) Adult Annual Physical Examinations, (c) Adult Immunizations, (d) Well Woman Examinations, (e) Screening Mammography, (f) Family Planning And Reproductive Health Services, (g) Bone Density Testing, (h) Annual Prostate Screening, (i) Screening Colonoscopy, (j) All other preventive services required by USPSTF and HRSA, as appropriate Pre-Hospital Emergency Medical Services and Ambulance Services Emergency and Urgent Care Services Outpatient and Professional Services: (a) Acupuncture, (b) Advanced Imaging Services, (c) Allergy Testing and Treatment, (d) Ambulatory Surgery Center, (e) Chemotherapy, (f) Chiropractic Services, (g) Clinical Trials, (h) Dialysis, 22

23 (i) Habilitation Services, (j) Home Health Care, (k) Infertility Treatment, (l) Infusion Therapy, (m) Interruption of Pregnancy, (n) Laboratory Procedures, (o) Diagnostic Testing and Radiology Services, (p) Maternity and Newborn Care, (q) Medications for Use in the Office, (r) Office Visits, (s) Outpatient Hospital Services, (t) Preadmission Testing, (u) Rehabilitation Services, (v) Second Opinions, (w) Surgical Services, (x) Oral Surgery, (y) Reconstructive Breast Surgery, (z) Other Reconstructive and Corrective Surgery, (z1)transplants Additional Benefits: (a) Autism Spectrum Disorder, (b) Diabetic Equipment, Supplies and Self-Management Education, (c) Durable Medical Equipment (DME) and Braces, (d) Hearing Aids, (e) Hospice, (f) Prosthetics, (g) Orthotics Inpatient Services: (a) Hospital Services, (b) Observation Services,(c) Inpatient Medical Services, (d) Inpatient Stay for Maternity Care, (e) Inpatient Stay for Mastectomy Care, (f) Autologous Blood Banking Services, (g) Rehabilitation Services, (h) Skilled Nursing Facility, (i) End of Life Care Mental Health and Substance Use Prescription Drugs Wellness Program Pediatric Vision Pediatric Dental Providers should talk to their patients regarding the any stipulations and limitations. More information is available in the member s Certificate of Coverage. Utilization Review To maintain close oversight of medical services, Health Republic performs review of a broad range of covered services. Health Republic reviews requests for health services as well as post-service documentation to determine whether the services are, or were, medically necessary or experimental/investigational in nature. This process, also known as Utilization Review, includes all review activities, whether they take place prior to the service being performed (Preauthorization); when the service is being performed (Concurrent Review); or after the service is performed (Retrospective Review). All determinations that services are not medically necessary will be made by medical directors who are licensed physicians; or by licensed, certified, registered or credentialed healthcare professionals who are in the same profession and same or similar specialty as the healthcare provider who typically manages the medical condition or disease, or provides the healthcare service under review. Health Republic does not compensate or provide financial incentives to our employees or reviewers for determining that services are not, or were not, Medically Necessary. We have developed guidelines and protocols to assist us in this process. Specific guidelines and protocols are available for review upon request. For more information, please can contact Health Republic at prompt 3 then prompt 2. 23

24 Determination of Medical Necessity Health Republic bases medical decisions on the appropriateness of care and service. We review coverage requests to determine if the requested service is a covered benefit under the terms of the member s plan and is being delivered consistent with established guidelines. Our Medical Management staff use evidence-based clinical guidelines from nationally recognized authorities to guide utilization management decisions involving preauthorization, concurrent review, discharge planning and retrospective review. Staff use the following criteria as guides in making coverage determinations which are based on information about the specific member s clinical condition: MCG Criteria Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCD) Local Coverage Determinations (LCD) Medicare Benefit Policy Manual Internally developed guidelines and Medical Policies Participating physicians may ask for the criteria that were used to make a determination by contacting us in writing or by phone at prompt 3 then prompt 2. Services Requiring Preauthorization A summary of services that require preauthorization is available in the For Providers section at of the Health Republic website. Providers should review this list of services when discussing services and treatment with Health Republic members. To request a preauthorization, contact Health Republic by phone at prompt 3 then prompt 2 or by fax at Emergency Department Services Health Republic does not require prior authorization of services rendered in the Emergency Department of a hospital. Hospital Admissions Protocol Health Republic must be notified of a member s hospital admission within one business day of the admission. We need notice of all inpatient admissions, including those through the Emergency Department, within one business day of the admission. 24

25 If the member is unable to provide coverage information, the hospital must contact us as soon as providers become aware of the member s MagnaCare/Health Republic Insurance of New York coverage. We do not require preauthorization of emergency admissions, but we do require an initial review; and for all admissions we will request periodic concurrent reviews beyond the initial authorized period. It is very important that providers let us know of an admission within one business day. Late notification may result in denying payment for the portion of the stay before we were notified. Failure to inform us of the stay at all (or until after discharge) may result in denying the entire hospital stay. This denial will not be based on medical necessity. The member cannot be billed for these denied services. Preauthorization Reviews If Health Republic has all the information necessary to make a determination regarding a preauthorization review, we will make a determination and provide notice to the provider, by telephone and in writing, within three (3) business days of receipt of the request. If we need additional information, we will request it within three (3) business days. Providers will then have forty five (45) calendar days to submit the information. If we receive the requested information within forty five (45) days, we will make a determination and provide notice to the provider, by telephone and in writing, within three (3) business days of our receipt of the information. If all necessary information is not received within forty five (45) days, we will make a determination within fifteen (15) calendar days of the end of the forty five (45) day period. Urgent Preauthorization Reviews With respect to urgent preauthorization requests, if we have all information necessary to make a determination, we will make a determination and provide notice to the provider by telephone within seventy two (72) hours of receipt of the request. Written notice will be provided within three (3) business days of receipt of the request. If we need additional information, we will request it within twenty four (24) hours of receipt of the request for authorization. The provider will then have forty eight (48) hours to submit the information. We will make a determination and provide notice to the provider by telephone within forty eight (48) hours of the earlier of our receipt of the information or the end of the 48 hour time period. Written notification will be provided within the earlier of three (3) business days of our receipt of the information or three (3) calendar days after the verbal notification. Concurrent Reviews Utilization review decisions for services during the course of care (concurrent reviews) will be made, and notice provided to the provider by telephone and in writing, within 25

26 one (1) business day of receipt of all necessary information. If we need additional information, we will request it within one (1) business day. The provider will then have forty five (45) calendar days to submit the information. We will make a determination and provide notice to the provider, by telephone and in writing, within one (1) business day of our receipt of the information or, if we do not receive the information, within one (1) business day of the end of the forty five (45) day time period. Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care, if the request for coverage is made at least twenty four (24) hours prior to the expiration of a previously approved treatment, we will make a determination and provide notice to the provider by telephone within twenty four (24) hours of receipt of the request. Written notice will be provided within one (1) business day of receipt of the request. If the request for coverage is not made at least twenty four (24) hours prior to the expiration of a previously approved treatment and we have all the information necessary to make a determination, we will make a determination and provide written notice to the provider within the earlier of seventy two (72) hours or one (1) business day of receipt of the request. If we need additional information, we will request it within twenty four (24) hours. The provider will then have forty eight (48) hours to submit the additional information. We will make a determination and provide written notice to the provider within the earlier of one (1) business day or forty eight (48) hours of our receipt of the additional information; or, if we do not receive the information, within forty eight (48) hours of the end of the forty eight (48) hour time period for submitting the information. Home Health Care Reviews After receiving a request for coverage of Home Care services following an inpatient hospital admission, we will make a determination and provide notice to the provider by telephone and in writing within one (1) business day of receipt of the necessary information. If the day following the request falls on a weekend or holiday, we will make a determination and provide notice within seventy two (72) hours of receipt of the necessary information. When we receive a request for Home Care services and all necessary information prior to a discharge from an inpatient hospital admission, we will not deny coverage for home care services while our decision on the request is pending. Inpatient Substance Use Disorder Treatment Reviews Effective on the date of issuance or renewal of member s Certificate, Contract, Policy on or after April 1, 2015: if a request for inpatient substance use disorder treatment is submitted to us at least twenty four (24) hours prior to discharge from an inpatient substance use disorder treatment admission, we will make a determination within twenty four (24) hours of receipt of the request, and we will provide coverage for the inpatient substance use disorder treatment while our determination is pending. 26

27 Retrospective Reviews If we have all information necessary to make a determination regarding a Retrospective Claim, we will make a determination and notify the provider within thirty (30) calendar days of the receipt of the request. If we need additional information, we will request it within thirty (30) calendar days of the receipt of the request. The provider will then have forty five (45) calendar days to provide the information. We will make a determination and provide notice to the provider in writing within fifteen (15) calendar days of the earlier of our receipt of the information or the end of the forty five (45) day period. Once we have all the information to make a decision, our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an Internal Appeal. Retrospective Review of Preauthorized Services Health Republic may only reverse a Preauthorized Treatment, service or procedure on Retrospective Review when: The relevant medical information presented to us upon Retrospective Review is materially different from the information presented during the Preauthorization Review; The relevant medical information presented to us upon Retrospective Review existed at the time of the preauthorization but was withheld or not made available to us; We were not aware of the existence of such information at the time of the Preauthorization Review; and Had we been aware of such information, the treatment, service or procedure being requested would not have been authorized. The determination is made using the same specific standards, criteria or procedures as used during the Preauthorization Review. Reconsideration If we did not attempt to consult with the provider before making an adverse determination, the provider may request Reconsideration by the same Clinical Peer Reviewer who made the adverse determination. For Preauthorization and Concurrent Reviews, the Reconsideration will take place within one (1) business day of the request for Reconsideration. If the adverse determination is upheld, a notice of adverse determination will be given to Provider by telephone and in writing. 27

28 UTILIZATION REVIEW APPEALS In the instance of Retrospective Review cases, a member, a member s designee or the provider on behalf of the member may request an Internal Appeal of an adverse determination either by phone or in writing. The member has up to one hundred and eighty (180) calendar days after receipt of the notice of the adverse determination to file an Appeal. We will acknowledge the request for an Internal Appeal within fifteen (15) calendar days of receipt. This acknowledgment will, if necessary, inform the requestor of any additional information needed before a decision can be made. A Clinical Peer Reviewer who is a physician or a healthcare professional in the same or similar specialty as the provider who typically manages the disease or condition at issue, and who is not subordinate to the Clinical Peer Reviewer who made the initial adverse determination, will perform the Appeal Review. Out-of-Network Service Denial An out-of-network health service is a service provided by a non-magnacare/health Republic Insurance of New York provider when the service is not available from the Magnacare/Health Republic Insurance of New York network. Effective on or after April 1, 2015, a member will have the right to appeal the denial of a preauthorization request for an out-of-network health service when we determine that the out-of-network health service is not materially different from an available in-network health service. The member is not eligible for a Utilization Review Appeal if the service he/she is requesting is available from a Participating Provider, even if the Non-Participating Provider has more experience in diagnosing or treating the condition (such an appeal will be treated as a grievance). For a Utilization Review Appeal of denial of an out-of-network health service, the member must submit: A written statement from the attending physician (who must be a licensed, board-certified or board-eligible physician qualified to practice in the specialty area of practice appropriate to treat the condition) that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that we approved to treat the condition; and Two (2) documents from the available medical and scientific evidence that the out-of-network service: 1) is likely to be more clinically beneficial to the member than the alternate in-network service; and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service. Out-of-Network Referral Denial Effective on or after April 1, 2015, a member will also have the right to appeal the denial of a request for an authorization to a Non-Participating Provider when we determine that we have a Participating Provider with the appropriate training and experience to 28

29 meet the particular healthcare needs, and who is able to provide the requested healthcare service. For a Utilization Review Appeal of an out-of-network referral denial, the member must submit a written statement from their attending physician (who must be a licensed, board-certified or board-eligible physician qualified to practice in the specialty area of practice appropriate to treat their condition): That the Participating Provider recommended by us does not have the appropriate training and experience to meet their particular healthcare needs for the healthcare service; and Recommending a Non-Participating Provider with the appropriate training and experience to meet their particular healthcare needs who is able to provide the requested healthcare service. First Level Appeal Standard Appeal (internally with Health Republic) - Preauthorization Appeal If an appeal relates to a preauthorization request, we will decide the appeal within either fifteen (15) or thirty (30) calendar days (depending on whether the member has a Group or an Individual policy) of receipt of the appeal request. Written notice of the determination will be provided to the member, the member s designee, and where appropriate, the provider within two (2) business days after the determination is made but no later than fifteen (15) or thirty (30) calendar days (depending on whether the member has a Group or an Individual policy) after receipt of the appeal request. - Retrospective Appeal If an appeal relates to a Retrospective Claim, we will decide the appeal within thirty (30) or sixty (60) calendar days (depending on whether the member has a Group or an Individual policy) of receipt of the appeal request. Written notice of the determination will be provided to the member, designee, and where appropriate, the provider, within two (2) business days after the determination is made but no later than thirty (30) or sixty (60) calendar days (depending on whether the member has a Group or an Individual policy) after receipt of the appeal request. Expedited Appeal (internally with Health Republic) An appeal of a review of continued or extended healthcare services, additional services rendered in the course of continued treatment, home healthcare services following discharge from an inpatient hospital admission, services in which a provider requests an immediate review or any other urgent matter will be handled on an expedited basis. An Expedited Appeal is not available for retrospective reviews. For an Expedited 29

30 Appeal, the provider will have reasonable access to the Clinical Peer Reviewer assigned to the appeal within one (1) business day of receipt of the request for an appeal. The provider and a Clinical Peer Reviewer may exchange information by telephone or fax. An Expedited Appeal will be determined within the earlier of seventy two (72) hours of receipt of the appeal or two (2) business days of receipt of the information necessary to conduct the appeal. If a member in a Group plan is not satisfied with the resolution of the Expedited Appeal, he/she may file a Standard Appeal or an External Appeal. Our failure to render a determination of the appeal within sixty (60) calendar days of receipt of the necessary information for a Standard Appeal or within two (2) business days of receipt of the necessary information for an Expedited Appeal will be deemed a reversal of the initial adverse determination. Substance Use Appeal Effective on or after April 1, 2015, if we deny a request for Inpatient Substance Use Disorder treatment that was submitted at least twenty four (24) hours prior to a discharge from an inpatient admission and the member, designee or provider files an Expedited Internal Appeal of our adverse determination, we will decide the appeal within twenty four (24) hours of receipt of the appeal request. If the member or the provider files the Expedited Internal Appeal and an Expedited External Appeal within twenty four (24) hours of receipt of our adverse determination, we will also provide coverage for the Inpatient Substance Use Disorder treatment while a determination on the Internal Appeal and External Appeal is pending. Second Level Appeal The Second Level Appeal is only applicable to members with a Group policy. If a Group member disagrees with the First Level Appeal determination, the member or their designee can file an Internal Second Level Appeal. The member or designee can also file an External Appeal (see process below). The four (4) month timeframe for filing an External Appeal begins on receipt of the Final Adverse Determination on the First Level of Appeal. By choosing to file a Second Level Appeal, the time may expire for the member to file an External Appeal. A Second Level Appeal must be filed within forty five (45) days of receipt of the Final Adverse Determination on the First Level Appeal. We will acknowledge the request for an Internal Appeal within fifteen (15) calendar days of receipt. This acknowledgment will inform the member, if necessary, of any additional information needed before a decision can be made. If the appeal relates to a preauthorization request, we will decide the appeal within fifteen (15) calendar days of receipt of the appeal request. Written notice of the determination will be provided to the member or designee, and where appropriate, the 30

31 provider, within two (2) business days after the determination is made but no later than fifteen (15) calendar days after receipt of the appeal request. If the appeal relates to a Retrospective Claim, we will decide the appeal within thirty (30) calendar days of receipt of the appeal request. Written notice of the determination will be provided to the member or designee, and where appropriate, the provider, within two (2) business days after the determination is made but no later than thirty (30) calendar days after receipt of the appeal request. Submitting an Internal Appeal All Internal Appeals should be submitted by phone at or by fax to Internal Appeals can also be submitted in writing to: Health Republic Insurance of New York PO Box 6329 Syracuse, NY External Appeals Member s Right to an External Appeal In some cases the member has a right to an External Appeal of a denial of coverage. If Health Republic denied coverage on the basis that a service does not meet our requirements for Medical Necessity (including appropriateness, healthcare setting, level of care or effectiveness of a covered benefit); or is an Experimental or Investigational treatment (including clinical trials and treatments for rare diseases); or effective on April 1, 2015 is an out-of-network treatment, the member or the member s representative may appeal that decision to an External Appeal Agent who is an independent third party certified by the New York State Department of Financial Services (DFS) to conduct these appeals. In order for the member to be eligible for an External Appeal, two requirements must be met: The service, procedure or treatment must otherwise be a Covered Service under the Certificate of Coverage; and In general, the member must have received a Final Adverse determination through the first level of our Internal Appeal process. But, the member can file an External Appeal even though they have not yet received a Final Adverse Determination through the first level of our Internal Appeal process if: - Health Republic and the member agree in writing to waive the Internal Appeal. (Please note that Health Republic is not required to agree to the member s request to waive the Internal Appeal); or 31

32 - The member files an External Appeal at the same time that they apply for an Expedited Internal Appeal; or - Health Republic fails to adhere to Utilization Review Claim processing requirements (other than a minor violation that is not likely to cause prejudice or harm to the member, and we demonstrate that the violation was for good cause or due to matters beyond our control, and the violation occurred during an ongoing, good faith exchange of information between the member and Health Republic). External Appeal of a Medical Necessity Determination If Health Republic denied coverage on the basis that the service does not meet our requirements for Medical Necessity, the member may appeal to an External Appeal Agent if they meet the requirements for an External Appeal in the paragraph above. External Appeal of a Determination that a Service is Experimental or Investigational If Health Republic denied coverage on the basis that the service is an Experimental or Investigational treatment (including clinical trials and treatments for rare diseases), the member must satisfy the two requirements for an External Appeal as noted above, and the Attending Physician must certify that the member s condition or disease is one for which: 1. Standard health services are ineffective or medically inappropriate; or 2. There does not exist a more beneficial standard service or procedure covered by Health Republic; or 3. There exists a clinical trial or rare disease treatment (as defined by law). In addition, the Attending Physician must have recommended one of the following: 1. A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to the member than any standard covered service (only certain documents will be considered in support of this recommendation the Attending Physician should contact the State for current information as to what documents will be considered as acceptable); or 2. A clinical trial for which the member is eligible (only certain clinical trials can be considered); or 3. A rare disease treatment for which the member s Attending Physician certifies that there is no standard treatment that is likely to be more clinically beneficial to the member than the requested service, the requested service is likely to benefit the member in the treatment of their rare disease and such benefit outweighs the risk of the service. In addition, the Attending Physician must certify that the member s condition is a rare disease that is currently or was 32

33 previously subject to a research study by the National Institutes of Health Rare Disease Clinical Research Network, or that it affects fewer than 200,000 U.S. residents per year The Attending Physician must be a licensed, board-certified or board-eligible physician qualified to practice in the area appropriate to treat the member s condition or disease. In addition, for a rare disease treatment, the Attending Physician may not be the member s Treating Physician. External Appeal of a Determination that a Service is Out-of-Network Effective on April 1, 2015, if Health Republic denies coverage of an out-of-network treatment because it is not materially different than the health service available in-network, the member may appeal to an External Appeal Agent if they meet the two requirements for an External Appeal as listed above, and if they have requested preauthorization for the out-of-network treatment. In addition, the Attending Physician must certify that the out-of-network service is materially different from the alternate recommended in-network health service and, based on two (2) documents from available medical and scientific evidence, is likely to be more clinically beneficial than the alternate in-network treatment, and that the adverse risk of the requested health service would likely not be substantially increased over the alternate in-network health service. The Attending Physician must be a licensed, board-certified or board eligible physician qualified to practice in the specialty area appropriate to treat the member for the health service. External Appeal of an Out-of-Network Referral Denial Beginning April 1, 2015, if we denied coverage of a request for an authorization to a Non-Participating Provider because we determine that we have a Participating Provider with the appropriate training and experience to meet the member s particular health care needs who is able to provide the requested healthcare service, the member may appeal to an External Appeal Agent if the member meets the two requirements for an External Appeal as noted above. In addition, the member s Attending Physician must: certify that the Participating Provider recommended by Health Republic does not have the appropriate training and experience to meet the member s particular healthcare needs; and recommend a Non-Participating Provider with the appropriate training and experience to meet the member s particular health care needs who is able to provide the requested healthcare service. The member s Attending Physician must be a licensed, board certified or board eligible physician qualified to practice in the specialty area appropriate to treat the member for the health service. 33

34 The External Appeal Process The member has four (4) months from receipt of a Final Adverse Determination or from receipt of a waiver of the Internal Appeal process to file a written request for an External Appeal. If the member is filing an External Appeal based on Health Republic s failure to adhere to claim processing requirements, the member has four (4) months from such failure to file a written request for an External Appeal. Health Republic will provide an External Appeal application with the Final Adverse Determination issued through the first level of our Internal Appeal process or our written waiver of an Internal Appeal. The member may also request an External Appeal application from Department of Financial Services (DFS) at The member must submit the completed application to DFS at the address indicated on the application. If the member meets the criteria for an External Appeal, DFS will forward the request to an independent, DFS-certified External Appeal Agent. The member can submit additional documentation with their External Appeal request. If the External Appeal Agent determines that the information the member submits represents a material change from the information on which Health Republic based our denial, the External Appeal Agent will share this information with Health Republic in order for us to exercise our right to reconsider our decision. If Health Republic chooses to exercise this right, we will have three (3) business days to amend or confirm our decision. Please note that in the case of an Expedited External Appeal (described below), we do not have a right to reconsider our decision. In general, the External Appeal Agent must make a decision within 30 days of receipt of the member s completed application. The External Appeal Agent may request additional information from the member, the member s physician or from Health Republic. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision. The External Appeal Agent must notify the member in writing of its decision within two (2) business days. If the member s Attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to the member s health; or if the Attending Physician certifies that the Standard External Appeal time frame would seriously jeopardize the member s life, health or ability to regain maximum function; or if the member received Emergency Services and has not been discharged from a facility and the denial concerns an admission, availability of care or continued stay, the member may request an Expedited External Appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of the member s completed application. Immediately after reaching a decision, the External Appeal Agent must notify the member and Health Republic by telephone or fax of that decision. The External Appeal Agent must also notify the member in writing of its decision. If the External Appeal Agent overturns Health Republic s decision that a service is not Medically Necessary; or approves coverage of an Experimental or Investigational treatment; or, beginning April 1, 2015, an out-of-network treatment, we will provide cover- 34

35 age subject to the other terms and conditions of the member s Certificate of Coverage. Please note that if the External Appeal Agent approves coverage of an Experimental or Investigational treatment that is part of a clinical trial, Health Republic will only cover the cost of services required to provide treatment to the member according to the design of the trial. We will not be responsible for the costs of Investigational drugs or devices, the costs of non-healthcare services, the costs of managing the research or costs that would not be covered under the member s Certificate of Coverage for non-investigational treatments provided in the clinical trial. The External Appeal Agent s decision is binding on both the member and Health Republic. The External Appeal Agent s decision is admissible in any court proceeding. Health Republic has the right to charge the member a fee for the filing of an External Appeal. POPULATION HEALTH PROGRAM AND CASE MANAGEMENT PROGRAM Population Health Program (PHP) The Population Health Program (PHP) works to engage members in managing their own health, improve the utilization of primary and preventive services and reduce risk of hospitalizations and high cost interventions. Fundamentally, the PHP helps members take charge of their health and their healthcare, altering cost and quality trends through efficient and effective member interventions. The PHP is embedded in the member experience of the health plan and will be a significant contributor to customer satisfaction and retention. Member Engagement In a high performing health system, patient engagement is crucial. Medical literature demonstrates that patients who are informed and supported with coordinated care will have a better consumer experience and better health outcomes. The definition of patient engagement varies widely in the public health literature, but it is defined here to frame the operational process and outcome measures: selection of a primary physician completion of the online or telephonic General Health Assessment (GHA) in English or Spanish regular visits to a primary physician adherence to recommended preventive services referral and/or adherence to the disease management program response to outreach from the PHP 35

36 PHP Member Engagement Approaches A variety of tactics are available to support patient outreach and engagement, which is conducted on a telephonic and electronic platform. The program design is engineered to leverage efficiencies through the use of electronic means, including: standardized s and text message campaigns condition specific push notifications physician alerts (admissions and Emergency Room visits, etc) scheduling of visits with physicians targeted mailings telephone call(s) with Wellness Coaches (personal coaching) referrals to case management website content use of incentives Patient Education Materials At the core of the member experience is the Member Center of the Health Republic website. The website is designed to facilitate the engagement process through selection of a primary physician, completion of the GHA and exploration of a large library of interactive health resources. Completion of the GHA is likely to trigger further exploration of the available resources by members. Role of the Wellness Coach The Wellness Coach is charged with enhancing the engagement of at-risk members through motivational interviewing strategies. The highest priorities are to encourage members to select a physician and complete the GHA. The Wellness Coaches conduct campaigns (e.g. targeted mailings, telephone and ) to promote regular screenings and use of preventive services. They also engage members who might benefit from better coordination of care (such as persons who use the emergency department and fail to follow up with their primary physician). Additional campaigns may focus on medical and behavioral risk factors. Role of StatDoctors for Telemedicine Services Health Republic encourages our members to manage their healthcare at all times while reducing the risk of hospitalizations and unnecessary high cost interventions. To achieve this goal, Health Republic partners with StatDoctors so members can immediately 36

37 access care and treatment nationwide* and at any time. A free service to all members, StatDoctors are board-certified emergency medicine physicians who can evaluate, diagnose and treat a variety of minor medical conditions online or over the phone. These physicians can also send electronic prescriptions to your pharmacy. Providers can refer Health Republic members to this service for after hour services. More information about this program is available at *STATDOCTORS operates subject to applicable state laws. All services may not be available in all states. Case Management Case Management is a standard component across all Health Republic plans and seeks to enhance coordination of services for members at high risk. Our Case Managers are Registered Nurses and Licensed Social Workers who review and coordinate services for members with multiple and complex needs (e.g., cardiac care, complex pediatric care, complex behavioral healthcare, medical psychiatric coordination, oncology, transplants, dialysis). Case Management services may also be provided as part of the discharge planning process for a hospital admission. Once we decide that a member is a good candidate for Case Management and the member or caregiver agrees to it, we make an individualized plan. We work with the member, the member s family, physician(s) and other healthcare professional(s). The assessment process leads to the development of a Case Management plan that meets the member s specific needs. The plan includes member-specific deficits, goals and objectives. There are targeted activities to meet these goals and objectives. The Case Manager helps the member achieve his or her health goals, and they work to resolve any identified issues or barriers. We regularly reassess the individualized plan to determine the member s progress in meeting the goals and objectives. As the member s condition progresses or regresses, we modify the plan accordingly. Once the stated goals and objectives are met, the member is discharged from Case Management; this is usually within an average of 30 to 90 days. Health Republic welcomes referrals from treating physicians to our Case Management program. Physicians who believe that their patient would benefit from Case Management should call , select prompt 3 and then prompt 2. Reimbursement for Care Coordination Services Health Republic provides reimbursement for a variety of services that support effective care coordination and improve patient health. Examples include telephone or online evaluation and management services, and transitional care management services. Providers are also reimbursed for counseling on smoking cessation, alcohol and substance abuse and preventive medicine for individual and group sessions. 37

38 PHARMACY Programs and Covered Services Pharmacy services are a covered benefit for Health Republic members. A comprehensive and up-to-date formulary is available on the Health Republic website at in the For Providers section of the website. Pharmacy services are provided by US Script and its network of participating pharmacy providers. Some medications require step therapy, prior authorization (PA) or have limitations on age, dosage and/or maximum quantities. If there are any questions, providers may call the US Script Help Desk at A list of participating pharmacies is available from the US Script website at Members should present their Health Republic member ID card to pharmacy staff when accessing pharmacy services. The US Script corporate logo and phone number appear on the member ID card. All prescriptions must be filled at a US Script participating pharmacy. Health Republic may require prior authorization of certain pharmaceuticals. Medication Formulary Health Republic has partnered with US Script to provide a robust pharmacy benefit for our members. To access the most recent version of the medication formulary, visit Pharmacy and Therapeutics Committee Process The US Script Pharmacy and Therapeutics Committee (P&T) process includes the selection of drugs considered to be the top choices based on their safety, effectiveness and value for our formulary. The P&T process is led by an independent group of practicing doctors, pharmacists and other healthcare professionals responsible for the research and decisions surrounding our drug list/formulary. This group meets regularly to review new and existing drugs and to choose the top medications for our formulary. The P&T process also helps improve customer health through programs such as drug utilization review, medication safety promotion and compliance encouragement. US Script uses a balanced approach to drug list/formulary management, based on a combination of research, clinical guidelines and member experience. The latest developments and submission guidelines from around the world are considered when developing and maintaining this list. Health Republic plans have adopted a medication formulary that is based on the benchmark requirements provided by the New York State Department of Health and is consistent with other formularies for plans on the NY State of Health Marketplace. Providers 38

39 are encouraged to consider the comparative cost and efficacy of pharmaceutical alternatives when prescribing medication for Health Republic members. When a step therapy or prior authorization is required, the prescriber should contact US Script directly. A provider can assist a member in filing a request for an exception to cover a non-formulary prescription by the same method. All prescription coverage exception determinations are made by US Script. Quantity Limitations Quantity limitations have been implemented on certain medications to ensure the safe and appropriate use of the medications. Quantity limitations are approved by the US Script P&T Committee and noted throughout the formulary. Please refer to our medication formulary for additional information on our quality limitations, which is listed as needed. Step Therapy Medications requiring step therapy are listed with an ST notation throughout the formulary list. The US Script claims system will automatically check the member profile for evidence of prior or current usage of the required agent. If there is evidence of the required agent on the member s profile, the claim will automatically process. If not, the claims system will notify the pharmacist that a prior authorization is required. Age Limits Some medications on the formulary may have age limits. These are set for certain drugs based on US Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals. Pharmacy Prior Authorization Process The formulary includes a broad spectrum of generic and brand name drugs. Clinicians are encouraged to prescribe from the formulary. Some preferred drugs require prior authorization and are listed with a PA notation throughout the formulary. Specific Exclusions The following drug categories are not part of the formulary: oral vitamins and minerals (except those listed in the formulary) drugs and other agents used for cosmetic purposes or for hair growth 39

40 Over-the-Counter (OTC) drugs (except those listed in the formulary) Pharmacy Drug Tiers Drug tiers have been structured to allow member co-payments to match the underlying ingredient cost. Tier 0 Preferred Preventive Drugs Preferred preventive drugs are required as part of the Affordable Care Act. This includes treatments or drugs for purposes such as smoking cessation or birth control. Tier 1 - Preferred Generic Drugs The lowest cost generic medications in any drug class are placed in this category. Generic drugs are chemically identical to brand drugs but are priced at a fraction of the cost and offer an excellent value to the member. To gain FDA approval, a generic drug must: contain the same active ingredients as the branded drug (inactive ingredients may vary) be identical to the brand drug in strength, dosage form, safety and route of administration be of the same quality, performance characteristics and use indications be manufactured under the same strict standards of the FDA s good manufacturing practice regulations required for branded products If a generic is chosen, the provider must leave blank the DAW (Dispense As Written) box on the prescription materials. This way, the pharmacist will fill the prescription with the generic drug. Tier 2 - Preferred Brand Drugs A listing of formulary brand drugs that are available at a lower co-pay than drugs in the non-preferred drug category. This generally happens when there are several equally effective, FDA-approved brand name drugs by different manufacturers for treatment of a particular condition. Tier 3 Non-Preferred Brand and Generic Drugs Drugs in the non-preferred category generally have a similar, more cost effective drug available in either the preferred generic drug category (Tier 1) or the preferred brand drug category (Tier 2). Most new FDA-approved drugs are initially placed in Tier 3 for about six months until the P&T Committee reviews them for safety, efficacy and clinical comparisons. At that time, the drug may be moved into a different tier. Tier 4 - Specialty Medications This tier uses a pharmacy vendor to help manage the care of members who need 40

41 oral and injectable specialty medications. The vendor verifies eligibility, submits requests for prior authorization and bills the member appropriate co-payments or co-insurance for medications. Providers must order specialty medications directly through the delegated vendor. Diabetic Drug Benefit Certain diabetic supplies, insulins and oral antidiabetic medications are classified under a separate benefit from the prescription drug benefit described above. This is called the Diabetic Drug Benefit. These medications and supplies are designated with a black c icon ( ) in the formulary and their co-payments may differ from the standard tier level co-payment associated with your plan. (See your Summary of Benefits for more detailed copay information.) The Diabetic Drug Benefit is designed to assist members ongoing management of their diabetes. Working with US Script Health Republic works with US Script to administer pharmacy benefits, including the prior authorization process. Certain drugs require PA to be approved for payment by Health Republic. These include: all medications not listed on the formulary some Health Republic preferred drugs (designated with a PA notation on the formulary) Guidelines for Processing of Prior Authorization requests: 1. Complete the Health Republic/US Script form: Medication Prior Authorization Request Form. This form is located in the For Providers section of the Health Republic website. Be sure to include any pertinent clinical notes/documentation for a complete review. 2. Fax to US Script at Once approved, US Script notifies the prescriber by fax. 4. If the clinical information provided does not explain the reason for the requested PA medication, US Script responds to the prescriber by fax, offering formulary alternatives. 5. For urgent or after-hours requests, a pharmacy can provide up to a seventy two (72) hour supply of most medications by calling the US Script Pharmacy Help Desk at: Prior Authorization Contact Information: US Script Phone: Prior Authorization Phone:

42 Prior Authorization Fax: Clinical Hours: Monday - Friday 10:00 a.m.- 8:00 p.m. (EST) Mailing Address: US Script, 2425 W Shaw Ave., Fresno, CA When calling, please have patient information, including Health Republic member ID number, complete diagnosis, medication history and current medications, readily available. If the request is approved, information in the online pharmacy claims processing system will be changed to allow the specific member to receive the specific drug. If the request is denied, information about the denial and appeal rights will be provided to the clinician. Clinicians are requested to utilize the Health Republic formulary when prescribing medication for those patients covered by the Health Republic pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA request, the pharmacist should attempt to contact the clinician to request a change to a product included in the Health Republic formulary. Exception Requests In the event that a clinician or member disagrees with the decision regarding coverage of a medication, the clinician may issue an appeal by submitting additional information to US Script. The additional information may be provided verbally or in writing. A decision will be rendered and the clinician will be notified with a faxed response. If the request is denied, the clinician will be notified of the appeals process at that time. An expedited pharmacy appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a patient by calling the US Script Prior Authorization department at A response will be rendered the same day upon receipt of complete information. In circumstances that require research, a same day response may not be possible. Working with our Specialty Pharmacy Provider, AccariaHealth Certain medications are only covered when supplied by Health Republic s preferred specialty pharmacy provider, AccariaHealth. These products are listed on the formulary as Tier 4. It is preferred that physicians using specialty medications seek prior authorization before initiating therapy. In most instances, AccariaHealth will be able to support a replacement program with timely delivery of medication to the provider s office or outpatient facility. Providers can request that AccariaHealth deliver the specialty drug to the office/member. If the provider would like AccariaHealth to deliver the specialty drug to the office/ member, call US Script at or fax the request form to for 42

43 prior authorization. If approved, AccariaHealth will contact the provider or member for delivery confirmation. Mail Order Option Health Republic offers a 90 day supply (3 month supply) of select maintenance medications through RxDirect. Please contact a US Script Member Service Representative if there are any additional questions regarding this program at To transfer a current prescription to mail order, please contact RxDirect at BILLING AND CLAIMS Verification of Eligibility All inquiries regarding member eligibility are handled by the customer service line at The provider may use the Provider Portal to verify their own status with the Health Republic network. Co-payments and Deductibles Co-payments and deductibles vary with Health Republic product type and are described in the Health Plan Information of this manual. Co-payments for physician office visits are also listed on the front of the member ID card. Once a member achieves the out-of-pocket maximum, the member should not pay any additional co-payment or deductible. Claims Submission Health Republic is Health Insurance Portability and Accountability Act (HIPAA) compliant and can accept electronic claims (also known as the 837 ). Health Republic encourages the use of electronic claims submission. POMCO, our Utilization and Claims Management vendor, can assist providers to become Electronic Data Interchange (EDI) compliant and implement electronic claims submission and processing. To Submit Electronic Claims: Emdeon (WEB MD) Payer ID # If electronic submission is not available, a separate CMS-1500 or UB-04 claim form must be submitted for each patient. All claims must contain the enrollee s ID number, plan code, service dates, itemized charges with Current Procedural Terminology (CPT) codes, diagnosis codes, place of service, name of provider rendering care, provider tax ID number and any other pertinent information necessary for claim consideration. Any 43

44 claims with attachments, such as explanation of benefits or operative reports, must be sent by mail and cannot be accepted in an electronic format. To Submit Paper Claims: Health Republic Insurance of New York P.O. Box 6329 Syracuse, NY Claims Processing Overview Health Republic follows National Correct Coding Initiative (NCCI) guidelines developed by the United States government. The Centers for Medicare and Medicaid Services (CMS) developed the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Medicare Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association s (AMA) CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices and a review of current coding practices. Professional and Technical Components Professional and technical components of global CPT procedures may be coverable when submitted separately for allowable services per the AMA CPT manual. Providers should use the appropriate modifiers on the claim form to ensure correct reimbursement. Assistant Surgeon Procedures being performed by the assistant surgeon must be allowable for the surgical procedure per AMA s CPT manual. Coordination of Benefits The Coordination of Benefits sets rules for the order of payment of covered charges when two or more plans provide healthcare coverage. When a member is covered by two or more plans, the plans will coordinate benefits when a claim is received. The plan that pays first, according to the rules, will pay as if there were no other plan(s) involved. The secondary and subsequent plan(s) will pay the balance due up to 100% of the total allowable expenses. 44

45 Request for Additional Information for Claim Review If we have determined that additional information is required, please provide this information within forty-five (45) calendar days of receipt of the Explanation of Benefits (EOB). Additional information should be mailed to the following address: Health Republic Insurance of New York P.O. Box 6329 Syracuse, NY If the requested information is not received within 45 days, the claim will be closed. Claims Appeal Process If a claim for benefits is denied in whole or in part, the member/provider may appeal the claim determination. Health Republic has a structured appeal process in compliance with state and/or federal regulations the appeal must be in writing and mailed to the Health Republic appeals department within sixty (60) calendar days from the date of the written denial. The plan may reserve the right to maintain denial of benefits without further review for any appeals received more than sixty (60) calendar days after the initial notice of claim denial. All appeals should be mailed to the following address: Health Republic Insurance of New York P.O. Box 6329 Syracuse, NY Upon receipt of an appeal, a review is conducted by an appeals specialist who is neither the individual who made the initial determination nor a subordinate of that person. If the adverse benefit determination was based, in whole or in part, on a medical judgment (including whether a particular treatment, drug, etc, is Experimental, Investigational or not Medically Necessary or appropriate), the specialist will consult with an appropriate healthcare professional. Any expert whose advice was obtained in connection with the adverse benefit determination will be identified to the member. POMCO will advise the member of the results in writing of their appeals review. Process 1. An appeal is received directly by the appeals department. 2. The appeal is reviewed by an appeals specialist. When a medical opinion is warranted, the specialist will send the appeal to an independent physician peer consultant for an opinion and/or recommendation. All appeals are sent directly to a consultant who is board-certified in the specific specialty/service in question. 3. The appeal determination sent to the member and/or provider documenting the rationale and applicable benefits found in the member s Summary Plan Document. 45

46 4. If the plan has a second step appeal process, POMCO will send the additional and initial appeal documentation to a different peer consultant of the same specialty for a second opinion. Appeal Turnaround Time Objective An appeal of an adverse decision (denial) regarding an urgent care claim will be decided within seventy-two (72) hours after the appeal request is filed. An appeal of an adverse decision (denial) regarding a pre-service claim will be decided within thirty (30) days after the appeal request is filed. An appeal of an adverse decision (denial) regarding a post-service claim will be decided within sixty (60) days after the appeal request is filed. Common Claim Remark Codes Listed below are common claim remark codes and descriptions. These codes appear on both the patient s and provider s Explanation of Benefits. Codes may change so please contact Health Republic at to verify. Remark Code 1 Remark Code 2 Remark Code Description 01 Benefits not in force when services were rendered 02 a+ Your plan does not allow these services 03 No benefits for these services at time rendered +} Other carrier s Explanation of Benefits required 06 1 Prenatal care is only payable at end of pregnancy 08 d+ Information submitted does not support services rendered 11 Patient not eligible for benefits under your plan 12 Max lifetime benefit met for this family member 14 Resubmit to your no-fault/auto insurance carrier 15 Resubmit to your employer s compensation carrier 16 3 Surgery considered inclusive with another service 17 Max benefit in a 12 month period 20 Treatments not prescribed by an MD are excluded 25 4 Claim submitted after filing deadline 5 Duplicate, please see original determination 30 Maximum benefit payable for this type of service 34 Maximum benefits for all services has been paid 46

47 35 Paid in accordance with maximum allowable benefit 36 Allowed amount applied towards annual deductible 6 Info not received, claim closed 39 p+ Payment based on discount/contract agreement 40 Z+ Paid in accordance with coordination of benefits 8 Requires breakdown of charge, date and diagnosis 45 Payment based on usual and customary allowances 46 Your annual deductible has been met 47 Provider of service not recognized under your plan 48 First 48 hours of nursing services are excluded 54 Reduced due to non-compliance with plan provisions 55 9 Benefit limited to 20% of surgeon s allowed amount 56 0 Multiple surgery reduction applies 75 Plan limits one in a 6 month period 76 Plan limits approved weight reduction programs +/ Claim is pending review by our Medical Department 85 +A Considered as part of another submitted service 86 Not medically indicated for reported condition +F Benefit adjustment of prior claim 93 Appears to be experimental/investigational 9p Patient responsible only for copayment/deductible +p Payment adjusted to reflect original DRG billed a2 Payment reduced to 50% due to pre-admission penalty a7 +B Services combined under appropriate CPT/CDT code S+ Claim pending, need additional information ab + Thorough review concurs with original determination ap +u Services allowed after review of appeal ar +G Code/benefit adjusted due based on review +v Please resubmit with anesthesia time aw Exclusion: determined to be maintenance nature ax +J Rentals are paid to the purchase price of the Partial payment, adjustment pending audit review B1 Completed claim form requested from insured 47

48 b4 +K Description of service is necessary, please resubmit b7 =+ Supplemental accident benefit has been applied b8 Regimen is considered experimental/investigational be Appeal closed, documentation has been requested by Appeal in review ca +z Info submitted after deadline. Claim denied CA Charges previously considered under basic policy cc Information not supplied by the enrollee, claim closed ch Per consultant s review, claim has been pro-rated cm Case management claim cr Benefit adjustment of copay(s) CR Please rebill appropriate modifier for CRNA service CS Please resubmit itemized bill cu Please submit proof of creditable coverage cy Services denied, does not meet Plan Benefits D4 This service is limited to 2 per year D5 Limited to twice every twelve consecutive months d5 1+ Services do not meet benefit guideline criteria b+ Duplicate of a claim currently in process dc Patient responsible for deductible coinsurance DH Benefit limited to one time per year DV Plan limits one service in a 6 month period e0 Benefit limited to professional fee component e6 +$ Not medically indicated for reported procedure F1 Facility must submit claim on UB-04 f7 Services performed more than once in allotted time f8 )+ New benefit period begins 12 months from this date fa \+ Final determination. Appeal process exhausted g5 Submit to prescription drug carrier for payment gf +Q Services are included in the global fee gr +R Services combined for global reimbursement 5+ Information from provider required. Please submit 6+ Please rebill the UB04 with requested information 48

49 h2 Please submit copy of UB04 and itemized bill h6 +S Payment based on negotiated rate with provider h8 Plan excludes custodial level of care hf?+ Discharge summary required. Please submit +: Provide office note including history & physical l5 +U Requested documentation not received, claim closed ll Requires invoice for implant per provider contract l+ Rebill as inpatient. Claim closed lr Inpatient review service ls Social Security Number invalid. Cannot locate ls Invalid Social Security Number. See comments j0 Based on clinical data, admission has been denied j2 Based on medical review, admission is denied md +X Requires medical documentation to support services me Considered as a major medical expense mn Provider may bill up to PPO/negotiated rate mo +Y Modifier not considered without office notes nc Please submit provider s name and credentials nd B+ NDC code is missing or invalid. Please resubmit nl C+ Paid at in-network level oc +a Please rebill with correct CPT/CDT code p1 Plan provision copayment applied for this service P1 Provider must submit claim on HCFA-1500 p3 +b Appeal date exceeds appeal filing deadline p4 +c Payment based on contracted per diem rate H+ Patient not responsible for amount not allowed y+ Office notes illegible or incomplete. Claim closed pp Benefit only allowed when PPO provider is utilized pr Private room balance is a patient responsibility ps Place of service does not meet benefit criteria r1 +g Payment based on average wholesale price f+ A refund has been requested 49

50 rf Please submit referring MD s name so that medical documentation may be requested rl K+ Received documentation incomplete. Claim closed rp +h Updated Rx required from physician RS Patient is liable for balance after payment ru M+ Benefit limited to 10% of surgeon s allowed amount rx sc sd sq Prescription drug copayment deducted Services do not comply with plan benefits Services denied see final appeal determination Payment reflects appeal determination +s Information needed letter sent under separate cover }+ Claim closed W-9 form not received from provider n+ Please submit ER report k+ Medical records do not support services w+ Payment issued at invoice cost x+ The patient has no financial responsibility +# Invalid primary diagnosis 50