Provider Manual. HealthLink, Inc Olive Blvd. St. Louis, Missouri

Transcription

1 Provider Manual HealthLink, Inc Olive Blvd. St. Louis, Missouri

2 Chapter 1 Introduction Welcome to HealthLink, Inc. PHYSICIAN INFORMATION Contact: HealthLink Network Services Olive Blvd St. Louis, MO HealthLink Mission About HealthLink Enrollee Rights and Responsibilities HealthLink, Inc., an Illinois corporation, owns and operates HealthLink HMO, Inc., a Missouri corporation. Both are separately formed corporations. HealthLink, Inc. is an organizer of independently contracted provider networks, which it makes available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers. Neither HealthLink, Inc. nor HealthLink HMO, Inc. has any control or right of control over the professional, medical judgment of contracted providers, and neither company is liable for any acts or failures to act, by contracted providers. HealthLink, Inc. is not an insurance company and has no liability for benefits under benefit plans offered or administered by payors. HealthLink is a registered trademark of HealthLink, Inc. 1-1 June 2003

3 Welcome to HealthLink, Inc. We thank you for being part of HealthLink s networks of participating physicians, health care professionals and medical facilities. HealthLink, Inc. was created as a hospital and physician-sponsored Preferred Provider Organization in We remain committed to collaboration with participating physicians and other health professionals in arranging for the delivery of health care services and benefit coverage. This administrative manual was created as a resource to help you and your staff understand HealthLink programs, policies and guidelines. As business practices evolve, we will keep you informed through periodic updates to this manual as well as through other communication channels. We encourage you to contact us if you have any questions or comments regarding HealthLink s programs or services. Your suggestions form an integral part of HealthLink s business plans and process improvement initiatives. We sincerely value your participation in the HealthLink networks. Our primary objective is to provide outstanding service within the framework of a common goal convenient access to quality health care at a reasonable cost. David T. Ott President & CEO HealthLink, Inc. 1-2 June 2003

4 HealthLink Mission HealthLink will stand at the forefront of health care evolution, bringing to business affiliates and program participants: Comprehensive Solutions In the form of innovative programs and administrative services that are flexible and accommodative, and that anticipate or exceed our customers expectations. Superior Service Beginning with employees who are committed to continuous quality improvement and administrative simplification, with a goal toward unprecedented loyalty from the many audiences we serve. Accountability Creating customer security through convenient access to physician-directed health care services and by demonstrating our commitment via understandable and meaningful reports. Cost Management Making sure that the costs of our programs provide excellent value to our customers. A philosophy of compassion and respect for the practice, delivery and consumption of health care services guides HealthLink s commitment to these ideals. 1-3 June 2003

5 About HealthLink Background HealthLink, Inc. is a for-profit organization incorporated in HealthLink was founded by a consortium of greater St. Louis hospitals, including Alton Memorial Hospital; Christian Hospitals Northeast and Northwest; Christian Health Services; Memorial Hospital of Belleville; St. Elizabeth Medical Center of Granite City; St. Joseph Hospital in Kirkwood; and St. Luke s Hospital in Chesterfield. Over time, three additional stockholders joined the original eight St. Louis University Medical Center, Missouri Baptist Medical Center and Blue Cross Blue Shield of Kansas City. In 1995, RightCHOICE Managed Care, Inc. acquired HealthLink, Inc. In January 2002, WellPoint Health Networks Inc. acquired RightCHOICE Managed Care. HealthLink is headquartered in St. Louis, Missouri and is licensed/registered to conduct business in Missouri, Illinois, Indiana, Kentucky, West Virginia, Iowa and Arkansas. Business Focus HealthLink s primary objective is to arrange access to contracted health care services. HealthLink is neither an insurance carrier nor a risk-bearing entity. Core to HealthLink are four services: (1) network development and maintenance; (2) marketing; (3) managed care administrative services including claim processing/pricing and medical review; and (4) information systems and health care data analysis. HealthLink s network development initiatives work in tandem with the company s marketing plans. HealthLink enters into contractual agreements with hospitals, physicians and ancillary health care professionals who then provide services at negotiated fees to enrollees of health plans contracted with HealthLink. HealthLink executes separate written agreements with payors and practitioners. These agreements define the type of managed care program offered by payors to enrollees, and the delineation of responsibilities, obligations and services of all involved parties. Once established in a specific service area, HealthLink leases network access, pursuant to network rental agreements, to insurance carriers, employers, labor trust funds and other organizations that self-insure their employees or union members. Thus, HealthLink functions as an intermediary, providing clients and payors with access to health practitioners who offer services at discounted rates. HealthLink markets its programs, networks and services to companies, governmental subdivisions (e.g., state employees, municipalities, and school districts), Taft-Hartley trust funds, multiple employer trust funds and hospitals. In addition, HealthLink s contractual arrangements with insurance carriers allow them to market HealthLink networks to insured and self-funded customers ranging from individual policyholders to large employer accounts. HealthLink does not sell directly to individual consumers, nor does HealthLink market Medicare or Medicaid programs. 1-4 June 2003

6 In addition to network development and sales, HealthLink offers Utilization Management services to payors. HealthLink s Utilization Management services may include the following options: Pre-Admission Certification of Planned Hospitalizations Emergency Admission Notification Concurrent Hospital Stay Review Discharge Planning Assistance Specialty Care Referrals Major Case Management Second Opinion Surgical Review Ambulatory/Outpatient Review Ancillary Services Review HealthLink s Utilization Management program is certified or registered, as required by the states in which HealthLink performs medical review for payors. To support the administrative needs of HealthLink s varied business arrangements, HealthLink has developed a proprietary information system. HealthLink s system capabilities integrate Utilization Management activity, physician contracting and enrollee eligibility information to reprice or fully adjudicate medical claims. URAC Accreditation HealthLink s commitment to continuous quality improvement is recognized through our Network and Utilization Management Accreditation by the American Accreditation HealthCare Commission/URAC. The Commission/URAC is nationally recognized as one of the preeminent accrediting boards for managed care organizations. URAC standards focus on: Network Management Physician Credentialing Enrollee Protection Quality of Care Quality of Services Utilization Management HealthLink Network Programs HealthLink can support a continuum of health benefit products offered by payors. HealthLink s programs are as follows: HealthLink PPO A Preferred Provider Organization network program that offers contracted payors access to a network of physicians, hospitals and other health care professionals who have contracted with HealthLink to provide health care services at negotiated, discounted rates. Enrollees of health plans accessing the HealthLink PPO 1-5 June 2003

7 program may self-refer to any health care practitioners they choose. The payor s plan benefits are designed to encourage enrollees to utilize physicians, hospitals and other health care professionals who participate in HealthLink. Claims administration is performed by the payor. HealthLink HMO A Health Maintenance Organization network program that offers contracted payors access to a network of physicians, hospitals and other health care professionals who have contracted with HealthLink to provide health care services at negotiated, discounted rates, and in accordance with specific features of the HealthLink HMO network program. These program features include: (1) Primary care physician-directed care; (2) Referral authorization to medical specialists and out-of-network health care services; (3) Utilization Management; and (4) Large case management. Enrollees accessing the HealthLink HMO network are required by the payor s health plan to select a primary care physician participating in HealthLink HMO. Payors health plan benefits include coverage for specified medical and preventive care delivered by physicians, hospitals and other health care professionals participating in HealthLink HMO. The HealthLink HMO program also includes access to specialty networks in behavioral health, vision, pharmacy and ambulatory laboratory services. Claims are administered by HealthLink HMO, Inc. in accordance with the payor s benefit plan. HealthLink POS A Point-of-Service network program that offers contracted payors access to a network of physicians, hospitals and other health care professionals who have contracted with HealthLink to provide health care services at negotiated, discounted rates, and in accordance with specific features of the HMO program. Payor health plans accessing the HealthLink POS program structure their benefit plans to offer HMO coverage and non-hmo coverage in a single benefit plan. Enrollees of health plans accessing HealthLink POS programs may self-refer to physicians and facilities that participate in HealthLink s network or to non-participating health care professionals. Self-referral to non-participating health care professionals affords a level of benefit coverage that is lower than the HMO benefit available when they use a HealthLink HMO participating primary care physician to coordinate care. Payors accessing HealthLink s HMO and PPO network arrangements (identified as HealthLink POS III) structure their health plan benefits to offer three levels of coverage, corresponding to the plan enrollee s choice in health care practitioner selection at the point of service. Claims are administered by HealthLink HMO, Inc. in accordance with the payor s benefit plan. HealthLink Open Access A network program that offers payors access to HealthLink s network(s) of participating physicians, hospitals and other health care professionals. The program differs from the HealthLink POS program described above in that the payor s benefit plan would not require primary care physician referral authorization/care coordination. Claims may be administered by HealthLink HMO, Inc. in accordance with the health plan s benefits or by the health plan payor. 1-6 June 2003

8 CompManagement Workers Compensation PPO A specialty Preferred Provider Organization network program that offers contracted Workers Compensation payors access to a network of participating physicians, hospitals, occupational medicine facilities/professionals and other health care professionals who have contracted with HealthLink to provide health care services at negotiated, discounted rates for treatment of work-related illness and injury covered by the employer s Workers Compensation plan. Claims are administered by the Workers Compensation payor. HealthLink Utilization Management A HealthLink program accredited by the American Accreditation HealthCare Commission/URAC and designed to provide clinical review of medical care to assist HealthLink s contracted payors in determining benefit eligibility. Physician and nurse review is conducted for clinical appropriateness, utilizing clinical criteria specific to the condition or service under review. HealthLink Utilization Management may be performed by HealthLink or the contracted health plan s Utilization Management agent, as designated on the health plan enrollee ID card. Additionally, through arrangements with its parent company, WellPoint Health Networks Inc., HealthLink offers payors access to contractual arrangements for pharmacy benefit management and network services. This is a product option for payors and is not uniformly offered in conjunction with the HealthLink network programs. Geographic Service Area HealthLink is a regional organization. Its service area includes: Greater Metropolitan St. Louis Regional Missouri (excluding Kansas City and northwestern Missouri) Central and Southern Illinois Southern Indiana North and Central Arkansas Central Iowa Eastern Kentucky West Virginia Network Arrangements Physician participation includes a balanced mix of primary care physicians and specialists. Hospital participation includes tertiary and community hospitals as well as specialty hospitals in pediatric and rehabilitative care. HealthLink provides access to contracted ancillary health care services through network hospital contracts and independent physician agreements. The doctors, hospitals and other health care professionals that are part of the network organized by HealthLink are independent contractors who exercise independent medical judgment, and over whom HealthLink has no control or right of control. They are not agents or employees of HealthLink, its parent or affiliated companies. 1-7 June 2003

9 Multi-Payor Distribution System HealthLink is not tied to any single payor organization. Rather, HealthLink contracts with approximately 200 payors. There are several ways to identify a payor: (1) The patient s enrollee ID card names the claims payor; (2) Monthly claims activity reports identify the claims payor by name and phone number for each patient account; (3) HealthLink s Customer Service staff, automated interactive voice response system (IVR) and the web-based claim query can identify the payor by name and phone number for each patient account. HealthLink payors have agreed to incorporate HealthLink s networks, fee arrangements and certain administrative services, including claim repricing and quality assurance, into the health plans they offer. Further, payors are solely responsible for administering benefit plan provisions, determining enrollee eligibility and paying claims according to the benefit plan for PPO clients. HealthLink HMO administers benefit plan provisions and pays claims on behalf of plan sponsors and carriers who contract for HealthLink HMO and HealthLink POS programs. HealthLink agrees to: (1) Develop and maintain relationships with its networks, physicians, health professionals and facilities; (2) Provide Utilization Management services, as contracted; (3) Perform quality assurance services; (4) Price participating practitioners claims according to HealthLink contractual allowance; (5) Provide customer service support; and (6) Assist in marketing efforts. The contents of this HealthLink provider manual are descriptive only and are not contractual. In the event of any inconsistency between the contents of this provider manual and the terms of the contract between HealthLink and the participating provider, the payor, or between this manual and the terms of payor s health plan, as applicable, the terms of the applicable contract or health plan control over the content of this provider manual. 1-8 June 2003

10 Enrollee Rights and Responsibilities HealthLink believes that health care should be physician-driven and based on a strong relationship between doctor and patient. The following lists of Enrollee Rights and Responsibilities acknowledge some fundamental elements of this relationship. Enrollee Rights To receive considerate and respectful care and services from participating physicians, hospitals and other health care professionals, and considerate and respectful services from HealthLink staff. To receive medically necessary care and services. To receive from one s physician (or the hospital/office personnel) complete and understandable information about one s illness, possible treatments and likely outcome, and to discuss this information with the attending physician(s). No restriction shall be placed on the dialogue between practitioner and patient. To participate in any decision-making related to care. To know the names and roles of the attending health care professionals. To consent to or refuse a treatment as permitted by law. If one refuses a recommended treatment, he or she will receive other needed, reasonable and available care. Consideration of privacy concerning medical care. Case discussion, consultations and treatments should be conducted discreetly, with only necessary individuals present. To have all communications and records pertaining to medical care treated as confidential, released only with the enrollee s permission or as permitted by law. To review medical records and to have the information explained, except when restricted by law. To be informed of complaint and grievance procedures and to file a complaint if dissatisfied with the health care received. To receive information about HealthLink, its services and its participating physicians, hospitals and other health care professionals in a clear and concise manner. 1-9 June 2003

11 Enrollee Responsibilities To select and establish a relationship with a medical practitioner. To seek medical care at the earliest possible time when one experiences symptoms that may indicate illness or injury. To provide, to the best of one s knowledge, accurate and complete information about present complaints, past illness, hospitalizations, medications or other health-related matters. To communicate to medical personnel if one does not clearly understand what is expected or how to take prescribed medications. To follow the treatment plan recommended by the physician primarily responsible for care. To keep scheduled appointments. To take medications as prescribed or communicate the reason for not doing so. To adhere to any prescribed diet or exercise program, or to consult with the prescribing health care professional to adjust the requirements or resolve problems. To recognize the effect of lifestyle and preventive care on personal health. To read all benefit plan information and to follow instructions regarding claims, eligibility and hospitalization. To carry one s health identification card and to identify oneself as an enrollee of a HealthLink program when seeking health care services. To provide, to the best of one s knowledge, accurate and complete information about current health coverage to physicians, hospitals and other health care professionals June 2003

12 Chapter 2 PHYSICIAN INFORMATION Contact: HealthLink Network Services Olive Blvd St. Louis, MO Standards, Guidelines and Requirements of HealthLink and Network Participation Professional Licensing Physician Personnel Licensing Periodic Certification of Credentials Physicians Right to Review Credentialing Confidentiality of Patient Information Records Inspection Physician Responsibilities - Coordination of Benefits - Physician Availability and Accessibility - Patient Selection and Transfer of Care - Administrative Charge 2-1 June 2003

13 Professional Licensing Physicians, health care facilities and health care professionals who participate in HealthLink s programs must be duly licensed in the state or states in which they practice. HealthLink recognizes physician specialty and subspecialty designations by evidence of board certification from the appropriate specialty board. Participating physicians must, at all times, during the term of the agreement with HealthLink: Be licensed to practice medicine in all states in which they practice. Maintain required professional credentials and meet continuing education requirements necessary to retain specialist professional designations. Maintain good standing for medical or allied medical staff membership at one or more HealthLink participating hospitals. Network Services may contract with physicians who do not have hospital privileges based upon exceptional circumstances that, if not addressed, might reasonably limit access to medical care. Also, Network Services may waive admitting privilege criteria if hospital care is generally recognized as outside the scope of the specialty. If applicable to the practice or specialty, maintain a current narcotic number issued by the Drug Enforcement Administration. Evidence of such licensing will be provided to HealthLink upon request. Physician Personnel Licensing All nurses and other health care personnel providing covered services to health plan enrollees under the direction or guidance of a physician must be duly licensed and certified in accordance with federal, state and local requirements. Periodic Certification of Credentials HealthLink s Medical Director oversees the credentialing process. The Medical Director s designated Associate Medical Director and a panel that includes physicians and health care professionals participating in HealthLink perform credentialing review. When credentialing is completed by HealthLink, it is effective for all contracted payors accessing HealthLink s networks and programs. 2-2 June 2003

14 The timeframe for initial credentialing depends on the amount of time required for primary source verification of education. Once a physician has submitted the necessary information and authorization form, the credentialing verification and review process typically takes one to two months to complete. Any practice adding a physician should contact HealthLink several months in advance to initiate the application and credentialing review process. Standard credentialing information to be sent to HealthLink should include copies of the following: Current DEA Certificate Current State Controlled Substance Certificate Board Certification or Recertification (at initial credentialing and/or status change) Board Eligibility Verification or Stated Intentions for Certification Current Professional Liability Policy Coversheet Professional Liability Claim Details Updated Work History (CV or application) W-9 Form Physician Practice Information Signed and Dated Attestation Form Please Note: Sample recredentialing package, initial credentialing application and selection criteria are available upon request. Contact HealthLink at HealthLink s credentialing process typically recurs on a three-year schedule. During the interim, participating physicians should send HealthLink notice of change to any of the following information: License Practice Location Board Certification Scope of Practice Services Hospital Affiliations Corporate FEIN (Tax Identification Number) 2-3 June 2003

15 Physicians Right to Review Credentialing 1. Each physician has the right to review information submitted in support of credentialing or recredentialing. Requests to review such information must be submitted in writing to: Credentialing Department P.O. Box St. Louis, MO If credentialing information obtained from other sources varies substantially from information provided by the physician, HealthLink will notify the physician in writing. The physician has the right to submit written corrections or clarifications. All such communication should be addressed to the Credentialing Department. 3. HealthLink will maintain credentialing files in a secure environment. These files are the property of HealthLink, Inc. and will not be released to third parties without a signed release from the physician or appropriate court order. Information contained within these files may be extracted into separate files for purposes of creating directories, claim procedures, etc. Confidentiality of Patient Information Federal and state law as well as generally accepted medical practice standards require that contracted physicians must maintain a medical record for each patient accessing HealthLink s networks and programs. The physician and physician s employees must treat the medical records of enrollees as confidential and comply with all federal and state confidentiality laws. The following section constitutes the standard HIPAA-Business Associate guidelines. HIPAA-Business Associate Guidelines Personal Health Information Uses, Disclosures and Safeguards The following provisions apply to all HealthLink participating providers unless expressly prohibited by applicable law. 1. Under the HealthLink participating provider agreement, HealthLink and/or one or more of its affiliates (collectively referred to as HealthLink ) provides certain administrative services in connection with a participating provider s participation in one or more networks of HealthLink that are available to health plans that are covered entities under HIPAA (as hereinafter defined). 2-4 June 2003

16 2. HealthLink desires to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996, as amended from time to time, and the regulations promulgated pursuant thereto (collectively, HIPAA ), regarding the receipt of protected health information or PHI (as such terms are defined in HIPAA) from participating providers, or creation or receipt of PHI by HealthLink on behalf of participating providers as their business associate (as such term is defined in HIPAA), as well as the requirements of the Gramm-Leach-Bliley Act, and any regulations promulgated by an appropriate state authority pursuant thereto (collectively GLB ), regarding the receipt of certain nonpublic personal information ( NPI ) should a participating provider be considered a financial institution and/or licensee (as such terms are defined in GLB). In connection therewith, HealthLink adopts the following: (a) Use and Disclosure of PHI. (i) In order for HealthLink to provide the services required under its participating provider agreements, HealthLink may receive PHI and/or NPI from participating providers, or create or receive PHI and/or NPI on behalf of participating providers as their business associate. In connection therewith, (1) HealthLink is not the business associate of a participating provider for the manner or form in which claims information, other information or claims are transmitted or submitted (i.e., electronically or hard copy) to health plans (as such term is defined in HIPAA), their business associates or others, (2) HealthLink is not the business associate of HealthLink s clients (including health plans as such term is defined in HIPAA) for the manner or form in which claims information, other information or claims received from such clients are transmitted or submitted (i.e., electronically or hard copy) by HealthLink or its delegate to participating providers, and (3) HealthLink is not assuming the role of, or acting as, a health care clearinghouse (as such term is defined in HIPAA) unless a separate written agreement is hereafter entered into by HealthLink and the applicable participating provider that expressly describes the health care clearinghouse services to be provided, the respective responsibilities of the parties and the compensation to be paid to HealthLink for such health care clearinghouse services. (ii) HealthLink will not use or further disclose any such PHI and/or NPI, other than as permitted or contemplated herein or the applicable participating provider agreement or as required or permitted by law. 2-5 June 2003

17 (iii) Pursuant to the participating provider agreements, HealthLink provides various services ( HealthLink Services ) to, or on behalf of, participating providers that involve the use and/or disclosure of such PHI and/or NPI. Except as otherwise specified herein, HealthLink may make any and all uses and/or disclosures of such PHI and/or NPI that it determines reasonably necessary to fulfill its obligations, and provide the HealthLink Services, under its participating provider agreements. (iv) In addition to using and/or disclosing such PHI to perform the HealthLink Services, HealthLink also may use and/or disclose such PHI for the following additional purposes: (1) for HealthLink s proper management and administration, including, but not limited to, the use and disclosure of PHI to clients, vendors and providers for purposes of billing for and collecting HealthLink s administrative fees, access fees and other fees and charges for its services; (2) to fulfill HealthLink s legal responsibilities; and (3) when appropriate and agreed to, in writing, by the parties, to provide data aggregation services (as such term is defined in HIPAA), to a participating provider, a client or others. (v) In the event that HealthLink discloses PHI pursuant to Sections 2(a)(iv)(1) and 2(a)(iv)(2) above, and such disclosures are not required by law, HealthLink agrees to use commercially reasonable efforts to obtain reasonable assurances from the entity to whom the PHI is disclosed that such entity (1) will treat the PHI as confidential and will not use and/or further disclose except as required by law or for the purpose for which HealthLink disclosed the PHI to the entity, and (2) will notify HealthLink of any instances of which it is aware in which the confidentiality of the PHI has been breached. (b) Safeguards. HealthLink will use reasonable and appropriate safeguards to prevent the use or disclosure of PHI for purposes other than as set forth herein. HealthLink will promptly notify the applicable contracted provider of any unauthorized use and/or disclosure of PHI or any breach hereof, of which HealthLink becomes aware. Participating providers must use reasonable and appropriate safeguards to prevent the use or disclosure of PHI received from HealthLink. Participating providers must promptly notify HealthLink of any unauthorized use and/or disclosure of PHI received from HealthLink of which the participating provider becomes aware. (c) Use of Subcontractors. In the event HealthLink engages a subcontractor or an agent in performing any of the services contemplated under a participating provider agreement, which require use and/or disclosure of PHI, HealthLink will require such subcontractor or agent to agree to the same restrictions and conditions herein that apply to HealthLink with respect to PHI. In addition, HealthLink will only disclose the minimum PHI necessary for the subcontractor or agent to perform or fulfill the authorized subcontracted services. (d) Access to PHI. In the event that HealthLink creates, receives or maintains PHI on behalf of a participating provider, that is not otherwise available to the participating 2-6 June 2003

18 provider (the Nonduplicative PHI ), HealthLink will make such Nonduplicative PHI available for inspection and copying by the applicable participating provider or the subjects thereof upon the participating provider s reasonable written request and as permitted by law. (e) Amendment of PHI. HealthLink will incorporate any amendments or corrections to PHI when notified by the applicable participating provider, in writing, that such PHI is inaccurate or incomplete. (f) Accounting of Disclosures. Upon the reasonable written request of a contracted provider, HealthLink will make available such of its information, which relates to the provision of the HealthLink Services or HealthLink s compliance with the provisions hereof, as is reasonably necessary for the participating provider to provide an accounting of the disclosures to the subject of the PHI. (g) Government Access to Records. HealthLink agrees to make available its policies, books and records relating to the use and disclosure of PHI to the Secretary of the U.S. Department of Health and Human Services or his or her designee for the purpose of determining whether a participating provider is in compliance with HIPAA. (h) Effect of Termination. The termination of the participating provider agreement will not affect the rights and obligations of the parties arising prior to such termination or prior to the expiration of any applicable continuation period under the participating provider agreement following termination of the participating provider agreement, or with respect to the services provided by a party, if any, for dates of service prior to such termination or prior to the expiration of any applicable continuation period under the participating provider agreement following termination of the participating provider agreement. (i) Disposition of Records upon Termination. HealthLink agrees to return or otherwise destroy all PHI received from or created or received on behalf of a participating provider in accordance with established medical records doctrine or upon termination of the participating provider agreement, if feasible. If such return or destruction of records is not feasible (e.g., if HealthLink is legally required to retain the PHI, or if PHI is necessary for HealthLink s future audits), HealthLink will continue to comply with the above with respect to such PHI and limit any further use of such PHI to those purposes that make the return or destruction of the PHI infeasible. SPECIAL INSERT HIPAA UPDATE 2-7 June 2003

19 Records Inspection Contracted physicians must document all services provided to health plan enrollees accessing HealthLink s networks and programs. Upon the request of any federal or state governmental agency that has jurisdiction or authority over HealthLink, physicians must permit inspection of the books, records and information regarding the provision of health care services to health plan enrollees. In addition, physicians must comply with requests from HealthLink or its affiliated payors to provide information contained within the medical record for purposes related to health care operations and benefit consideration. HealthLink will make reasonable efforts to secure this information. Physicians participating in HealthLink s networks and programs agree to supply necessary information at no copying costs to HealthLink, its affiliated payors or patients. Physician Responsibilities Coordination of Benefits HealthLink does not direct how coordination of benefits is performed. Coordination of benefits may vary and procedures are specified in the payor health plan document. To verify which health plan is primary when a patient has two or more health plans, the physician should contact the claims administrator listed on the enrollee s ID card. Physician Availability and Accessibility Ongoing Availability. Primary care physicians (i.e., specialties of Family Practice, General Medicine, Internal Medicine and Pediatrics) participating in the HealthLink network agree to be available or to arrange for medical coverage/consultation to patients enrolled in a HealthLink program 24 hours a day, seven days a week for consultation on medical concerns. Availability of Services. Participating physicians and hospitals cooperate with HealthLink in working toward timeliness in performing medical services. HealthLink s guidelines for physician appointments are as follows: TYPE OF CARE Emergency Urgent Routine Care with Symptoms Baseline Physical Exams Well Child Care (< age one) Well Child Care (> age one) GUIDELINE Within four hours on the basis of medical need Within 24 hours on the basis of medical need Within one week on the basis of medical need Within 30 days Within three weeks Within six weeks 2-8 June 2003

20 TYPE OF CARE Prenatal Care First Trimester Second Trimester Third Trimester High Risk Pregnancy Referrals (HMO) Specialty Physician Specialty Emergency Care Specialty Urgent Care Routine Specialty Care Wait Time in Physician Office Scheduled Unscheduled (worked in) Telephone Response After Hours Emergency Urgent Non-Urgent GUIDELINE Within one week Within one week Within three days Within three days or immediately for emergency care Within 48 hours, within one hour for emergency care Within four hours on the basis of medical need Within 48 hours on the basis of medical need Within four weeks on the basis of medical need Within 30 minutes in waiting room; 15 minutes in exam room Within 60 minutes in waiting room or exam room Within 30 minutes Immediate Within one hour Same day Covering Physicians. All participating physicians are required to make arrangements for coverage in their absence, and must disclose this information to patients by telephone or answering service. HealthLink urges physicians to use HealthLink participating physicians for coverage, since patient benefits are typically reduced if patients utilize non-participating practitioners. In the capitation arrangement that many participating primary care physicians have with HealthLink HMO, the primary care physician receives a monthly capitation payment for certain covered, routine health services. HealthLink HMO cannot double-pay to accommodate a covering physician who provides routine care to another primary care physician s patient. A physician may arrange with other HealthLink participating physicians for coverage of duties in the event of his or her temporary absence. Compensation for capitated basic health care services provided by a covering participating physician is included in the compensation payable to the covered physician. The covered physician is solely responsible for compensating the covering physician. HealthLink does not credential or contract with Locum Tenen. If a physician is unable to arrange for coverage by another HealthLink contracted physician, the physician may contract with a physician who does not participate in HealthLink s network and programs during a temporary absence. In such an instance, the covering physician must meet the following guidelines: Comply with and fulfill the criteria established in HealthLink s credentialing program and provide HealthLink with such information necessary to determine that he or she fulfill the criteria (including, but not limited to, proof of insurance coverage for general liability and malpractice). 2-9 June 2003

21 Execute a written agreement, in a form acceptable to HealthLink, in which the physician agrees to: - Abide by and comply with the terms and conditions of the physician agreement with respect to the provision of covered services to enrollees. - To the extent applicable, be solely responsible for compensating such physician for basic health care services provided to enrollees. - Accept, as payment in full, compensation based on the lesser of billed charges or the amount set forth in the rate schedule. This is less any co-payment, deductible or other amount that is the responsibility of the enrollee and amounts payable by another payor, for the provision of other health care services to enrollees. Patient Selection and Transfer of Care Acceptance of Enrollees as New Patients. A physician must accept a reasonable number of enrollees of health plans accessing HealthLink s programs, as mutually agreeable at the time the physician applies for participation in HealthLink programs, and as notified thereafter. If a primary care physician participating in HealthLink HMO is no longer able to accept new enrollees from health plans accessing the HealthLink HMO network program, the primary care physician must provide written notice to HealthLink 30 days in advance of the effective date so that HealthLink HMO can update its records for health plan enrollees and applicants seeking physician selection. The intent of this provision is to accommodate the participating physician s practice needs and to accurately reflect availability of care within HealthLink s networks. Physician and Enrollee Transfer Requests. Participating physicians in HealthLink HMO should notify HealthLink HMO of a request for the transfer of patient care to another physician. Health plan enrollees electing to transfer from one primary care physician to another may notify HealthLink Customer Service by phone or in writing. The change of physician will be effective on the first day of the month following such notice. Administrative Charge HealthLink charges participating physicians, facilities and health care professionals an administrative fee. The fee is compensation for services provided by HealthLink. These services include: Payor contract management (i.e., one set of HealthLink negotiated rates and standards designed to protect network physicians interests on such matters as timely claim processing, fee schedules, Explanation of Benefits and notification requirements); Centralized credentialing and recredentialing; network development and management; physician-coordinated, prospective Utilization Management; Physician complaint/appeal resolution; and periodic education programs related to health care business June 2003

22 The fee also compensates HealthLink, in part, for the costs it incurs in receiving, processing, researching when necessary, and forwarding network physicians claims for payment to the approximately 200 payors that work with HealthLink and access its networks. HealthLink provides customized monthly claims activity reports to participating physicians. These reports accompany the monthly administrative fee invoice and are valuable records for reconciling patient accounts. The reports list the names of patientenrollees, names of payors, dates of service, line-itemized amount of billed charges, and the associated amount allowed to the physician or health care professional on claims received and processed. The administrative fee is not payable on amounts paid to the physician for the provision of health care services if Medicare or Medicaid makes payment for all or any portion of the services; nor is the administrative fee applicable if the services were denied by the payor due to enrollee noneligibility or non-covered services. The physician must indicate these circumstances on the invoice statement upon payment of the monthly administrative fee, referring to the invoice number at issue. HealthLink will adjust and reconcile the physician s account accordingly June 2003

23 Chapter 3 Preferred Provider Organization (PPO) Network Program PHYSICIAN INFORMATION Contact: HealthLink Network Services Olive Blvd St. Louis, MO HealthLink PPO Network Program Quick Reference Sample Enrollee ID Cards About the HealthLink PPO Network Program HealthLink PPO Network Program Features and Services Verifying Eligibility Claims Procedures Utilization Management Procedures 3-1 June 2003

24 HealthLink PPO Network Program Quick Reference Benefit Information To verify health plan benefit coverage for health services or patient eligibility, please contact the health plan benefit administrator identified on the patient s enrollee ID card. Customer Service Call Center For inquiries about referral resources, claim status, and for health plan benefit administrator phone numbers to verify patient eligibility or covered services, please call: HealthLink Customer Service or toll-free Hours: 7:30 a.m. to 5:30 p.m. CST Open business days. Please note: HealthLink PPO enrollee ID cards identify the office phone number of the health plan benefit administrator. Questions regarding eligibility or benefit coverage may most efficiently be directed to the patient s health plan benefit administrator. You also may obtain claim status and payor information at the patient account level through HealthLink s IVR (Interactive Voice Response) system and by logging onto HealthLink s website, Your PIN number (EDI claim filing and claim status authorization number) will allow you to access claim activity up to nine months old for multiple or single patient accounts specific to the practitioner or facility. IVR and web access for claims information are available from 5:00 a.m. to midnight CST. Utilization Management Utilization Management components vary among payor health plans accessing the HealthLink PPO network program. Please refer to your patient s enrollee ID card for specific directions and components of Utilization Management. The following Utilization Management components may be included in the HealthLink PPO network program: Pre-Admission Certification of Planned Admissions (standard) Emergency Admission Notification (standard) Concurrent Hospital Stay Review (standard) Discharge Planning Assistance (standard) Second Opinion Surgical Review (elective) Major Case Management (elective) Outpatient/Ambulatory Review (elective) Ancillary Service Review (elective) 3-2 June 2003

25 For medical necessity pre-certification of inpatient and select outpatient procedures, please call: HealthLink Utilization Management or toll-free Hours: 8:00 a.m. to 5:00 p.m. CST Recorded messages after 5:00 p.m. CST Pre-admission and concurrent hospital stay patient information forms are available to print at For medical necessity pre-certification, please be prepared to provide the following information: Patient Name Diagnosis Patient ID Number (SSN#) Procedure Required Hospital Name Date of Admission Admitting Physician Name and Tax ID Number HealthLink s Utilization Management services are not health plan benefit determinations. Benefit determinations are the responsibility of the payor health plans. Select insurance companies and third party administrators are allowed to provide Utilization Management services directly or through a vendor, provided they are URAC-accredited and suitably licensed. Please refer to your patient s enrollee ID card for verification. Network Services For general information about programs, contracts, administrative services and credentialing information, please call your Network Services representative. If your representative is out of the office, you may leave a voic message or contact HealthLink s Customer Service Call Center for assistance and/or transcription of your inquiry: HealthLink Network Services or toll-free Hours: 8:00 a.m. to 5:00 p.m. CST Open business days. Messages to Network Services representatives will be returned within two business days. You may access network representative territory assignments on the web, at Claims Submission Submit electronic claims through your electronic clearinghouse vendor: HealthLink Payor ID Submit paper claims to: Specific PO Box and claim filing addresses listed on the patients ID cards. Please refer to the Claims Procedures section of this chapter for additional information. 3-3 June 2003

26 Office Visit Co-payment The office visit co-payment varies by payor health plan. Typically, a specific dollar amount copayment is indicated on the patient s enrollee ID card if the health plan coverage includes a flat co-payment. Collect this co-payment at the time of service. If the health plan has a co-insurance percentage and/or deductible, the amount payable by the patient may vary as benefits are used during the health plan benefit year. Co-insurance and deductibles usually are not printed on the patient s enrollee ID card. File your claim as directed on the patient s enrollee ID card. The Explanation of Benefits will advise you and your patient of the expense paid by the health plan and the amount payable by the patient, if any. Practices are responsible for collecting any monies due from patients. Appeals Submission Claim denials, payment reviews (not pertaining to fee allowances), claim status, lack of precertifications, etc. should be directed to the health plan claims administrator listed on the patient s enrollee ID card. For all other types of administrative, service and clinical appeals, please submit a typed explanation of the appeal consideration along with supporting information, and mail to: HealthLink Appeals Division P.O. Box St. Louis, MO June 2003

27 Sample Enrollee Identification Cards (front) Group Name Group Number Program Name Enrollee Name Enrollee Number Network Information Phone Number (back) SAMPLE 1 Utilization Management Information Benefit Administrator Phone Number HealthLink Web Site Where to Submit Claims Electronic Claims Information (front) Group Name Group Number Program Name Network Information Phone Number Enrollee Name Enrollee Number Co-payment Amount (back) SAMPLE 2 Utilization Management Information Benefit Administrator Phone Number HealthLink Customer Service Number Where to Submit Claims HealthLink Web Site Electronic Claims Information NOTE: Affiliated insurance carriers, select TPAs and self-funded groups print their own patient ID cards in accordance with HealthLink specifications. 3-5 June 2003

28 About the HealthLink PPO Network Program More than one million individuals are enrolled in health plans that access the HealthLink PPO network program. The HealthLink PPO service area includes portions of Missouri, Illinois, Indiana, Iowa, Arkansas, West Virginia and Kentucky. Multi-Payor System HealthLink is not tied to any one payor organization. Rather, HealthLink provides network access and administrative services to approximately 200 payors (contracted insurance carriers, self-funded self-administered payor clients, and third party administrators) that administer benefits on behalf of self-funded clients contracted directly with HealthLink. HealthLink is not the insurer or claims administrator in these arrangements. In exchange for access to HealthLink s networks and certain related administrative services, these contracted payors and plan sponsors agree to: provide benefit incentives to plan participants who use the HealthLink network; administer claims promptly; and make payments to network physicians and facilities in accordance with HealthLink s negotiated rates and the plan s benefit provisions. Reimbursement Model HealthLink s negotiated rates with physicians and facilities are based on an agreed discounted fee-for-service basis. Participating physicians, hospitals and other health care professionals may not balance bill patients in excess of the negotiated maximum discounted fee-for-service rate allowed for services covered by the payor health plan. Self-Referral to Health Care Services Enrollees may self-refer to physicians and other health care services. Referrals are arranged between the physician, patient and specialist. Please refer patients to other participating physicians, hospitals and health care professionals in recognition of the enhanced benefits for covered services that typically exist when enrollees utilize the HealthLink PPO network services. You may contact HealthLink s Customer Service Department or access HealthLink s web site at to verify other participants in your area, and/or request a directory. Claim Repricing/Processing Activity As a network service, HealthLink receives and reprices claims in accordance with the contract agreements with physicians or facilities. Afterwards, we forward the claims and worksheets to the claims administrator for benefit determination and payment. A repricing worksheet is produced for every claim. The worksheet shows the applicable contracted rate that corresponds to the billed service. HealthLink works with regional and national electronic claim vendors. 3-6 June 2003