SELECT NETWORK. Provider Manual

Transcription

1 SELECT NETWORK Provider Manual

2 TABLE OF CONTENTS GUNDERSEN HEALTH PLAN COMMERCIAL PROVIDER MANUAL SECTION 1: INTRODUCTION 1.1 Mission Statement 1.2 Using the Provider Manual 1.3 Provider Responsibilities Gundersen Health Plan s Expectations of Providers 1.4 Gundersen Health Plan Responsibilities Providers Expectations of Gundersen Health Plan 1.5 Gundersen Health Plan Service Area SECTION 2: STAFF AND SERVICES 2.1 Hours, Location, Mailing & Internet Addresses 2.2 Telephone Directory 2.3 Gundersen Health Plan Marketing 2.4 Culturally and Linguistically Appropriate Services (CLAS) SECTION 3: MEMBER RELATED INFORMATION 3.1 Introduction to Gundersen Health Plan Customer Service Representatives 3.2 Eligibility and Effective Dates 3.3 Termination of Coverage 3.4 Practitioner/Provider Responsibility for Verification of Eligibility 3.5 Member Identification Cards 3.6 Member Grievance Process 3.7 Member Complaint Process 3.8 Advance Directives 3.9 Member Rights and Responsibilities 3.10 Emergency Room/Urgent Care Access Standards 3.11 Confidentiality SECTION 4: BENEFIT INFORMATION 4.1 Benefit Information 4.2 Coordination of Benefits 4.3 Subrogation 4.4 Workers Compensation SECTION 5: PHARMACY 5.1 Introduction to Pharmacy Department Services 5.2 Prescription Drug Formulary 5.2a Non-Covered Drugs 5.2b Generic Dispensing Policy 5.2c Restrictions/ Limitations 5.3 Utilization Management Process 5.3a Failure to obtain Drug Prior Authorizations

3 SECTION 6: PROVIDER RIGHTS AND RESPONSIBILITIES 6.1 Identification of Members 6.1a Prohibition of Interference - Advice to Members 6.2 Provider Reporting of Member Complaints Process 6.3 Notification Process to Providers 6.4 Provider Contracting 6.4a Agreement with Contracting and Subcontracting Entities 6.4b Termination of Provider or Contracting Entity 6.5 Continuity of Care 6.6 Credentialing Process 6.6a Network Participation Standards Overview 6.6b Network Practitioner Criteria 6.6c Facility/Organizational Participation Criteria 6.6d Credentialing Staff and Committee Structure 6.7 Payable Providers 6.7a Request for Exceptions 6.7b Medicare and Medicaid Sanctions/Exclusions 6.7c Mental Health Providers 6.8 Types of Review & Appeal Processes 6.8a Overview 6.8b Professional Review Action 6.8c Provider Grievance Resolution and Appeal Process 6.8d Disciplinary Action Procedure 6.9 Standards of Conduct 6.10 Access Standards 6.11 Telephone Nurse Advice Line 6.12 Medical Record Documentation Audit for Minnesota Plan Clinics 6.13 Practitioner Credentialing and Notification of Practitioner/Provider Changes SECTION 7: MEDICAL MANAGEMENT SERVICES 7.1 Introduction to Medical Management Services 7.1a Medical Management Department 7.1b Overview of Utilization Management 7.2 Admission Notification 7.3 Elective Admissions Out of Network 7.4 Concurrent Hospital Review 7.5 Discharge Planning 7.6 Retrospective Review 7.7 Case Management 7.8 Utilization Review Criteria 7.9 Referrals and Authorizations 7.9a Overview 7.9b Referral Authorization Procedure 7.9c Prior Authorization 7.9d Prior Authorization Process 7.9e Failure to Obtain Prior Authorization

4 SECTION 8: QUALITY MANAGEMENT PROGRAM 8.1 Overview of Quality Management 8.1a Guiding Principles 8.1b Description 8.1c Purpose 8.1d Goals/Objectives 8.2 Conflict of Interest 8.3 Authority 8.4 Quality Measurement and Evaluation Methodology 8.4a Data Collection 8.4b Adverse Events 8.5 Practice Guidelines 8.5a Overview 8.5b Preventive Care Guidelines 8.5c Clinical Practice Guidelines 8.6 Disease Management 8.6a Diabetes Disease Management 8.6b Heart Failure Disease Management 8.6c Asthma Disease Management 8.7 HEDIS 8.7a HEDIS Effectiveness of Care Measures 8.7b HEDIS CAHPS Measures 8.8 On-site Provider Evaluation 8.9 Quality Improvement Work Plan 8.10 Annual Evaluation SECTION 9: PROVIDER BILLING AND REPORTING 9.1 Billing/Claim Submission Requirements 9.1a Claim Submission Requirements 9.1b Billing Reduced Services Modifiers 9.1c Prompt Payment 9.1d Claims Filing Limit 9.1e Provider Claim Payment Inquiries 9.1f Claims Submission Address 9.1g Filing Adjustments/Amended Claims 9.1h Electronic Claim Submission 9.1i Therapy Claim Submission Requirements

5 SECTION 1: INTRODUCTION 1.1 Mission Statement 1.2 Using the Provider Manual 1.3 Provider Responsibilities Gundersen Health Plan s Expectations of Providers 1.4 Gundersen Health Plan Responsibilities Providers Expectations of Gundersen Health Plan 1.5 Gundersen Health Plan Service Area 1.1 MISSION STATEMENT Mission We distinguish ourselves through service excellence, and by providing value through affordable insurance solutions and access to high quality, cost-effective medical care. Vision We will be the Health Plan of choice in our service area, known for our nationally recognized quality and service, and our affordable insurance products. 1.2 USING THE PROVIDER MANUAL Purpose This manual is designed specifically for Gundersen Health Plan providers. This manual provides specific information needed for the care and treatment of Gundersen Health Plan members. This manual defines policies, procedures, and a guidelines required by Gundersen Health Plan. It applies to the Select and Plus Networks. Please note that for GundersenOne members, the Select Network would apply. Updates or Revisions Gundersen Health Plan Provider Manual will be updated on a routine basis. A complete on line version which provides the most up to date information can be found within the Provider menu of our website at

6 1.3 PROVIDER RESPONSIBILITIES GUNDERSEN HEALTH PLAN S EXPECTATIONS OF PROVIDERS Gundersen Health Plan expects contracted providers to: Act in the best interest of our members; Communicate fully with members regarding their illness, as well as diagnostic, treatment options, medication treatments and therapeutic options available to them regardless of benefit coverage; Allow members to participate in their health care decisions; Provide continuity of care for members by ensuring that there is an appropriate confidential exchange of medical information between all providers involved; Refer members for specialty care or second opinions within the Gundersen Health Plan provider network and obtain written approval from Medical Management when it is felt that care is necessary outside of the Gundersen Health Plan s network; Assist Gundersen Health Plan members in obtaining prior authorization, as necessary, to facilitate claim payment; Participate in Gundersen Health Plan s utilization management and quality improvement initiatives, including allowing Gundersen Health Plan reasonable access to member medical records; Inform the Medical Director when Gundersen Health Plan procedures or actions are perceived as threatening the health or well-being of the member; Understand that Gundersen Health Plan does not deny patient care, but simply makes payment decisions based on the member s coverage through Gundersen Health Plan; Communicate with members and Gundersen Health Plan in a way that assumes that all parties are acting in good faith with the goal being good care for the member; Recognize that Gundersen Health Plan is obligated to develop policies and procedures on benefit administration and to administer these in a fair and consistent manner even though this occasionally results in denial of payment for individual members; Understand that Gundersen Health Plan has many different benefit plans that members may choose from. A benefit may be payable for one member, but may not be payable for another, depending on the benefit plan that each member has chosen; Understand that Gundersen Health Plan s goal is to improve access and quality of health care; and; Complete a successful credentialing program prior to contact with Gundersen Health Plan members.

7 1.4 GUNDERSEN HEALTH PLAN RESPONSIBILITIES PROVIDERS EXPECTATION S OF GUNDERSEN HEALTH PLAN Participating Providers can expect Gundersen Health Plan to: Assist the provider in meeting the expectations of Gundersen Health Plan participation; Pay claims fairly and efficiently; Provide due process to the provider when complaints or grievances are lodged against him or her; Support the provider in practice by identifying opportunities to improve care when information is available on a practice basis or an individual member basis; Maintain an appeals process that can respond quickly and appropriately to members and providers; Educate and encourage members to be seen for appropriate preventive services; Inform providers of quality or other initiatives that may affect them or our members ; and Work in all of our operational areas to improve service to our members and providers. 1.5 GUNDERSEN HEALTH PLAN SERVICE AREA The Provider Network Gundersen Health Plan has a comprehensive network that includes clinics, hospitals, skilled nursing facilities, home health, chiropractic and other health care professionals. Gundersen Health Plan offers two different provider networks; Gundersen Health Plan and Gundersen Health Plan Plus. Gundersen Health Plan ensures the integrity of the network through quality initiatives such as credentialing, utilization review and ongoing quality programs. Providers are encouraged to use Gundersen Health Plan s online directories at to determine if a provider is part of Gundersen Health Plan or Gundersen Health Plan Plus network. The online directories are updated daily for the most current listings.

8 SECTION 2: STAFF AND SERVICES 2.1 Hours, Location, Mailing & Internet Addresses 2.2 Telephone Directory 2.3 Gundersen Health Plan Marketing 2.4 Culturally and Linguistically Appropriate Services (CLAS) 2.1 HOURS, LOCATION, MAILING & INTERNET ADDRESSES Hours of Operation Gundersen Health Plan is open Monday through Friday, 8:00 a.m. - 5:00 p.m. A complete Gundersen Health Plan Telephone Directory is listed on the following pages for your reference regarding specific functions and the areas that are responsible for these functions. Gundersen Health Plan Location Gundersen Health Plan offices are located on the 2 nd floor of the Support Services Building in Onalaska, 3190 Gundersen Drive, Onalaska, WI Gundersen Health Plan also staffs an information desk at the Resource Center, which is located on the first floor of the Gundersen Clinic in La Crosse. Customer Service Representatives will be available Monday through Friday, 8:00 a.m. - 5:00 p.m. Mailing Address Written inquiries to Gundersen Health Plan should be sent to: Gundersen Health Plan NCA South Avenue La Crosse, WI Internet Address Please visit Gundersen Health Plan s website for additional information:

9 2.2 TELEPHONE DIRECTORY Gundersen Health Plan Services Customer Service and Claims Verify member eligibility Provide member schedule of benefits Provide general information or assistance Record member address or name changes Provide benefit information Record member complaints Verify newborn coverage Coordination of benefits questions Check for co-payments Pre-existing conditions/investigations Determine Claim Status Adjustment Procedure and Inquiry Questions regarding Explanation of Payments Durable Medical Equipment Assistance in identifying Gundersen Health Plan providers Configuration Questions regarding Electronic Claim Submission Provider Network Management Network application and credentialing status Provide administrative support to Plan requirements Contractual issues/fee schedule Provide educational training and assistance Discuss primary care group administration Initiate physician affiliation, disaffiliation, and transfer Medical Management Admission review/discharge planning Case Management Home Health/IV therapy Referrals for Out of Plan services Skilled Nursing Facilities Procedures/services requiring prior authorization Hospice Telephone Numbers (608) or (800) Extension (608) or (800) Extension (608) /8034 or (800) Extension or (608) or (800) Extension 58022

10 Quality Management Disease Management Clinical Practice Guidelines Health Promotion/Preventive Care HEDIS Clinical Quality Reviews Compliance Monitor compliance of Gundersen Health Plan Provide information on state and federal laws affecting HMOs Monitor pending legislation affecting HMOs Coordinate member grievance and appeal process Address privacy and confidentiality issues and concerns Privacy Officer/Compliance Officer (608) or (800) Extension (608) or (800) Extension Extension Nurse Advisor Program Advice from a registered nurse at Gundersen is available 24 hours a day, 365 days a year Chiropractic Information Members can call ChiroCare to confirm whether their chiropractor is a participant in the Gundersen Health Plan network Marketing Questions from prospective employer groups Group Administration Eligibility and effective dates of members Termination of coverage Proof of creditable coverage (608) or (800) (800) (608) or (866) (608) or (800) Extension GUNDERSEN HEALTH PLAN MARKETING Gundersen Health Plan has assembled a dedicated staff of marketing representatives who are specifically trained and licensed for marketing activities. Gundersen Health Plan encourages providers to address their marketing questions to the Director of Sales and Marketing at (608)

11 Marketing Restrictions Due to the complexity of the regulations, Gundersen Health Plan does not allow providers to act in a manner where they might be viewed as Marketing Agents for Gundersen Health Plan. Reasons why Providers should not act as Marketing Agents are listed below: 1. Gundersen Health Plan retains all authority for the marketing and sales. 2. All materials that are shared with a member, including newspaper or other articles that reference Gundersen Health Plan, require prior approval by Office of the Commissioner of Insurance (OCI) for Wisconsin and the Department of Health for Minnesota. 3. If marketing sites were allowed: Members may be confused whether the physician is acting in the role of a provider or as an agent of Gundersen Health Plan. Provider s knowledge of their member s health status may increase the potential for both their discriminating in favor of beneficiaries with positive health status, as well as steering unhealthy patients to the higher benefit level offered by Gundersen Health Plan. Providers may not be aware of membership plan benefits or costs, or other membership information. Gundersen Health Plan and/or the provider may bear responsibility if a benefit or cost is misrepresented. 4. Providers may not be the best source of membership information for their patients. 5. Marketing activities for Gundersen Health Plan are strictly regulated by the Office of the Commissioner of Insurance for the State of Wisconsin and the Department of Health for the State of Minnesota. Discussion of certain topics, including presentation or discussion of premiums or benefits, may require state licensure as an insurance agent. 2.4 CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES (CLAS) Gundersen Health Plan, Inc. does not discriminate based on race, religion or national origin or limit the opportunities of minorities to gain equal access to services. Gundersen Health Plan is committed to providing superior service without discrimination to all of our members including those who have special needs as described above and those who are at high risk of developing special needs. Gundersen Health Plan s working definition of special needs refers to any population of members that require special assistance or intervention in order to meet their customer service and/or health care needs. This includes but is not limited to culturally sensitive populations; visually, hearing, physically and mentally impaired populations; and members with chronic disease states such as diabetes, congestive heart failure (CHF), asthma, etc. An increasing body of health service research indicates that the provision of culturally and linguistically appropriate services leads to improved health outcomes, increased patient or beneficiary satisfaction, and organizational efficiencies that result in decreased expenditures.

12 Gundersen Health Plan is committed to providing optimal services to all our members and to assisting physicians and other health care providers in delivering these services. An increasing number of people in our communities have limited English proficiency and come from various cultural backgrounds. In order to provide optimal care we need to be aware of the ever-changing diversity in our community and proactively identify strategies to meet these needs. In an effort to reduce health care disparities, the Center for Medicare and Medicaid Services (CMS) chose to focus on Culturally Appropriate services. Gundersen Health Plan participates in quality improvement projects as required by CMS and recognizes the importance of proactively identifying strategies to meet the needs of these members. Gundersen Health Plan Providers play a major role in the provision of culturally appropriate services through their increased awareness and sensitivity to the diverse needs of their patients and community. Culturally and linguistically appropriate services and strategies for Gundersen Health Plan Providers include but are not limited to: Increased awareness of those patients/members with limited English proficiency Interpretive services through on-site interpreter or Language line service For members who are deaf, hard of hearing, or speech impaired please call 711, or member may call through a Video Relay Service company of their choice. Educational materials available in appropriate languages Increased cultural awareness and sensitivity of staff through training programs

13 SECTION 3: MEMBER-RELATED INFORMATION 3.1 Introduction to Gundersen Health Plan Customer Service Representatives 3.2 Eligibility and Effective Dates 3.3 Termination of Coverage 3.4 Practitioner/Provider Responsibility for Verification of Eligibility 3.5 Member Identification Cards 3.6 Member Grievance Process 3.7 Member Complaint Process 3.8 Advance Directives 3.9 Member Rights and Responsibilities 3.10 Emergency Room/Urgent Care Access Standards 3.11 Confidentiality 3.1 INTRODUCTION TO GUNDERSEN HEALTH PLAN CUSTOMER SERVICE REPRESENTATIVES Gundersen Health Plan Customer Service Department Customer Service Representatives are available to assist members and providers with any questions or concerns. Customer Service Representatives maintain direct contact with Claim Specialists and Group Administration. They can provide status on claim processing, member eligibility, and plan benefits. If unable to answer your question, Customer Service Representatives will direct you to the appropriate person(s). Providers who encounter members who have questions regarding benefits, should instruct the member to call Gundersen Health Plan Customer Service Department with their questions. As a provider, you may not always be aware of your patient s individual plan benefits or the costs involved. Gundersen Health Plan and/or you the provider may have to bear the financial responsibility if a benefit or cost is misrepresented. For this reason, providers should refrain from quoting member benefits. However, providers may call the Customer Service Representative to verify member eligibility and can inquire about member benefits. Customer Service Representatives can be reached Monday through Friday, 8:00 a.m. - 5:00 p.m. at (608) (external), ext (internal), or (800)

14 3.2 ELIGIBILITY & EFFECTIVE DATES The eligibility and effective dates of a member are based upon the criteria established by each employer group. Employer groups apply their eligibility rules to determine the waiting period (if any) as it applies to eligible members, in accordance with their Employer Group Agreement. To verify or confirm eligibility for a particular member, please contact the Group Administration Department, at (800) ext or TERMINATION OF COVERAGE Termination of a member is based upon the criteria established by each employer group. Each employer group applies their own termination rules to determine the termination date of members, in accordance with the Employer Group Agreement. To verify or confirm the termination date for a particular member, please contact the Group Administration department at (800) , ext or PRACTITIONER/PROVIDER RESPONSIBILITIES FOR VERIFICATION OF ELIGIBILITY The practitioner/provider shall request the member s ID card before services are provided, and verify that all demographic and insurance information is correct in order to assure correct registration, billing, and reporting processes. The practitioner, provider or designee shall contact the Customer Service Representative at (800) or (608) any time verification of eligibility or verification of insurance is necessary. The practitioner s office shall contact the Customer Service Representative at (800) or (608) any time the practitioner or designee becomes aware of incorrect member information. 3.5 MEMBER IDENTIFICATION (ID) CARDS Member ID cards are distributed by the Group Administration department directly to the enrolled contract holder. The ID card format and language vary depending on the plan type, i.e., HMO, POS, and Self-Funded. 3.6 MEMBER GRIEVANCE PROCESS Customer Service Representatives are available to assist members and providers with most complaints or concerns. When resolution cannot be reached via phone call, the member has the right to file a grievance by documenting the complaint in writing. As the provider of care, you may grieve on behalf of the member.

15 Grievance Procedure A grievance is a written complaint from a member, or from an individual on behalf of a member, expressing dissatisfaction with the provision of services, determination to reform or rescind a policy, determination of a diagnosis or level of service required for evidence-based treatment of autism spectrum disorders, or claims practices. All grievances and related questions should be directed to Gundersen Health Plan s Member Advocate. Member Advocate Contact Information: Gundersen Health Plan, Inc. Attn: Member Advocate 1900 South Avenue, Mail Stop: NCA2-01 La Crosse, WI (608) A grievance from, or on behalf of, a member is acknowledged with five (5) business days of receipt and resolved within thirty (30) days of receipt. Members who remain dissatisfied with a Gundersen Health Plan decision, will have additional voluntary level of appeal rights offered to them. Members will have the option to submit a complaint to the Office of the Commissioner of Insurance in the state of Wisconsin, the Iowa Insurance Division in the state of Iowa, the Department of Health in the state of Minnesota, American Arbitration Association, or an Independent Review Organization. Contact information for these organizations can be found on Gundersen Health Plan s web site or by contacting the Member Advocate. Members, or their designated representative, also have the option of requesting and expedited grievance if using the standard process could result in any of the following: (a) serious jeopardy to the life or health of the member or the ability of the member to regain maximum function; (b) in the opinion of a physician with knowledge of the member s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance; or (c) it is determined to be an expedited grievance by a physician with knowledge of the member s medical condition. The Member Advocate will respond with written confirmation acknowledging the expedited grievance request on the same day the expedited grievance is received, both verbally and in writing. The grievance will be reviewed by a Gundersen Health Plan s Medical Director, or his/her designee, for resolution within seventy-two (72) hours of Gundersen Health Plan s receipt of the expedited grievance. Medical Record Retrieval Providers will work cooperatively with Gundersen Health Plan in submitting medical records when requested by the Member Advocate for review of standard and expedited grievance

16 requests. Due to the limited time frame for making decisions under an expedited grievance request, the Member Advocate may request medical records be sent within twenty-four (24) hours via fax. For a more detailed description of Gundersen Health Plan s grievance procedure, please call the Gundersen Health Plan s Member Advocate at (608) or (800) , ext MEMBER COMPLAINT PROCESS All Gundersen Health Plan providers and staff share in the responsibility for assuring that members are satisfied with our services. If a member has a complaint relating to the administration, claims practices, or provision of services, the member should contact a Gundersen Health Plan Customer Service Representative at (608) or (800) The Customer Service Representative shall assist the member in trying to resolve the complaint on an informal basis. If the matter cannot be resolved informally, the member may file a grievance with the Gundersen Health Plan s Member Advocate according to the procedures described in Section 3.6, Grievance Procedure. 3.8 ADVANCE DIRECTIVES Overview As capable adults, patients have the right to accept or refuse medical treatment, including lifesustaining treatment. In addition, a member may appoint someone else to make health care decisions on their behalf should they become mentally or physically unable to do so. To comply with these rights, Gundersen Health Plan educates staff and providers concerning Advanced Directives. An Advance Directive is a document by which a person s wishes and decisions for future health care can be placed in writing and communicated to their family and health care providers. They can also designate a Health Care Agent who will make health care decisions on their behalf when it is determined that they are no longer capable of making these decisions for themselves. Two types of Advance Directives are commonly used: Living Will Power of Attorney for Health Care Living Will A Living Will is a written statement by the member, of his/her choices regarding the type of lifesustaining care they would want if they had a life-threatening condition and were no longer able to communicate their wishes.

17 Power of Attorney for Health Care The Power of Attorney for Health Care (POA-Health Care) form allows a member to appoint another person or persons to make health care decisions on their behalf should they become unable to make these decisions for themselves. The person (or persons) appointed is called their Health Care Agent. This form does not give the Health Care Agent any authority to make financial or other business decisions on behalf of the member. If a member has an Advance Directive, they are encouraged to provide copies to their health care providers, family, and their Health Care Agent, if they have designated one. 3.9 MEMBER RIGHTS AND RESPONSIBILITIES Members Have The Right: To Choose: Members have the right to choose a personal physician from among Gundersen Health Plan s network of physicians. To Receive Information About Their Health Plan Relating To: Covered and excluded health care benefits; Available primary and specialty care providers; Preventive care information; Their illness and treatment options; The process to file a complaint, appeal or grievance; Policies and procedures relevant to their care; To Privacy and Confidentiality Members have the right to privacy and confidentiality of all communications and records about their care. To Participate in Their Care Members have the right to be active in decisions about their treatment. They have the right to a candid discussion of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. They have the right to be informed about the risks and benefits of treatment and to refuse care. To Present a Complaint or Grievance/Appeal Members have the right to voice concerns about Gundersen Health Plan or the care provided, and to receive a prompt and fair review of their complaints. To Be Treated with Respect and Dignity Members have the right to be treated with respect and dignity regardless of their race, age, gender, sexual orientation or creed.

18 Members Responsibilities: To Know Their Benefits and Requirements: Understand their Gundersen Health Plan benefits; Follow the required procedures; Present their ID card each time they receive services; Know how to use the Gundersen Health Plan s provider network; and Ask questions about things they don t understand. To Provide Accurate Information Members have a responsibility to provide accurate and complete information about their health history and their eligibility/enrollment to Gundersen Health Plan and providers. To Participate in Their Care Members have a responsibility to participate in their care by; Asking questions to understand their health care problems; Developing mutually agreed upon treatment goals, to the degree possible; Following the recommended, agreed upon treatment goals for their care; and Making healthy lifestyle choices to try to maintain their health and prevent illness. To Keep Their Appointments Members have a responsibility to keep their appointments or to give early notice if they must cancel. To Show Consideration and Respect Members have a responsibility to show consideration and respect to health care providers and staff EMERGENCY SERVICES/URGENT CARE - ACCESS STANDARDS Emergency Services An emergency is defined as a services related to a medical condition involving acute symptoms that would lead a prudent layperson, who possess an average knowledge of health and medicine, to reasonably conclude that a lack of immediate medical attention would result in serious jeopardy to the person s health, impairment to bodily functions, or serious dysfunction to one or more organs. Emergency services are covered regardless of whether or not services are received from a participating provider. In case of an emergency, the member should seek care from the nearest provider of health care equipped to handle their condition. If they are admitted to the hospital following emergency treatment, Gundersen Health Plan should be contacted within twenty-four (24) hours of the admission or as soon as reasonably possible. If the member requires follow-up care before being able to return to the service area, a prior authorization must be obtained.

19 Urgent Care Urgent care is defined as care that needed sooner than a scheduled physician s visit, but is not an emergency. Some examples of urgent care are sprains, minor cuts and burns, drug reactions, and non-severe bleeding. Urgent care services are covered when received from a participating provider or a nonparticipating outside of Gundersen Health Plan s service area CONFIDENTIALITY Both providers and Gundersen Health Plan (staff, committee members and business associates) agree to safeguard all individually identifiable member information and to protect the confidentiality and integrity of all healthcare information exchanged between providers and Gundersen Health Plan. Both the provider and Gundersen Health Plan agree to comply with all applicable requirements of both state and federal law regarding health information, including but not limited to, the HIPAA administrative simplification laws concerning privacy, security and electronic transactions. Gundersen Health Plan Notice of Privacy Practices describes how Gundersen Health Plan uses and discloses member s medical information; member s rights (the right to inspect and copy, request amendment, accounting of disclosures, request confidential communications, and request restrictions to disclosures); how to file a complaint; and who to contact regarding privacy issues. The Notice of Privacy Practices is available on the Gundersen Health Plan website at or by contacting our Customer Service Department at (608) You may also contact the Gundersen Health Plan Privacy Specialist at (608) or the Privacy Officer at (608) with privacy related questions or concerns.

20 SECTION 4: BENEFIT INFORMATION 4.1 Benefit Information 4.2 Coordination of Benefits 4.3 Subrogation 4.4 Workers Compensation 4.1 BENEFIT INFORMATION Gundersen Health Plan administers self-funded plans, HMO and Point-of-Service plans, all with variations in benefits. This section contains information on some of the benefits available for HMO and Point-of-Service plans. Note that members of our HMO plans must receive primary care from a participating provider, except for urgent and emergency situations. Please contact our Customer Service Department with questions concerning benefits available for each plan. Customer Services Representatives can be reached Monday through Friday, 8:00 a.m. - 5:00 p.m. at (608) (external), ext (internal), or (800) These are general guidelines that apply to fully insured HMO and POS plans. Benefits vary for self-funded groups. Please call Customer Service for full benefit verification. 4.2 COORDINATION OF BENEFITS Definition A coordination of benefits (COB) provision is an insurance contract provision intended to avoid claim payment delays and duplication of benefits when a person is covered by two or more insurance plans. Coordination of Benefits Rules Gundersen Health Plan determines the order of benefits using the birthday rule. This means that the subscriber with the earliest day of birth in the calendar year has primary coverage if coverage exists under more than one insurance plan. There are exceptions to the birthday rule, including but not limited to other coverage from a plan that does not follow the birthday rule or a court order. Other insurance coverage information should be provided on the claim when it is submitted. If Gundersen Health Plan is the primary insurance, the claim will be processed as if no other coverage exists. If Gundersen Health Plan has determined that primary coverage exists, claims will be denied for the Explanation of Payment (EOP) or the Explanation of Benefits (EOB) from the primary carrier. Gundersen Health Plan will reprocess claims upon receipt of the primary insurance payment information.

21 4.3 SUBROGATION Gundersen Health Plan maintains a right of subrogation when claims have been paid for which a third party is liable, i.e. accidents on private property, motor vehicle accidents, and non-work related injuries. Gundersen Health Plan will request information from members to determine if third party liability exists. If a third party payer, such as an auto carrier, agrees to pay first, Gundersen Health Plan will not pay until medical payments through that carrier are exhausted. When the determination of liability is unresolved, Gundersen Health Plan will allow payment of claims and pursue post-payment reimbursement from the other carrier. Customer Service Representatives are available to assist members and providers with any questions and can refer calls to our Subrogation Specialist if additional information is needed. Customer Service Representatives can be reached Monday through Friday, 8:00 a.m. - 5:00 p.m. at (608) , or (800) WORKERS COMPENSATION Gundersen Health Plan policies exclude coverage of treatment, services, or supplies for any illness or injury arising out of, or in the course of, any activity for pay, profit or gain. This exclusion applies regardless of whether benefits under Workers Compensation or Occupational Health laws have been claimed, paid, waived or compromised. Work-related claims must be filed with the Workers Compensation carrier. Gundersen Health Plan does not coordinate benefit payments with Workers Compensation.

22 SECTION 5: PHARMACY 5.1 Introduction to Pharmacy Department Services 5.2 Prescription Drug Formulary 5.2a Non-Covered Drugs 5.2b Generic Dispensing Policy 5.2c Restrictions/Limitations 5.3 Utilization Management Process 5.3a Failure to obtain Drug Prior Authorization 5.1 INTRODUCTION TO PHARMACY MANAGEMENT SERVICES Pharmacy Management oversees the operation and administration of the prescription drug benefit program for Gundersen Health Plan members. Our Pharmacy Department is staffed with a Pharmacy Director, Pharmacy Specialists and Pharmacy Benefit Coordinators. In working closely with our Pharmacy Benefit Manager (PBM), we develop policies and procedures that meet all federal and state regulatory requirements. The department also monitors formulary compliance, coordinates prescription authorization activities, and monitors utilization of pharmacy services. In addition, Pharmacy Management analyzes new pharmaceuticals and oversees the drug formulary, reviews drug utilization information in order to promote rational, safe, and cost effective drug therapy for Gundersen Health Plan members. All of these processes are done in accordance with Center for Medicare and Medicaid Services (CMS) regulations, National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) standards. It is the expectation of Gundersen Health Plan that all plan providers review, cooperate and participate with the Pharmacy Management requirements outlined below and assist members with understanding of any requirements and responsibilities. Pharmacy Management inquiries should be directed to: Gundersen Health Plan Pharmacy Department NCA South Avenue La Crosse, WI Fax: (608) Telephone: (608) or toll free at (800) ext

23 Please refer to Section 2.1 for Gundersen Health Plan business hours. In situations where a member s life or health is in serious jeopardy and it is after regular business hours, a weekend, or holiday; you may contact the PBM directly at (800) for immediate assistance. 5.2 PRESCRIPTION DRUG FORMULARY The formulary is a list of medications identified by the Gundersen Health Plan s interdisciplinary Pharmacy and Therapeutics (P&T) Subcommittee. The subcommittee is composed of physicians, pharmacists, nurses, and other healthcare professionals. These members work in collaboration to establish and maintain the drug formulary and review drug utilization information in order to promote rational, evidence based, safe, and cost effective drug therapy for Gundersen Health Plan members. The formulary applies to outpatient prescription medications dispensed by participating pharmacies. Drugs requiring the assistance of a medical professional (office-based injectables) are not covered under the pharmacy benefits. Medically necessary office based injectables are covered under the major medical benefits and may be subject to prior authorization review for medical necessity. Providers may request that the P&T Subcommittee review a new or existing medication. The provider will be required to complete a Request for Drug Review form. These forms can be accessed on our Gundersen Health Plan website at Once completed the form may then be forwarded to the Gundersen Health Plan Pharmacy Management Department. The request may be reviewed and presented at the next quarterly P&T Subcommittee meeting. If it is determined the drug was reviewed at the P&T Subcommittee within the past year of the request, a new review will not be done until the following year. New medications recently approved by the FDA will be excluded from coverage until reviewed and approved by our P&T Subcommittee. Unless excluded by the benefit or benefit design, only drugs with an FDA approved indication will be eligible for coverage. Experimental or investigational drugs prescribed by a physician for the treatment of HIV infection or a medical condition arising from or related to HIV infection are covered if the drug is in, or has completed a Phase III clinical investigation. Such investigation must have been performed according to federal regulations. The drug must be prescribed and administered in accordance with the treatment protocol approved for it under federal regulations. Most Formularies are administered with a Four Tier* cost share design: Tier 1-Generic medications Tier 2-Preferred formulary brand medications. Tier 3-Non-preferred formulary brand Tier 4-High Cost/Specialty Drugs

24 However, some plans offered by Gundersen Health Plan have a Three Tier* design: Tier 1-Generic medications Tier 2-Preferred formulary brand medications. Tier 3-Non-preferred formulary brand * A member s benefit will determine coverage and may be independent of the formulary. Gundersen Health Plan formularies can be located on the Gundersen Health Plan Website at Gundersen Health Plan strongly encourages the use of generic drugs or preferred brand formulary alternatives. The P&T Subcommittee will monitor and contact practitioners who prescribe non-formulary drugs to request compliance with formulary alternatives. When prescribing medications for a Gundersen Health Plan member, it is important to keep in mind that they are required to use an in-network pharmacy. A searchable provider directory is available on our website at These directories are updated daily to include a current listing of practitioners and facilities, including network pharmacies, contracted with Gundersen Health Plan. The availability of providers is subject to change. Gundersen Health Plan is unable to consider a Drug Prior Authorization request for drugs that are specific benefit exclusions. Some examples are listed below in the non-covered drugs section. 5.2a Non-Covered Drugs Over-the-counter medications and their equivalents (unless the medication has been approved for coverage by the Pharmacy and Therapeutics Committee as part of an overthe-counter program); Replacement drugs (lost, stolen, damaged or destroyed); Drugs used for the treatment of obesity; Drugs used to enhance athletic performance; Drugs requiring prior authorization that was not obtained; Drugs used for cosmetic purposes; Emergency contraceptives (e.g. Preven and Plan B); Medication quantities exceeding the limitations established by us; Investigational and or experimental drugs with the exception of investigational drugs used for the treatment of HIV as required by Section (9) Wis. Stats; Unit dose medication (individually packaged doses of a medication); Charges for medications administered during a nursing home stay; Take home prescription drugs dispensed by a hospital or other outpatient facility;

25 Medications with no approved FDA indication; Drugs used to prevent a travel related illness; Drugs that do not meet prior authorization criteria for medical necessity; Both oral and injectable drugs used to treat impotence or erectile dysfunction; Compounded medication when formulary alternatives are available; Medications used to treat onychomycosis Early refill requests Nutritional Products 5.2b Generic Dispensing Policy Generic equivalents may be dispensed by the pharmacy if allowed by the provider or by law. All brand drugs that have a generic equivalent may be subject to an ancillary charge: If you or the member chooses a brand name medication and there is a generic equivalent available, the member will be required to pay the difference in cost between the brand name medication and the generic equivalent in addition to the co-payment/coinsurance. If there is a medical reason that a member cannot use a generic equivalent, the practitioner will need to indicate on the prescription that a brand name drug is medically necessary. The ancillary charge may then be overridden at the pharmacy level. 5.2c Restrictions/Limitations Some covered drugs may have additional requirements or limits on coverage. These may include: Prior Authorization To promote the most appropriate utilization, selected highrisk or high-cost prescriptions or devices require prior authorization. The criteria necessary for a prior authorization is established by our P&T Committee. Upon enrollment and upon request, members receive a list of drugs which require prior authorization. These medications are also identified on the Formulary. Step Therapy - Certain prescription drugs may be subject to step therapy, which means a member must try and fail a drug(s) listed in the first-line category before we will consider coverage of the second-line drug. Several drug classes require step therapy where generics or lower cost brand name drugs are available and equally effective. If there is medical documentation to indicate that the first line drug was unsuccessful, or that members are unable to attempt a trial of first line drugs, practitioners may submit a drug prior authorization along with medical documentation for review. Quantity Limits - Some medications may have a quantity limit per prescription fill and/or per month supply. Medications with a quantity limit are identified on the formulary. One copayment and/or coinsurance will apply to each prescription fill.

26 Maintenance Medications - Some drugs, depending on the member s benefits, can be dispensed in quantities greater than a 30 day supply. These drugs are called maintenance drugs. Maintenance drugs are medications taken on a regular basis for chronic, long-term conditions and this list is determined by Medispan in collaboration with the PBM. Examples of chronic conditions that may require maintenance medications are: high blood pressure, high cholesterol, and diabetes. Although maintenance drugs can be written and dispensed up to a 90 day supply, the member s copayment will still apply for each 30 days (or 3 copayments/coinsurance amounts). 5.3 UTILIZATION MANAGEMENT PROCESS As described above, certain prescription drugs, as determined by the Gundersen s Health Plan s P&T Subcommittee, require prior authorization, or may be subject to quantity limits or step therapy. Utilization Management (UM) criteria will be established with input from our plan practitioners, pharmacy benefit manager, and consideration of current medical literature. Practitioners and providers can find the criteria for drugs requiring prior authorization, step therapy, as well as the maintenance list, and formularies with quantity limits noted, by accessing Gundersen Health Plan s website at Prior authorization forms, which are located on our website at will need to be completed and directed to Pharmacy Management at the address listed below: Gundersen Health Plan Pharmacy Department NCA South Avenue La Crosse, WI Fax: Telephone: (800) ext or (608) Requests will be reviewed by the appropriate pharmacy staff. All denials will be reviewed by the Pharmacy Director or a Medical Director. Gundersen Health Plan does not allow financial incentives to staff or healthcare practitioners/providers at any time. All UM decisions are based only on the appropriateness of care and services and the existence of coverage. No practitioner, provider, or individual will be rewarded for issuing denials of coverage, service, or care. Within 15 days upon receipt of a request, the member will be notified by a phone call, or in writing, of the prior authorization determination. If a practitioner or provider fails to follow Gundersen Health Plan s procedures for filing the prior authorization, they will be notified within five days upon receipt of the request. The period of the initial decision may be extended up to 15 days if the plan determines it is necessary due to:

27 Matters beyond the control of the plan (including failure to submit medical documentation and/or additional information requested by Gundersen Health Plan), and; The Pharmacy Department will notify the requesting practitioner prior to the expiration of the initial 15 days, regarding the circumstances of the extension with the date the plan expects to render a decision. To obtain coverage of a prescription requiring prior authorization in an urgent care situation, practitioners may contact our Pharmacy Management at (608) or toll free at (800) ext The time frame for an urgent review and determination will not exceed 72 hours from receipt of the request. A Pharmacy Management representative will notify the submitting practitioner and the member of the decision by telephone, writing, or fax within 72 hours of receipt of the prescription prior authorization request. Denials Gundersen Health Plan provides the practitioner information to understand and decide whether to appeal a decision to deny coverage. The following information is included in all denial notices: The specific reason or reason(s) for the denial, in easily understandable language Reference to the specific plan provision, guideline, or protocol on which the denial is based. Instruction for filing a grievance/appeal regarding the denial and independent external review (if applicable) Also included in the letter will be notification that members and practitioners may obtain a copy of the criteria, clinical guidelines, or benefit provisions used for making the decision. Please contact us by phone at (800) ext , or (608) , or send your request to us at the following address: Gundersen Health Plan Pharmacy Department NCA South Avenue La Crosse, WI Gundersen Health Plan is staffed with a full time Pharmacy Director who is able to discuss medical necessity decisions. In the event the Pharmacy Director is unavailable, our Gundersen Health Plan also staffs a Medical Director and Associate Medical Directors to address questions regarding determinations.