2016 Provider Directory. Commercial Unity Prime Network

Transcription

1 2016 Provider Directory Commercial Unity Prime Network

2 TM IMPORTANT CONTACT INFORMATION Read the instructions for using this network and then complete this page after you have selected Primary Care Physicians (PCPs) for you and your family. YOUR PCP: My PCP is: Clinic Name: Address: Phone: OTHER FAMILY MEMBERS PCPS: Member s Name: PCP Name: Clinic Name: Address: Phone: Member s Name: PCP Name: Clinic Name: Address: Phone: The availability of practitioners and providers within this network changes periodically. Continued participation of any one doctor, hospital or other provider cannot be guaranteed. For the most up-to-date list of practitioners and providers, please visit /findadoctor. If you have questions regarding the status of a practitioner or provider, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) , Monday through Friday, from 7 a.m. to 7 p.m. central time. Please contact individual clinics for specific clinic hours. Practitioners and providers are independent contractors and not employees of Unity Health Plans Insurance Corporation. If you receive services from a network hospital, the hospital may arrange with physicians and other providers, who are not in Unity s network, to assist in your care. Unity encourages its network hospitals to hold these providers to Unity s standards for member billing; however, if a hospital does not require its providers to comply with Unity s standards, Unity cannot influence the manner or amounts that you may be billed by the provider. Unity Health Insurance does not discriminate on the basis of disability in the provision of programs, services or activities. If you need this printed material interpreted or in an alternative format, or if you need assistance using any of our services, contact Unity Customer Service at (800) or (608) (TDD / TTY Only). For printed information about hospital affiliations, medical group affiliations, board certifications, hospital accreditation, gender of each practitioner, languages spoken by practitioner as well as an explanation of each item listed above, its source, any limitations and how often this information is validated, please send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace Unity Customer Service (800) (toll-free) (608) (local) (608) (TDD / TTY only) (608) (fax) MyChart unitymychart.com Member Advocate (800) (toll-free) Web Site Pharmacy Services Department (800)

3 WELCOME TO UNITY HEALTH INSURANCE CONTENTS As a managed care organization, Unity s goal is to help its members be healthy while managing the quality and cost of their care. To do this, Unity works with a large network of providers who are committed to providing quality health care services ranging from preventive care to specialty care. This guide will give you the information you need to Choose a Primary Care Physician (PCP) Access specialty care Understand the basics of managed care Be a wise health care consumer Learn how Unity Customer Service can assist you with your benefit questions Through you have access to MyChart, a secure online tool where you can access benefit and claims information, review pharmacy claims (if applicable), receive electronic explanation of benefits (EOBs) and more. Plus, if you receive care from UW Health you can access portions of your UW Health medical information and communicate with your health care team. Sign up for an account today! Find a Doctor, Unity s provider search function, provides the most up-to-date listing of practitioners and providers Wellness programs that offer incentives for making healthy lifestyle choices Health information such as the Preventive Health Care Guideline, Unity s health management programs such as 9 Months & More and chronic condition education and support services Links to other helpful web sites To make the most of your health benefits, we encourage you to read through this directory along with your Unity Member Guide and Certificate of Coverage. Read on to learn more! i ii iii vi vii Welcome to Unity Health Insurance Map of Service Area Using the Network Know Your Benefit Plan Primary Care Physicians (PCPs) Why Choose a PCP? Steps to Follow to Select a PCP Tips for Selecting a PCP Changing your PCP Understanding Managed Care What is Managed Care? What are the Benefits of Managed Care? What is Medical Management? What is Complex Case Management? Being a Wise Health Care Consumer Member Rights and Responsibilities Member Confidentiality and Privacy Policies Unity Customer Service Complaint and Grievance Procedures Accessing Emergency and Urgent Care i

4 U N I T Y H E A L T H I N S U R A N C E P R I M E N E T W O R K The Prime Network offers access to a wide range of participating provider clinics located within these seven counties For a list of participating providers and clinics in the Unity Health Insurance Prime Network visit /findadoctor ii

5 U S I N G T H E P R I M E N E T W O R K Know Your Benefit Plan HMO Members HMO members must select or be assigned a Primary Care Physician (PCP) at the time they enroll. To be covered under your Unity benefits, you must obtain care from specialty clinics*, hospitals or other health care facilities within the network. Please see your Certificate of Coverage for details about your Unity health benefits coverage. * Please note: There may be some exceptions if you seek services from specified specialty clinics if your PCP is located in Dane County (excluding the communities of Mazomanie and Cambridge.) These exceptions are indicated with an asterisk in a specialist section of this network. POS Members All POS members must select or be assigned a PCP at the time they enroll. Utilizing your PCP ensures you have coordinated care for all your health care needs. As a POS member, you may choose to see either in-plan (participating) or out-of-plan providers. The In-Plan Benefit Level applies to services you receive from your PCP and from any specialist* within this network. The Out-of-Plan Benefit Level applies to medically necessary services received from a provider not listed in the network or services received from certain specialty clinics (as noted by an asterisk in a specialty section of this network.) The Out-of-Plan Benefit Level applies to medically necessary services received from a provider not listed in this network. As a reminder, you must notify Unity of any inpatient services you receive from an out-of-plan provider; failure to inform Unity may result in a penalty being assessed. When you receive care at the Out-of-Plan Benefit Level, you are responsible for submitting a claim form to Unity within three months from the date the services were provided. Please see your Certificate of Coverage for details about your Unity health benefits coverage. * Please note: There may be some exceptions if you seek services from specified specialty clinics if your PCP is located in Dane County (excluding the communities of Mazomanie and Cambridge.) These exceptions are indicated with an asterisk in a specialist section of this network. Important Notice to all POS Enrollees Before scheduling appointments, Unity strongly encourages you to contact us to verify the status of the providers involved in your care. Such information may influence your selection of a provider and affect the level of copayment, deductible and coinsurance amount applicable to the care you receive. The participating providers in your network may change during your plan year. Please send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) to learn more about the participating providers in your network and the financial implications of receiving care from non-participating providers. Primary Care Physicians (PCPs) All Unity members must select or be assigned a PCP at the time they enroll. Each member of your family may have a different PCP to best suit his or her health care needs. There are seven types of physicians that can serve as PCPs for Unity members Family Practice Physician (FP) Family Practice with Obstetrics Physician (FP / OB) General Practice Physician (GP) Geriatric Physician (Ger) Internal Medicine Physician (IM) Pediatrician (Ped) OB / GYN Physician (OB / GYN) Each PCP listed in this network has an abbreviation behind his / her name indicating his / her PCP type. These abbreviations will assist you in selecting PCPs that best meet the individual needs of your family members. You ll also find practitioners listed who have other abbreviations behind their names (NP, PA, PA-C, CPNP, etc.). While you may not select any of these practitioners as your PCP, they are available for annual exams, urgent or problem visits and follow up of ongoing health care. When calling your clinic for an appointment, keep in mind that you may be able to see a nurse practitioner (NP) or physician assistant (PA) instead of waiting for an appointment with your PCP. iii

6 U S I N G T H E P R I M E N E T W O R K Why Choose a PCP? A PCP is a physician who works with you to manage your health care. A PCP helps ensure you receive continuous, quality care in an efficient, cost-effective manner. Your PCP coordinates your medical care through Unity s network of specialty practitioners. To effectively manage your care and help you reach an optimal level of health, it s beneficial for you to have a strong working relationship with your PCP. To help you receive the best care, your PCP should Know your medical history and coordinate all of your health care needs, including working with medical / surgical specialists and behavioral health (mental health / alcohol and other drug abuse) practitioners Monitor and coordinate your care if you have a medical condition such as asthma or diabetes Recommend that you seek regular preventive health services, such as immunizations, age appropriate physical exams and screenings Steps to Follow to Select a PCP Now you re ready to follow these steps to select a PCP. Step 1 If you are currently seeing a PCP, check to determine if your PCP is a participating physician. If the physician is listed, you can continue to see him / her. (If you are a POS member, please refer to page iii.) Step 2 If you have not selected a Unity PCP, determine which PCP location works best for you. If you are not familiar with the PCPs at the clinic you select, you can simply list the name of the clinic and Unity will assign an available PCP or you may contact the clinic to discuss which PCP would best meet your needs. Each member of your family can have a different PCP. If you are looking for a PCP at a UW Health clinic and need help selecting one, contact the UW Health Welcome Center at (800) Monday through Friday from 8 a.m. to 5 p.m. (CST). You can also send an to patient.resources@uwmf.wisc.edu. The Welcome Center will Help you select a new primary care physician Work with you to transfer your medical records from your previous health system Gather your medical history Discuss any chronic and / or preventive issues or needs you may have Help you schedule any appointments if there is an immediate need iv

7 U S I N G T H E P R I M E N E T W O R K Step 3 Be sure to read the primary care physician information on page iii. It provides information about the providers available to you. Step 4 All Unity members with a Unity Prescription Drug Benefit can seek services from any of the Unity participating pharmacies. If you have questions regarding participating providers or your health benefits, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) Monday through Friday 7 a.m. to 7 p.m. (CST). (See page ix for emergency and urgent care information.) Tips for Selecting a PCP It is important to choose your PCP with care. PCPs are trained to serve as your main doctor over the long term. They provide your medical care and help you stay healthy. Changing your PCP Unity provides convenient ways to change your PCP 1. Go to unitymychart.com and log into MyChart 2. Contact Unity Customer Service at (800) and press 2 If you have a UW Health PCP, you can change your PCP at your clinic. Since Unity and UW Health share the same database for member and patient information, you only need to notify one of us of your change. The database is automatically updated so both of us are informed at once. Visit /findadoctor for the most up-to-date list of practitioners and providers Look for a PCP who z Is highly recommended by your friends, family or coworkers z Has the training and background that meet your needs z Takes steps to help you prevent illness for example, helps you identify ways to stop smoking z Has admitting privileges at the hospital of your choice z Encourages you to ask questions z Listens to you z Explains things clearly so you can understand z Treats you with respect v

8 U N D E R S T A N D I N G M A N A G E D C A R E What is Managed Care? Managed care is designed to help keep members healthy. Managed care empowers members to seek preventive health care services and to work with their PCP to make the appropriate health care choices. Managed care consumers have rights and responsibilities to assure they receive quality care and services. This includes the right to choose a PCP, the right to privacy and confidentiality and the responsibility for providing accurate information (see Unity s Member Rights and Responsibilities Statement for more details.) In addition, Unity expects you, as a member, to be responsible for 1. Using your Unity PCP to coordinate your care 2. Knowing about Unity s Prescription Drug Formulary (list of prescription drugs) 3. Contacting Unity Customer Service an y time you have questions about your Unity benefits What are the Benefits of Managed Care? Unity s managed care plans promote the following Coordination of Care Your relationship with your PCP is an important one. He / she should help coordinate your health care services. Convenient Access In the Unity Prime Network, participating provider clinics are located to provide you and your family with accessible heath care services in Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk counties. Streamlined Administration There is very little, if any, follow up paperwork when you seek care from a Unity participating provider. Just show your member ID card at the time of service, pay any copayment, coinsurance or deductible (if applicable) and, in most instances, your practitioner will submit claims and prior authorizations on your behalf. (If you are a POS member, please refer to page iii.) Care Management Unity s doctors, nurses and other health professionals work with your PCP to review your care and help ensure you receive medically necessary and appropriate services. Health Education and Wellness Unity partners with UW Health and a variety of community providers to offer health education classes and services to improve your health and well-being. Visit /healthandwellness for more information. vi Preventive Health Care Unity promotes preventive health care services such as age appropriate physical exams, well-child care, routine Pap tests, mammograms and many others to keep you and your family healthy. Unity has adopted the Preventive Health Care Guideline, based on the US Preventive Task Force, to help you plan routine care visits. This guideline includes recommendations for adults, children and pregnant women. For a copy of the guideline, visit /preventive, send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) What is Medical Management? Unity carefully reviews prior authorization requests and pre-certification notifications which are submitted by participating practitioners. This process of medical management, sometimes called utilization management, is conducted by experienced staff that includes registered and licensed practical nurses with the support of board certified physicians. Medical management staff work with your PCP or your treating provider to coordinate pre-service review (before care or services are delivered), concurrent review (while care or services are being provided) and post-service review (after care or services have been provided) related to your care. Unity works with participating physicians and medical management staff to help ensure decisions regarding treatment are based only on appropriateness of care and service. Unity does not reward practitioners or other individuals involved in the medical management process for issuing denials of coverage or care. Unity does not offer financial incentives or rewards for medical management decision makers to encourage decisions that result in underutilization. What is Complex Case Management? If you have a serious or complicated medical problem, you may qualify for complex case management services. Complex case management is a process in which experienced registered nurses work with both you and your doctor to coordinate, monitor and evaluate the options and services available to best meet your health care needs. Unity s complex case management staff may become involved with you if you experience a critical event or a diagnosis for a complicated problem. Your doctor may refer you to our care team or you may contact us at (888) In addition, you may be referred for case management through Unity s medical management processes, a treating practitioner or by a referral from one of Unity s health management programs.

9 B E I N G A W I S E H E A L T H C A R E C O N S U M E R Member Rights and Responsibilities Unity is committed to maintaining a mutually respectful relationship with our members and practitioners. We have a written policy that states our commitment to respecting your rights and communicates our expectations of your responsibilities including your right to privacy and confidentiality, your right to be treated with respect and dignity and your responsibility to show consideration and respect to health plan staff and health care practitioners. Unity s Member Rights and Responsibilities can be found on page xi. Member Confidentiality and Privacy Policies Unity has policies and procedures to protect the confidentiality of member information in oral, written, and electronic form. Our Confidentiality Committee sets standards for Unity employees as well as external parties, such as practitioners and providers. Unity also has a privacy official who monitors adherence to our policies. The Confidentiality Committee Reviews internal and external requests for member information Identifies opportunities for reducing unnecessary collection of member data Monitors and regulates the use of member data The following is a brief summary about how Unity uses and protects member information. General Policy Unity has policies and procedures designed to safeguard the confidentiality of personally identifiable member information. These policies and procedures establish guidelines for the proper handling of records and information used to administer health plan benefits. When responding to a request for information, Unity s policy is to release only the information necessary to respond to the request. Authorization for Release of Information Unity does not need authorization to obtain or disclose member information for treatment, payment or health care operations. For other purposes, Unity will ask the member to sign an authorization form that gives permission to release the information. Authorization must be obtained when information is to be used for the following purposes Release of information to a family member, power of attorney, employer or lawyer Release of information that could result in another company contacting you for marketing purposes Release of information for research (if the disclosure includes personally identifiable member information) In instances where a member is unable to provide necessary authorization, Unity will require a valid court order or other written proof of legal authority prior to releasing information. Member Access to Medical Records Unity does not maintain original medical records. Members may access their medical records by contacting their practitioner s office or the provider of care, such as a hospital. Members must follow the practitioner s or provider s procedures for accessing medical information. Disclosure of Information to Employers Unity provides certain types of information to employers as part of standard health insurance processes. Disclosure of information to employers is limited to the information the employer needs to administer the health plan and is a summary of the utilization of benefits. There is no individual data provided to the employer. Employers must agree not to use the information to make employmentrelated decisions (for example promoting, hiring, layoff) or to administer other benefit plans (for example, life and disability plans). The employer must identify persons or positions that may have access to the information and must ensure there are measures in place to prevent unauthorized access. vii

10 B E I N G A W I S E H E A L T H C A R E C O N S U M E R Treatment Setting Practitioners and providers are expected to implement confidentiality policies and procedures that address the disclosure of medical information, patient access to medical information, and the storage and protection of medical information. Unity reviews practitioner confidentiality processes during pre-contractual site visits for primary care physicians and certain specialty practitioners. Quality Improvement Data for quality improvement measures is collected from claims, pharmacy records and medical records. Unity protects confidential information by reviewing records in non-public areas and excluding member identifiable information from written reports. Opting Out of Information Sharing or Gathering You may have received notices from other organizations that allow you to opt out of certain disclosures. The most common type of disclosure that applies to opt outs is the disclosure of personal information to a non-affiliated company so that company can market its products or services to you. As a health plan, we must follow many federal and state laws that prohibit us from making these types of disclosures. Because we do not make disclosures that apply to opt outs, it is not necessary for you to complete an opt out form or take any action to restrict such disclosures. Unity s privacy and confidentiality policies protect member privacy and address the following topics Routine use and disclosure of member health information Use of authorizations for non-routine disclosure of member health information Procedures used to monitor access to information Protection of information disclosed to external entities You may access Unity s Notice of Privacy Practices online at /privacy. If you would prefer a printed copy, please call Unity s Privacy Official at (800) , Ext or privacy.official@. Customer Service Unity is committed to member satisfaction. Unity Customer Service can assist you with any questions about your Unity health benefits quickly. Unity Customer Service can be reached by sending a message through the message center within MyChart at unitymychart.com or calling (800) or (608) (TDD / TTY Only). Customer service representatives are available Monday through Friday from 7 a.m. to 7 p.m. (CST). Outside of normal business hours, you may leave a voice mail message including your name, subscriber number, telephone number where you can be reached, and the best time (any time, day or night) for a customer service representative to return your call. Unity monitors and phone messages during normal business hours. Complaint and Grievance Procedures Unity is dedicated to providing quality service for its members. To continuously improve care and service, Unity looks to you for comments or suggestions. There may be a time when you have a complaint or concern regarding Unity benefits or service. As a member, you have the right to voice a complaint or appeal a decision made by Unity and to receive a prompt and fair review. If you have a complaint you would like addressed, please send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) A customer service representative will investigate your complaint. If you disagree with the outcome of the investigation, you will be notified of your right to file a formal written grievance to be reviewed by Unity s Reconsideration Committee. viii

11 B E I N G A W I S E H E A L T H C A R E C O N S U M E R You can direct your written grievance or appeal to Member Advocate Unity Health Insurance 840 Carolina Street Sauk City, WI Unity will notify you of our determination within 30 calendar days from the date we received your grievance. If additional review is necessary, we will resolve the matter within 30 additional days. If you disagree with the final determination of the Reconsideration Committee you may be entitled to request an independent, external review of our decision. You can file an external review electronically by going to or by fax to (888) or by sending it by mail to HH Federal Services, 3750 Monroe Ave., Suite 705, Pittsford, NY If your claim is not eligible for independent external review but you still disagree with the denial, your state insurance regulator may be able to help to resolve the dispute. For questions about your rights or for assistance, you can contact Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI or, if coverage is group health plan coverage, contact the Employee Benefits Security Administration at (866) 444-EBSA (3272). For more information about your appeal rights, you can visit /appeals. Accessing Emergency and Urgent Care Emergency Care Services If you have a life-threatening medical situation, call 911 or go directly to the nearest medical facility. You should notify your PCP so he / she can help you coordinate any follow-up services. Urgent Care Services Some medical problems are not life threatening but do need prompt attention. If you believe you need urgent care, contact your primary care clinic first, even after hours. Your primary care clinic will tell you how to get appropriate care. You must notify Unity of any urgent care treatment from a non-participating provider within three business days. Follow-up care after you receive the initial treatment for the urgent or emergent condition is not considered urgent or emergency care. You should work with your PCP to arrange your follow-up care and it must be provided within the Unity service area. (If you are a POS member, please refer to page iii.) You may have some out-of-pocket expenses if you use an emergency room or urgent care facility. Refer to your Schedule of Benefits or Summary of Benefits and Coverage, or Certificate of Coverage, or send a message to Unity Customer Service through the message center within MyChart at unitymychart.com or call (800) for more information. ix

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13 M E M B E R R I G H T S A N D R E S P O N S I B I L I T I E S Take a moment to review your Member Rights and Responsibilities so that you can continue to take an active role in managing your family s health care Member Rights To choose Members have the right to choose a personal physician from Unity s network of Primary Care Physicians (PCPs). To obtain information Members have the right to receive information about their rights and responsibilities as a member of Unity. Members have the right to make recommendations regarding Unity s Member Rights and Responsibilities Statement. Members have the right to obtain information about Unity and information relating to covered and excluded health plan benefits. Members also have the right to obtain information on available primary and specialty care practitioners and providers. Members have the right to receive preventive care information and information about their illnesses and treatment options. Members have the right to obtain information about how to file a complaint, appeal or grievance. To have privacy and confidentiality Members have the right to privacy and confidentiality in communications and records about their care. To participate in their care Members have the right to be active in decisions about their treatments. Members have the right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. Members have the right to obtain information about the risks and benefits of treatment. Members also have the right to refuse care. To present a complaint, appeal or grievance Members have the right to voice concerns and to receive a prompt and fair review of their concerns. 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. Member Responsibilities To choose a personal physician Members have a responsibility to choose a personal physician from among Unity s network of PCPs and to establish a relationship with that physician. To know their benefits and requirements Members have a responsibility to understand their health plan benefits and limitations and to follow required procedures. Members also have a responsibility to know how to use Unity s provider network and to ask questions about things they do not understand. To provide accurate information Members have a responsibility to provide accurate and complete information about their health history, their eligibility and their enrollment. Members have a responsibility to show their ID card each time they receive services and to pay any out-of-pocket expenses they incur. To participate in their care Members have a responsibility to participate in their care by asking questions about their health. Members also have a responsibility to follow the recommended and agreed upon treatment plan for their illness, and to make healthy lifestyle choices to maintain their health or manage their 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 plan staff and health care providers. xi