Please remember any vision problems, which are medical in nature (i.e. cataracts) are handled as medical referrals.

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2 A. VISION PROGRAMS January 1, 2005, Cole Managed Vision was selected by HealthAmerica, HealthAssurance, and Advantra to administer our vision care benefits and can be reached by calling Effective January 1, 2008, Cole Managed Vision Care has a name change to EyeMed Vision Care. EyeMed Vision Care phone number is: Website: Below is a description of our vision programs. HealthAmerica Optometry Rider These members may have a co-payment for an annual routine eye exam and also may have an allowance towards the purchase of eyewear. Members must use a participating provider. Vision benefits and services did not change as a result of the name change. It is the same vendor but with a larger network. HealthAssurance Optometry Rider Members with this rider may have a co-payment for their annual exam and may have an allowance towards the purchase of eyewear. In order to utilize the full benefit the members must see a participating provider. We recognize that PPO, POS, and PHCS PPO members might choose to use out-of-network benefits for examinations and/or corrective materials. These members will pay more for using out-ofnetwork providers. To obtain out-of-network benefits, eligible members will need to submit an itemized bill with the non-par claim form to the address listed on the claim form: The claim form can be obtained by visiting our website, at and using the link. If you have any questions regarding the routine vision benefits for a HealthAmerica and HealthAssurance members, please call the Customer Service Organization. Please remember any vision problems, which are medical in nature (i.e. cataracts) are handled as medical referrals. EyeMed s One Eyecare Program is a value-added service that is offered to all members of HealthAmerica and HealthAssurance for no additional charge. Members are able to receive a discount on vision services if the services are rendered by a participating EyeMed provider. EyeMed s One Eyecare Program offers immediate savings on eye care needs including discounts on frames, lenses, conventional contacts, and even LASIK surgery at participating providers through the Eyemed network. The EyeMed Vision Care network includes Sears Optical, participating Pearle Vision locations, LensCrafters (effective 1/1/08) Target Optical, JCPenney Optical, and many independent doctors of optometry. Members don t need a Cole s Discount ID card to receive the benefit but, if they would like a copy please refer them to our website to print one out. All that a member needs to do to receive the program discounts is to show his/her HealthAmerica or HealthAssurance ID card to the participating EyeMed provider. Refer to Advantra Section for Vision Guidelines for Advantra Members. 2

3 B. CHIROPRACTIC SERVICES Effective January 1, 2006 No longer affiliated with ASHN. No treatment plans required. Members may self-refer. No referral or pre-authorization is required for Chiropractic Services. Pre-authorization is required for Physical Therapy Services for HMO members. (Please use the Therapy Progress Summary Worksheet found on page 8 of this section) Contact the Customer Service Department to confirm members benefit. Refer to Chiropractors contract for appropriate CPT codes. Advantra coverage limited to Chiropractic Manipulative Treatment using CPT codes 98940, and Claim editing software may apply.

4 C. Physical Therapy Coverages: HMO: 15 visits per condition, per contract year or an unlimited number of visits provided within 60 consecutive days per condition, per contract year. Contact the Authorizations Department for Pre-authorization. CCPPO and PPO: Benefits will vary according to plan. Pre-authorization is not required. Contact the Customer Service Department to determine eligibility. Subject to Benefit limits/exclusions. Surgery is considered a new condition and constitutes a new benefit period. **Therapy services for HMO members must be pre-authorized. The ordering physician or therapy office can request the authorization. Services must be administered by a participating provider. Physical Therapy services shall be reimbursed on a per visit basis. The per-visit reimbursement will be associated with code Initial Evaluation will be reimbursed an additional amount utilizing code when billed along with All claims should be submitted on a HCFA 1500 form and need to reflect CPT Code in addition to each modality performed per visit. Occupational Therapy services shall be reimbursed on a per visit basis. The per-visit reimbursement will be associated with code Initial Evaluation will be reimbursed an additional amount utilizing code when billed along with All claims should be submitted on a HCFA 1500 form and need to reflect CPT Code in addition to each modality performed per visit. Speech Therapy services shall be reimbursed on a per visit basis. The per-visit reimbursement will be associated with code In the event the provider's billed charges are less than the per visit rate, MCO shall reimburse the provider at billed charges. Follow the above billing guidelines unless your contract states otherwise.

5 Please read the information about MHNet Behavioral Health on the next page.

6 Effective September 1, 2008 D. BEHAVIORAL HEALTH SERVICES / MENTAL HEALTH / SUBSTANCE ABUSE MHNet Behavioral Health (MHNet) is managing the mental health / substance abuse benefits for all products. Have the member contact MHNet prior to initiating behavioral health services to discuss pre-authorization, provider selection and benefit information. Physicians may contact MHNet with treatment or referral recommendations. The Mental Health Provider (MHP) is responsible for obtaining a release of information from the member, after which, the physician will be kept apprised of the member s status and progress during treatment. MHNet will assist the physician in obtaining consultation regarding behavioral health issues. MHNet is available 24 hours a day, seven (7) days a week for emergencies by calling or during normal business hours, Monday through Friday, 8:00 AM to 5:00 PM EST, for routine referrals to a provider. MHNet Mailing Address MHNet Mailing Address For Clinical Operations: For Claims Submissions: MHNet - HAPA MHNet 1211 State Road 436, Suite 355 P.O. Box Casselberry, FL Austin, TX Phone: Phone:

7 E. LABORATORY SERVICES HealthAmerica, HealthAssurance and Advantra LABORATORY POLICY 1. If you collect laboratory specimens in your office, these samples should be directed to a participating laboratory for analysis. Quest Diagnostics, LabCorp or HealthNetwork must be utilized for all laboratory services. 2. Effective June 15, 2006, HealthAmerica expanded the number of lab tests for which physicians will be reimbursed when performed in the provider office to include all current CLIA-waived codes. Please reference the attached list of codes. If your contract with HealthAmerica does not include reimbursement for the CLIA-waived codes on the enclosed list please contact your HealthAmerica representative to discuss adding these codes to your HealthAmerica contract 3. Reimbursement will not be made for any lab test performed in a physician s office which is not listed on the attached table, and the member must be held harmless, in accordance with existing provider contracts. Instead, the physician should continue to use the currently contracted HealthAmerica and HealthAssurance laboratory providers for all other labs. 4. Pre- and post-operative testing should be performed at the hospital facility where the procedure will take place and does not require pre-authorization.

8 CLIA-Waived and Current HealthAmerica Stat Lab Codes Code Description G0107 CA screen; fecal blood test Electrolyte panel Lipid panel Drug screen, single Assay of lithium Urinalysis, nonauto w/scope Urinalysis, auto w/scope Urinalysis nonauto w/o scope Urinalysis, auto, w/o scope Urine screen for bacteria Microscopic exam of urine Urine pregnancy test Acetone assay Microalbumin, semiquant Assay of ethanol Occult blood, other sources Occult blood, feces, single Blood occult peroxidase Assay test for blood, fecal Assay, bld/serum cholesterol Collagen crosslinks Assay of creatinine Assay of urine creatinine Assay of estrone Assay, glucose, blood quant Reagent strip/blood glucose Glucose test Glucose tolerance test (GTT) GTT-added samples Glucose blood test Glycated protein Gonadotropin (FSH) Gonadotropin (LH) Helicobacter pylori breath test Helicobacter pylori drug test Hemoglobin, copper sulfate Glycosylated hemoglobin test Glycosylated hb, home device Immunoassay, dipstick Assay of lactic acid Assay of lipoprotein Assay of blood lipoprotein Natriuretic peptide

9 Code Description Assay of body fluid acidity Assay thyroid stim hormone Transferase (AST) (SGOT) Alanine amino (ALT) (SGPT) Assay of triglycerides Assay of urea nitrogen Chorionic gonadotropin assay Ovulation tests Automated diff wbc count Bl smear w/diff wbc count Spun microhematocrit Hematocrit Hemoglobin Complete cbc w/auto diff wbc Complete cbc, automated Manual cell count, each Blood smear, peripheral, interpretation Bone Marrow, smear interpretation Blood platelet aggregation Prothrombin time Prothrombin time, sub, plasma fractions Rbc sed rate, nonautomated Thromboplastin time, partial Immunoassay, tumor, qual Heterophile antibodies Immunoassay,infectious agent Particle agglutination test Skin test, tuberculosis, intradermal Lyme disease antibody HIV HIV-1/HIV-2, single assay Culture aerobic identify Culture screen only Smear, gram stain Smear, wet mount, saline/ink Tissue exam for fungi Strep a ag, eia Ag detect nos, eia, mult Candida, dna, dir probe Garnerella vaginalis, amplified probe

10 Code Description Infectious agent detection by DNA RNA Influenza assay w/optic Rsv assay w/optic Strep a assay w/optic Cytopathology, evaluation of fin needle aspirate Cytopathology, evaluation of fin needle aspirate interpretation Complex prep Semen analysis w/huhner Evaluation, cervical mucus Bolded is the list of lab procedures which can be performed in your office according to current lab policy. All remaining codes are the CLIA-waived codes. Please refer to number two above.

11 F. RADIOLOGY To ensure our radiology program continues to reinforce quality practice standards and manage costs in a fair and consistent manner, HealthAmerica has entered into an agreement with National Imaging Associates, Inc. (NIA), an affiliate of Magellan Health Services. Under the agreement between HealthAmerica and NIA, HealthAmerica will continue to be responsible for claims adjudication and medical protocols. NIA will manage the prior authorization of non-emergent, high-tech, outpatient radiology services. The agreement is effective December 1, The agreement with NIA is consistent with industry-wide efforts to coordinate the increasing utilization of these services and to ensure quality care for our members. NIA is NCQA and URAC accredited and offers our participating providers a program that supports standard protocols and offers the expertise of peer radiologists. Prior authorization will be required for the following outpatient radiology procedures: CT / CTA MRI / MRA CCTA Nuclear Cardiology PET Scan Nuclear Stress (MPI) Echo Stress Diagnostic Nuclear Medicine Prior Authorization guidelines will be posted under the Pre-Authorization Requirements section of our website and at Key Provisions: Emergency room, observation and inpatient imaging procedures do not require authorization. The ordering physician must obtain authorization. Failure to verify that affected services have been preauthorized may result in nonpayment of your claim. All other procedures requiring authorizations will be managed by HealthAmerica s Pre- Authorization Department. Providers have three options for requesting authorizations. Phone: The toll free pre-authorization phone number is If the authorization request is for a procedure managed by NIA, your call will be transferred to NIA. Online requests: If the procedure you are requesting is one of the procedures listed above as managed by NIA you should send your requests through If the procedure you are requesting is not managed by NIA, you should send your requests through Faxes: If the procedure you are requesting is one of the procedures listed above as managed by NIA, you can not fax your request. NIA does not accept faxes. If the procedure you are requesting is not managed by NIA you may fax your request to HealthAmerica at the following fax number. The toll free pre-authorization fax number is

12 NIA Privileging Providers who perform the following services in their office, must submit a Coventry Privileging Application so they can authorize and reimbursed for the services. CT / CTA MRI / MRA CCTA Nuclear Cardiology PET Scan Nuclear Stress (MPI) Echo Stress Diagnostic Nuclear Medicine To access the online application: Direct your web browser to Click on the link for Coventry Privileging Application (located under Online Tools) Enter your login and click login. NIA will manage the prior authorization of non-emergent, high-tech, outpatient radiology services. The following Claim Matrix lists all procedure codes managed by NIA.

13 Claim Resolution Matrix 2010 HealthAmerica The matrix below contains all of the CPT-4 codes for which National Imaging Associates (NIA) authorizes on behalf of HealthAmerica. This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those services authorized by NIA. If an exam is billed under any one of the given codes for that grouping and a valid authorization number has been issued within the date of service validity period, the charge for any of the codes should be allowed. If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. If the exact match does not occur, the charge should be adjudicated accordingly. *Please Note: Services rendered in an Emergency room, Observation Room, Surgery Center, Urgent Care or Hospital Inpatient setting are not managed by NIA. Authorized CPT Description Allowable Billed Groupings Code MRI Temporomandibular Joint CT Head/Brain 70450, 70460, CT Orbit 70480, 70481, CT Maxillofacial/Sinus 70486, 70487, 70488, CT Soft Tissue Neck 70490, 70491, CT Angiography, Head CT Angiography, Neck MRI Orbit, Face, and/or Neck 70540, 70542, MRI Internal Auditory Canal 70551, 70552, 70553, 70540, 70542, MRA Head 70544, 70545, MRA Neck 70547, 70548, MRI Brain 70551, 70552, Functional MRI Brain 70554, CT Chest 71250, 71260, CT Angiography, Chest (non coronary) 71275

14 71550 MRI Chest 71550, 71551, MRA Chest (excluding myocardium) CT Cervical Spine 72125, 72126, CT Thoracic Spine 72128, 72129, CT Lumbar Spine 72131, 72132, MRI Cervical Spine 72141, 72142, MRI Thoracic Spine 72146, 72147, MRI Lumbar Spine 72148, 72149, MRA Spinal Canal CT Angiography, Pelvis CT Pelvis 72192, 72193, MRI Pelvis 72195, 72196, MRA Pelvis CT Upper Extremity 73200, 73201, CT Angiography, Upper Extremity MRI Upper Extremity, other than Joint 73218, 73219, MRI Upper Extremity Joint 73221, 73222, MRA Upper Extremity CT Lower Extremity 73700, 73701, CT Angiography, Lower Extremity MRI Lower Extremity, other than Joint 73718, 73719, 73720, 73721, 73722, MRI Lower Extremity Joint 73721, 73722, 73723, 73718, 73719, MRI Hip 72195, 72196, 72197, 73721, 73722, MRA Lower Extremity CT Abdomen 74150, 74160, CT Angiography, Abdomen MRI Abdomen 74181, 74182, 74183, S MRA Abdomen Diagnostic CT Colonoscopy (Virtual 74261, Colonoscopy, CT Colonography) MRI Heart 75557, 75559, 75561, 75563, Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT CT Heart CT Heart congenital studies, non-coronary arteries , S CTA coronary arteries (CCTA) CT Angiography, Abdominal Arteries Follow Up, Limited or Localized CT 76380, 70486, 70487, Unlisted Computed Tomography Procedure Unlisted Magnetic Resonance Procedure MRI Breast 77058, CT Bone Density Studies 77078, MRI Bone Marrow Liver SPECT Imaging 78205, Bone and/or Joint SPECT Imaging Myocardial Perfusion Imaging Nuclear Cardiology 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481, 78483, 78494, PET Scan, Heart 78459, 78491, MUGA Scan 78472, 78473, Brain SPECT Imaging 78607

15 78608 PET Scan, Brain 78608, Cerebrospinal Fluid Flow Imaging (SPECT) Kidney SPECT Imaging PET Scan 78811, 78812, 78813, 78814, 78815, PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization , 78812, 78813, 78814, 78815, Stress Echocardiography 93350, 93351, T CAD Breast MRI for Lesion Detection 0159T G0235 PET imaging, any site, not otherwise specified G0235 S8037 MR Cholangiopancreatography S8037, 74181, 74182, S8042 MRI low field S8042