Self-Funded Provider Manual Section 3 Member Eligibility and Benefits Determination Product Descriptions Drug Benefits and Formulary

Transcription

1 Self-Funded Provider Manual Section 3 Member Eligibility and Benefits Product Descriptions Drug Benefits and Formulary Self-Funded Provider Manual 1

2 Table of Contents SECTION 3: ELIGIBILITY AND BENEFITS DETERMINATION SELF-FUNDED PRODUCTS Exclusive Provider Organization (EPO) Point of Service (POS) - Two-Tier Point of Service (POS) Three Tier Out of Area Preferred Provider Organization (PPO) SELF-FUNDED IDENTIFICATION CARDS Colorado Denver/Boulder Colorado - Southern Colorado ELIGIBILITY AND BENEFIT VERIFICATION BENEFIT EXCLUSIONS AND LIMITATIONS DRUG BENEFITS RETROACTIVE ELIGIBILITY CHANGES VISITING MEMBERS... 9 Self-Funded Provider Manual 2

3 Section 3: Eligibility and Benefits 3.1 Self-Funded Products is offering Self-Funded products, administered by KPIC, including Self-Funded Exclusive Provider Organization, Self-Funded Point-of-Service, and Self- Funded Preferred Provider Organization Exclusive Provider Organization (EPO) Mirrors our HMO product, offered on a Self-Funded basis Self-Funded EPO Members choose a primary care Provider and receive care at or plan medical facilities Self-Funded EPO Members are covered for non-emergent care only at designated plan medical facilities and from designated plan practitioners (unless referred by a KP primary care Provider) Point of Service (POS) - Two-Tier Tier 1 is the EPO Provider network Tier 2 is comprised of all other providers Self-Funded Members incur greater out-of-pocket expenses in the form of higher copayments, coinsurance and/or deductibles when they use Tier 2 benefits Point of Service (POS) Three Tier Tier 1 is the EPO Provider network Tier 2 is comprised of our contracted PPO network Providers. Tier 3 includes non-contracted providers Self-Funded Members incur greater out-of-pocket expenses in the form of higher copayments, coinsurance and/or deductibles when they self-refer to a contracted PPO network Provider (Tier 2) Generally, the out-of-pocket costs will be highest for self-referred services received from non-contracted Providers (Tier 3) 3.1.4Out of Area Preferred Provider Organization (PPO) At this time, of Colorado does not offer a self-funded PPO. 3.2 Self-Funded Identification Cards Self-funded members will be issued ID cards, which differ in appearance from other ID cards. Self-funded ID cards are green. Self-funded members should bring their ID card and photo ID when they seek medical care. Please verify photo ID prior to rendering care. Self-Funded Provider Manual 3

4 Each self-funded member is assigned a unique Health/Medical Record number, which is used to verify eligibility, benefit and medical information. Every self-funded member receives an ID card that shows his or her unique number. The card is for identification only and does not give a self-funded member rights to services or other benefits unless he or she is eligible. Examples of self-funded cards are shown below. Please note the actual card may vary slightly from the images shown Colorado Denver/Boulder EPO CARD POS CARD PPO CARD Self-Funded Provider Manual 4

5 3.2.2 Colorado - Southern Colorado EPO CARD POS CARD PPO CARD Self-Funded Provider Manual 5

6 3.3 Eligibility and Benefit Verification You can verify a self-funded member s benefits and eligibility online via the Harrington Health Web site or by calling Self-Funded Customer Service at You may also verify via KP Online -Affiliate. You are responsible for verifying Self-Funded members eligibility and benefits. Each time a Self-Funded Member presents at your office for services, you should: Verify the patient s current eligibility status Verify covered benefits Obtain necessary authorizations (if applicable) Do not assume that coverage is in effect because a person has a member ID card. Please check a form of photo identification to verify the identity of the Health Plan Member. You must verify that the member has coverage for the service prior to providing such service to a member. Certain services require prior authorization. This manual provides further details on the process for obtaining referrals and authorizations. Contact Self-Funded Customer Service at or through one of the methods detailed below to verify the validity of the Self-Funded ID card/number and benefits. Otherwise, you provide services at your own financial risk. Option Description #1 Affiliate Link If you have electronic access to our systems. You can view referrals, demographic information, and look up eligibility/benefits for Kaiser Permanente Self-Funded members anytime, 24 hours a day, seven days a week. To request internet access to our systems, please contact your Provider Relations Representative. The Self-Funded Member information is in a secured site, for which you need a user ID number and a password. You will be given a packet detailing the requirements for obtaining a user ID and password. Once your password is obtained, we will forward you a user guide with instructions. Due to HIPAA regulations, you must keep your office s user information current. User ID and passwords are unique. New staff members are required to obtain their own unique user ID s and passwords. #2 Harrington Health Website Self-Funded Provider Manual 6

7 Option Description Self-Funded Provider Manual hours / 7 days a week To verify Self-Funded Member eligibility, benefit, and claims information for Self-Funded Members #3 Self-Funded Customer Service Department Telephone Monday - Friday from 5 A.M. to 7 P.M. Eastern Time Zone (MT). To verify Self-Funded Member eligibility, benefits or PCP assignment, you may speak with a customer service representative by calling the Self-Funded Customer Service Line at Please provide the Self-Funded Member s name and Self-Funded ID card number, inclusive of suffix, which is located on the Self-Funded ID card. 3.4 Benefit Exclusions and Limitations Self-Funded benefit plans may be subject to limitations and exclusions. It is important to verify the availability of benefits for services before rendering the service so the Self- Funded Member can be informed of any potential payment responsibility. Contact Self-Funded Customer Service to verify and obtain information on Self-Funded Member benefits at If you provide services to a Self-Funded Member and the service is not a benefit or the benefit has been exhausted, denied or not authorized, the Plan Sponsor will not be obligated to pay for those services. 3.5 Drug Benefits The drug benefits, drug formulary and the process for a formulary exception may vary based on the benefit plan. To verify a Self-Funded Member s drug benefit, to obtain our drug formulary, or for general questions, please contact the Self-Funded Customer Service at The formulary is available on the provider Website: Self Funded Members may receive medications for their prescription drug benefit provided the medication is on the Drug Formulary (A copy has been provided with this manual), and the plan sponsor offers a drug benefit. Providers should instruct members to obtain their prescriptions from a pharmacy or

8 participating network pharmacy in order for them to receive them under their prescription benefit. A list of participating pharmacies can be found at Providers may call the prescription into a or participating network pharmacy Kaiser encourages the use of generic medications when available and appropriate. However, in some circumstances, a patient may need the brand name drug. If a patient is in need of a brand name drug, in which we normally cover the generic, or a drug that is not currently on our formulary, the drug may be reviewed for medical necessity under the formulary exception process. If approved, the drug would then be covered for the members applicable prescription drug benefit. Non formulary request for medical necessity are reviewed by Health Plan which includes the final determination being made by a physician. Request for a formulary exception can be directed to. When formulary exceptions are not approved, the patient has the option of paying full price for the non- formulary drug. The patient can also request an appeal to the decision by calling the Pharmacy Benefit Manager, Innoviant at In addition the Drug Formulary may have quantity limits on certain medications as well as drugs that are restricted to certain prescribing providers. This information is included in the Drug Formulary. 3.6 Retroactive Eligibility Changes If you have received payment on a claim(s) that is impacted by a retroactive eligibility change, a claims adjustment will be made. The reason for the claims adjustment will be reflected on the remittance advice. If you provide services to a Member and the service is not a benefit, or the benefit has been exhausted, denied or not authorized, you do so at your own financial risk. A Plan Sponsor may determine retroactively that a person was not eligible for coverage on the date of service. The applicable Payor is not responsible to pay for services in that case, but if you obtained a financial responsibility form from the person, you may bill the person directly for the services. If you have already received payment for the services, the applicable Payor will notify you of the adjustment. Member eligibility may change retroactively in the following conditions: A Plan Sponsor receives delayed information, e.g., from Self-Funded member, that a former spouse is no longer entitled to health care benefits under the employee s coverage. Self-Funded Provider Manual 8

9 The individual has been terminated. The Self-Funded member decides not to purchase continuation coverage The eligibility information received by Plan Sponsor is later determined to be false. If you have received payment on a claim(s) that is impacted by a retroactive eligibility change, a claim adjustment will be made. The reason for the claim adjustment will be reflected on the remittance advice. 3.7 Visiting Members offers a Visiting Member Program to ensure that Members can receive a variety of health care services when temporarily visiting another Kaiser Permanente Region. Visiting Members are directed to seek health care services at the nearest Medical Office and contracted facilities/hospitals. If a Permanente Medical Group physician needs to refer a Visiting Member to a Participating Provider, you will receive an authorization letter explaining the start and end dates of the referral and a description of the authorized services. The Member's home region health or medical record number must be included with the claim submission. To obtain the home region health or medical record number, please refer to the member s ID card or contact the Customer Service Department at Claims should be submitted to the Insurance Company claims department. KPIC - SF Claims Administration P.O. Box Salt Lake City, UT Self-Funded Provider Manual 9