Health Net Federal Services. Preferred Provider Network Provider Manual

Transcription

1 Health Net Federal Services Preferred Provider Network Provider Manual March 2015

2 Contents Overview...3 Provider Tools...5 Address Change Or Other Practice Information Online Network Provider Directory... 6 Provider Updates... 6 Contact Information...6 Contact Us... 6 Important Provider Information...7 General Administrative Requirements... 7 Fraud, Waste And Abuse... 7 Beneficiary Identification (ID) Card... 9 Covered Services... 9 Credentialing Delegation Prior Authorization And Referral...14 Prior Authorization And Notification Referrals Claims Procedures...15 Claims Submission Claims Ajudication Claims Adjustment Procedures Timely Filing Criteria Reimbursement Office Procedures...19 Medical Records Clinical Information Submission Provider Inquries...20 Grievances And Appeals/Disputes...21 Grievances Appeals/Disputes Contractual Disputes Health Care Management And Administration...23 Utilization Management Case Management Clinical Quality Management Discharge Planning Policy on Separation of Medical Decisions and Financial Concerns Rights And Responsibilities...25 Beneficiary Rights And Responsibilities Index...27 Page 2 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

3 Overview About Preferred Provider Network: Health Net Federal Services, LLC develops and maintains preferred provider products to serve multiple governmental program populations through PPO style networks of providers who agree to offer medical and behavioral health services at competitive reimbursement rates. Vital to our success, MHN (Health Net s behavioral health company), develops and maintains the behavioral health network. The Health Net Preferred Provider Network (PPN) is comprised of those hospitals, physicians, physician organizations, other health care providers, suppliers, and other organizations that have met Health Net credentialing and recredentialing requirements and are participating through an executed Provider Participation Agreement (PPA). About Health Net Federal Services, LLC: Health Net Federal Services, LLC is the government operations division of Health Net, Inc. Health Net Federal Services has a 25-year history with government and military health care programs for the Departments of Defense (DoD) and a 15-year history with the Department of Veterans Affairs (VA). Health Net Federal Services has supported and managed federal contracts since About Health Net, Inc.: Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and governmentsponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as Part D ), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Through its subsidiaries, Health Net also offers behavioral health, substance abuse and employee assistance programs, managed health care products related to prescription drugs, managed health care product coordination for multi-region employers, and administrative services for medical groups and self-funded benefits programs. For more information on Health Net, Inc., please visit Health Net s website at Your PPA is between Health Net Federal Services, on behalf of itself and the subsidiaries and affiliates of Health Net, Inc. (collectively, Health Net ) and you. Purpose of this Manual: Health Net s PPN Provider Manual is an extension of the PPA between Health Net and Preferred Provider Network and all provider types including, but not limited to, physicians, hospitals, and ancillary health care provider ( provider(s) ) and furnishes such providers and their office staff with information concerning policies and procedures, claims, and guidelines used to administer Health Net programs. This manual replaces and supersedes the previous version and is available at Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 3 of 27

4 In accordance with the Health Net Policies clause of the PPA, providers must abide by all provisions contained in this manual, as applicable. Revisions to this manual constitute revisions to Health Net s policies, procedures, and programs. Revisions become binding thirty (30) days after notice is posted on (or provided by electronic means), or such other period of time as necessary for Health Net to comply with any statutory, regulatory and/or accreditation requirements. If a provision in this PPN Manual conflicts with Federal, state or municipal law or terms of your PPA, the applicable law or your PPA will control. The terms of this PPN Manual may be modified at the sole discretion of Health Net. Responsibility for Provision of Services: Network providers are independent contractors. Providers and Health Net do not have an employer-employee, principalagent, partnership, joint venture, or similar arrangement. Providers make all independent health care treatment decisions and are responsible for the costs, damages, claims, and liabilities that result from their own actions. Health Net does not endorse or control the clinical judgment or treatment recommendations made by providers and not all services are contracted or covered services. Please refer to the benefit program requirements section for what are contracted and covered services under programs applicable to you. are provided. Health Net s prior authorization determination relates solely to payment by Health Net. Health Net Products: Health Net offers a variety of preferred provider products through its Preferred Provider Network to serve multiple government programs; however, not all programs are available in all markets. Visit periodically, to keep yourself abreast of updates on programs available to you. QUESTIONS OR COMMENTS: Questions, comments, or suggestions regarding this manual or its contents should be directed to: Health Net Federal Services, LLC Provider Network Management Department P.O. Box Atlanta GA Fax: [email protected] Health Net sometimes requires prior authorization with respect to some services and procedures. Health Net does this solely for the purpose of determining whether the services or procedures qualify for payment under the patient s benefit program. Providers, along with the patient, make the decision whether the services or procedures Page 4 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

5 Provider Tools Address Change or Other Practice Information In order for Health Net to maintain accurate network provider directories and also for reimbursement purposes, all changes to address or other practice information should be submitted electronically via com. Notices of any changes must adhere to time frames outlined in the Provider Participation Agreement (PPA). Changes that require notice to Health Net may include, but are not limited to, the following: Provider information Tax identification number National Provider Indicator (NPI) Address Phone number Practice name Adding a provider provider joining practice/group Provider deletions provider no longer participating with the practice/group Medicare numbers You can update your demographics using the Provider Demographic Update Form located at The updated form can be submitted by fax or ed to: Health Net Federal Services, LLC ATTN: Provider Network Management Fax: [email protected] Note: Changes to your Tax Identification Number or group name also require submission of an updated Form W-9 by fax to For network practices adding a provider who has not been credentialed by Health Net, the new provider must send in a Provider Information Form (PIF) to ensure they are credentialed by Health Net and all data is current and accurate. For your convenience, a PIF can be downloaded from com. In addition, providers must have all information current with the Council for Affordable Quality Healthcare (CAQH ). If you are adding a provider who has been credentialed by Health Net within the last three years, send us the provider s information by filling out a Provider Demographic Update Form and submitting your request, cover letter on your letterhead, by fax to Health Net requires that all network providers be recredentialed by Health Net every three years. The Health Net Federal Services website at provides information about PPN benefits, processes, requirements and operations, as well as access to business tools. Visit the VA provider section of to: View the Health Net PPN Provider Handbook Download forms Read important updates about PPN programs and Health Net processes 1 Changes in tax ID numbers may require an amendment or new participation agreement depending on the reason for the change. Visit for specific information. 2 If adding a provider, the new provider must first be credentialed before rendering treatment to any beneficiary. Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 5 of 27

6 Online Network Provider Directory An online network provider directory may be available on the Health Net website at which would include: Location Provider name Provider type Provider specialty Gender Office phone number Office Fax number Additional language(s) It is important that network providers keep demographic information up to date to ensure Health Net provides accurate information to program beneficiaries and other providers. Network providers are strongly encouraged to visit the online network provider directory to confirm individual listings are accurate. If you are a network provider and you are not listed in the network provider directory and you wish to be listed, please Provider Network Management at [email protected]. Provider Updates To keep providers current about PPN programs, products, policies, and procedures, Health Net s website, includes up-to-date information about important program benefits, updates, and other topics. Health Net encourages providers to visit often for the latest PPN program information. Contact Information Contact Us Health Net Federal Services Provider Relations ATTN: Provider Network Management Fax: [email protected] Fraud, Waste and Abuse: Health Net Fraud Hotline: Most, but not all, network providers are listed in the directory. Emergency room physicians, urgent care physicians, and other hospital-based providers may not be listed. Information in the network provider directory is subject to change without notice. Before choosing a network provider, beneficiaries are encouraged to call and confirm the provider is accepting new patients. Page 6 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

7 Important Provider Information Network providers must abide by the rules, procedures, policies and program requirements specified in this PPN Provider Manual and its updates, which summarize regulations and requirements related to PPN products programs. For more information, visit General Administrative Requirements Office and Appointment Access Standards: Network providers must ensure beneficiaries receive timely care within a reasonable distance from their homes. Emergency services must be available 24 hours a day, seven days a week. Providers must adhere to the following access standards for nonemergency care: urgent care or acute illness appointment 24 hours routine care appointment one week (seven calendar days) and within 30 minutes travel time of the beneficiary s residence Note: A routine care appointment applies to a treatment request for a new health condition or exacerbation of a previous diagnosed condition for which intervention is required, but is not urgent. specialty care appointment four weeks (28 calendar days) and within one hour travel time from the beneficiary s residence preventive care appointment four weeks (28 calendar days) Initial behavioral health care appointment with a behavioral health care provider one week (seven calendar days) Response to urgent calls within 15 minutes Response to routine calls within the same business day After hours, non-urgent response in 30 minutes Office wait times for non-emergency care appointments should not exceed 30 minutes except when the provider s normal appointment schedule is interrupted due to an emergency. If running behind schedule, notify the patient of the cause and anticipated length of the delay and offer to reschedule the appointment. The patient may choose to keep the scheduled appointment or reschedule for a future date or time. Health Net may monitor compliance with the access standards through a variety of ways including telephone survey, surveys, and beneficiary surveys and complaints. Note: State regulations will apply when more stringent than these time frames. Fraud, Waste and Abuse Fraud, Waste and Abuse Policy: Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment. Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary. Health Net s Program Integrity Department is dedicated to combating health care fraud and abuse committed against PPN programs. In addition, all Health Net associates are trained and responsible for reporting any potential or actual fraud and abuse incidents. Each report of potential fraud or abuse goes through an exhaustive review process. Cases in which there is clear evidence of intent to defraud or serious issues concerning quality of patient care are referred to the government Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 7 of 27

8 for further investigation and possible prosecution. In order to detect and act upon fraud or abuse incident, Health Net: Formed a dedicated Program Integrity Department and a Special Investigations Unit. Implemented state of the art fraud detection software. Requires all Health Net associates complete fraud and abuse training. Follows reporting procedures required by the government. Some examples of fraud include: Billing for costs of non-covered or nonchargeable services, supplies, or equipment disguised as covered items Billing for services, supplies or equipment not furnished, necessary, or at a higher level to the beneficiary Billing the claim for an M.D. when it was a P.A. or N.P. delivering the services Duplicate billings (e.g., billing more than once for the same service, billing the payor and the beneficiary for the same services, submitting claims to both the payor and other third parties without making full disclosure of relevant facts or immediate full refunds in the case of overpayment by the government payor) Misrepresentations of dates, frequency, duration, description of services rendered, or the identity of the recipient of the service or who provided the service Practicing with an expired, revoked or restricted license in any state or U.S. territory services furnished by another provider or furnished by the billing provider in a capacity other than billed or claimed) Violation of the PPA that results in the beneficiary being billed for amounts that exceed the government program allowable charge or cost Falsifying eligibility Examples of abuse include: Pattern of waiving coinsurance/deductible Failure to maintain adequate medical or financial records A pattern of claims for services not medically necessary Refusal to furnish or allow access to medical records Improper billing practices Providers are cautioned that unbundling, fragmenting or code gaming to manipulate the CPT codes as a means of increasing reimbursement is considered an improper billing practice and a misrepresentation of the services rendered. Such practices can be considered fraudulent and abusive. Fraudulent actions can result in criminal or civil penalties. Fraudulent or abusive activities may result in administrative sanctions, including suspension or termination as a Health Net provider. Providers who engage in fraud may also be terminated as a Medicareauthorized provider and prohibited from participation in all federal health care programs. The applicable government program office of General Counsel works in conjunction with the Program Integrity Branch to deal with fraud and abuse. Reciprocal billing (i.e., billing or claiming Page 8 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

9 During an investigation into any allegation of fraud, the Program Integrity Department will determine the following information: Who committed the fraud When the fraud occurred (time frame) Where the fraud occurred Detailed description of the fraudulent activity Providers can report an incident or learn more about fraud and abuse through one of five methods of communication: Phone Health Net Fraud Hotline Fax Online Health Net Federal Services, LLC Mail ATTN: Program Integrity P.O. Box Virginia Beach, VA Providers and their office staff are legally required to report suspected cases of fraud and abuse to Health Net. Entities are protected from retaliation under 31 U.S.C. 3730(h) for False Claims Act complaints. Health Net ensures non-retaliation against callers and has a zero tolerance policy for retaliation or retribution against any person who reports suspected misconduct. Conflicts of Interest: Providers are prohibited from having any financial relationship relating to the delivery of or billing for covered services that: Would violate the federal Stark Law, 42. U.S.C. 1395nn, if health care services delivered in connection with the relationship were billed to a federal health care program; or that would violate comparable state law. Would violate the federal Anti-Kickback Statute, 42 U.S.C. 1320a-7b, if health care services delivered in connection with the relationship were billed to a federal health care program; or that would violate comparable state law. In the judgment of Health Net, could reasonably be expected to influence provider to utilize or bill for covered services in a manner that is inconsistent with professional standards or norms in the local community. Providers are subject to termination by Health Net for violating this prohibition. Health Net reserves the right to request such information and data as it may require ascertaining ongoing compliance with these provisions. Beneficiary Identification (ID) Card Not all government programs assign or require a beneficiary ID card (e.g., Department of Veterans Affairs Non-VA Care), while others do (e.g., Medicare Advantage). Refer to the benefit program requirements for the programs applicable to you for beneficiary ID card requirements and sample images. Covered Services The benefit program requirements determine whether services are covered services. To verify covered or non-covered services, refer to the benefit program requirements for the programs applicable to you. All services may be subject to applicable copayments, coinsurance, and deductibles. Health Net makes coverage determinations, including medical necessity determinations, based upon its benefit program requirements. However, Health Net is not a provider of medical services and it does not control the clinical judgment or treatment recommendations made by the providers in Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 9 of 27

10 its networks or who may otherwise be selected by beneficiaries. Providers make independent health care treatment decisions. Note: A service must be medically necessary and covered by the beneficiary s benefit program to be paid. Health Net uses the current nationally approved criteria for any medical necessity reviews required as well as peer review. Not all services are contracted or covered services. Credentialing Credentialing is the process by which the appropriate committee reviews documentation for each individual provider to determine participation in the health plan network. Such documentation may include, but is not limited to, the applicant s education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, professional competency, and any physical or mental impairments. The credentialing process includes verification that the information obtained is accurate and complete. The provider must respond to any reasonable Health Net request for additional information including, but not limited to, a medical record review as well as a site visit as applicable. The credentialing process generally is required by law. The fact that the provider is credentialed is not intended as a guarantee or promise of any particular level of care or service. Council for Affordable Quality Healthcare (CAQH): Health Net participates with the Council for Affordable Quality Healthcare (CAQH), which is an online single, national process that eliminates the need for multiple credentialing applications. Physicians and other health care providers who are members of CAQH can provide Health Net with the appropriate information in lieu of completing Health Net s credentialing application. Additional information may be requested. Health Net Credentials Committee: The Health Net Credentials Committee is composed of a chairperson and Health Net s network providers. Functions of the committee include credentialing, ongoing and periodic assessment, recredentialing, and establishment of credentialing and recredentialing policies and procedures for Health Net. Minimum Criteria: Health Net conducts an initial credentials review on each potential network provider to determine if the provider meets the minimum criteria. All providers who wish to enter into an agreement with Health Net are required to complete an application form and participate in an extensive review of qualifications, education, licensure, malpractice coverage, etc. Health Net retains the right to deny or terminate any provider who does not meet or no longer meets Health Net conditions of participation. Additionally, Health Net conducts a full recredentialing review of health care providers every three years to help maintain current, accurate files and to ensure all providers meet the credentialing requirements. There may be times between credentialing cycles when it is appropriate to add, change or delete a specialty description as represented in the provider directory. To make this change, you may need additional education or training documentation if it was not verified or requested during the previous credentialing process. Please visit for the appropriate forms, information and instructions. Note: Behavioral health providers should call MHN at for questions about Page 10 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

11 joining the behavioral health network and the MHN credentialing process. Liability Insurance: Providers must maintain their own insurance to protect themselves and their employees against any claim resulting from the provision of medical services. This coverage should include, but is not limited to, professional liability insurance in the amounts as required by their PPA. Upon request, all providers are required to provide Health Net with evidence of insurance coverage in accordance with their PPA requirements. Health Net Conditions of Participation for Network Providers: The following summarizes the general conditions required to participate as a network provider: Have a signed Medicare agreement or participate with Medicare on a claimby-claim basis for eligible Medicare beneficiaries Not be listed on the U.S. Department of Health & Human Services, Office of Inspector General List of Excluded Individuals and Entities (LEIE) Provide a SSN for all claims processing. An Employer Identification Number (EIN) can be provided, at the group level, but additional information will need to be collected for the required individual criminal background history checks, at the individual level Provide a Network Provider Identifier (NPI) for all individuals (Type I) and entities (Type II) billing with your organization Provide a service that is a covered benefit to the program beneficiary Agree to conditions of participation per the Provider Participation Agreement (PPA) Maintain professional liability coverage with limits of at least $1 million per occurrence and $3 million aggregate, or as listed in your PPA Have active hospital privileges, in good standing, at a Joint Commission or Healthcare Facilities Accreditation Program (HFAP)-accredited facility or Det Norske Veritas (DNV)- accredited facility (May be waived under specific conditions.) Have a current, valid, unrestricted Drug Enforcement Administration (DEA) certificate or State Controlled Substance certificate, if applicable Have completed education and training appropriate to application specialty Have no unexplained gaps in work history for the most recent five (5) years Have malpractice history not excessive for area and specialty Have no felony convictions Have no current Medicare or Medicaid sanctions Have no current disciplinary actions (including, but not limited to, licensure and hospital privileges) Sign an unmodified Credentials Attestation, Authorization and Release Provide supporting documentation to all confidential questions on the application (no patient-specific PII or PHI, please) Recredentialing: In accordance with the Health Net credentialing and recredentialing process, recredentialing is conducted at least every three 3 An Employer Identification Number (EIN) is also known as a Federal Tax Identification Number, and is used to identify a business. You can obtain your EIN, online, from the IRS at 4 The Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard unique identifier for health care provider. The National Plan and Provider Enumeration System (NPPES) collects identifying information on health care providers and assigns each a unique National Provider Identifier (NPI). You can obtain your NPI, online, from NPPES at Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 11 of 27

12 (3) years. Failing to respond to a recredentialing request may result in administrative termination from the Health Net Preferred Provider Network. Only licensed, qualified providers meeting and maintaining Health Net standards for participation requirements are retained in the Health Net PPN. Providers due for recredentialing must complete all items on an approved Health Net application form found on the Health Net website at and supply supporting documentation if required. Documentation includes, but is not limited to: Current state medical license Attestation to the ability to provide care to Health Net beneficiaries without restriction Valid, unencumbered DEA certificate or CDS certificate, if applicable. A provider who practices medicine in more than one state must obtain a DEA certificate for each state. Evidence of active admitting privileges in good standing, with no reduction, limitation or restriction on privileges, with at least one Health Net network hospital or surgery center, or a documented coverage arrangement with a Health Net credentialed or network provider of a like specialty Malpractice insurance coverage that meets Health Net standards Trended assessment of provider s beneficiary complaints, quality of care and performance indicators Termination without Cause: Where required by law, before terminating a PPA, Health Net will provide notification to the provider. The time frames vary as required by agreement or applicable state and federal regulations. Note: If a provider s name appears on the current Office of the Inspector General s (OIG) sanctioned provider listing, the provider s participation agreement with Health Net will be terminated immediately. No hearing is allowed. Other sanctions (e.g., loss of professional license) may result in immediate termination. Delegation Delegation is a formal process by which a plan gives a provider group (delegate) the authority to perform certain functions on its behalf, such as credentialing, utilization management, and claims payment. A function may be fully or partially delegated. Full delegation allows all activities of a function to be delegated. Partial delegation allows some of the activities to be delegated. The decision of what function may be considered for delegation is determined by the type of PPA a provider group has with Health Net, as well as the ability of the provider group to perform the function. Although Health Net can delegate the authority to perform a function, it cannot delegate the responsibility. Delegated Credentials/Subcontracted Provider Functions: Network providers who have delegation agreements with Health Net must comply with agreement standards and functions as they apply to credentialing of network providers and/or other subcontracted functions. Network providers must comply with the following: Network provider s credentialing plan, and policies and procedures meet Health Net s reasonable standards, guidelines and any required national accrediting standards Network provider complies with Health Net s credentialing criteria (credentialing standards) Network provider complies with applicable state and federal regulations (including compliance with applicable Medicare laws, Page 12 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

13 regulations and CMS instructions) Health Net retains the right to approve new professional providers and sites, and to terminate or suspend individual professional participation agreements Current and future professional providers who join the provider network must be properly credentialed and recredentialed before they may render covered services to beneficiaries Network provider will notify Health Net in writing of all new professional providers who become affiliated with and are credentialed by him or her Network provider will cooperate with Health Net s timelines and schedules related to the production of accurate provider directories Network provider will maintain all records necessary for Health Net to monitor the effectiveness of network provider s credentialing and recredentialing process, including, but not limited to, records related to the credentialing of all current or future professional providers (professional provider records) Durable medical equipment (DME) network providers must agree to participate with Medicare on all dual-eligible claims Annually, or upon reasonable request, a network provider will provide Health Net with its credentialing policies and procedures for review and evaluation and will permit and cooperate with Health Net s review of network provider s records Network provider will submit credentialing and recredentialing reports that identify those professional providers credentialed/ recredentialed, the effective date of such actions, the most recent prior date of credentialing/ recredentialing and the effective date of such professional provider s participation Health Net retains the ultimate authority to approve or deny any provider or site seeking to participate with Health Net Health Net will have the right to audit network provider s performance of delegated functions at any time and at least every three years. Health Net reserves the right to audit network provider as frequently as necessary to assess performance and quality Health Net must be notified by network provider of any material change in performing delegated functions. Upon written notice, Health Net has the right to revoke and assume the functions and responsibilities delegated to network provider if Health Net determines network provider either does not or will not have the capacity, ability, or willingness to effectively perform, or is not effectively performing the delegated function If a network provider wishes to subdelegate any delegated functions to another organization, network provider must request Health Net s prior approval in a written request. No sub-delegation may occur prior to Health Net s review and written approval. At Health Net s sole discretion, it may approve or deny any requested sub-delegation. If Health Net approves any sub-delegate, then any sub-delegated function remains subject to the terms of the delegation agreement between network provider and Health Net. Health Net retains ultimate oversight of any functions of the sub-delegate Health Net has the right to revoke and assume the functions and responsibilities delegated to the network provider if the network provider fails to comply or correct any delegated functions within a specified period identified by Health Net in a written notice Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 13 of 27

14 Prior Authorization and Referral Prior Authorization and Notification A prior authorization is a process of reviewing certain medical, surgical and behavioral health care services prior to services being rendered. For example, a specific diagnostic service, hospitalization or an invasive or therapeutic procedure may require a prior authorization. Prior authorization requests must be submitted to Health Net prior to services being rendered. Prior Authorization Requirements: Prior authorization requirements vary subject to benefit program requirements. Prior authorization requirements are reviewed annually in accordance with Health Net and PPN program policy to evaluate medical and behavioral health care trends and to better control health care costs for the government. See the benefit program requirements for the programs applicable to you for prior authorization requirements. Referrals A referral is the process of sending a patient to another professional provider for medically necessary consultations or health care services the attending physician is not prepared or qualified to provide. Referral services are not considered primary care. An example of a referral is a primary care physician sending a patient to see a cardiologist to evaluate chest pain. Note: Referral requirements are based on the benefit program. See the benefit program requirements for the programs applicable to you for referral requirements. In addition, Health Net requires notification of inpatient facility admissions and discharge dates within 24 hours or by the next business day following the admission and discharge. The medical facility will receive an authorization number after Health Net receives a medical review and discharge date information. To expedite claims payment, network providers should submit the authorization number with their claim. If the request is not approved, the notification letter may include a request for additional information to determine medical necessity. Page 14 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

15 Claims Procedures Claims Submission Electronic Claims Submission: Currently, providers are required to use electronic submission to submit all claims to Health Net or its designee, as applicable, using the Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant 837 electronic format or a CMS 1500 and/or UB-04, or their successors. As new submission forms become available, Health Net may require a different electronic submission process. Claims are to include the provider s NPI and the valid taxonomy code that most accurately describes the services reported on the claim. Provider acknowledges and agrees that no reimbursement is due for a covered service and/or no claim is complete for a covered service unless performance of that covered service is fully and accurately documented in the beneficiary s medical record prior to the initial submission of any claim. Further, provider acknowledges and agrees that at no time will beneficiaries be responsible for any payments to provider except for applicable copayments, coinsurance, deductibles, and non-covered services provided to such beneficiaries. Providers must bill using the provider s usual billed charges, which charges will not discriminate based upon the identity of the payer. Requests for Review of Denied Claims: If, after reconciling your accounts, you determine payment has not been received or you disagree with the payment amount, do not resubmit the same claim. Instead, explain your circumstance or disagreement by submitting written correspondence per the claim review process for the applicable program. Claims Adjudication Prompt Payment of Claims: A claim is processed promptly if it is approved or denied within the time required by the PPA, benefit program requirements, or the applicable regulation of the state in which Health Net is operating. Most clean claims (claims that comply with billing guidelines and requirements, have no defects or improprieties, include substantiating documentation when applicable and do not require special processing that would prevent timely payment), will be processed within 30 days. Claims aged more than 30 days will be paid interest in addition to the payable amount. Balance Billing: Balance billing is the practice of a network provider billing a beneficiary for the difference between the contracting amount and billed charges for covered services. When network providers contract with Health Net, they agree to accept Health Net s contracting rate as payment in full. Billing beneficiaries for any covered service is a breach of contract, as well as a violation of the PPA and, in some states and programs, state and federal statutes. Participating providers can only seek reimbursement from Health Net beneficiaries for copayments, coinsurance or deductibles. Collection of Copayments and Other Beneficiary Liabilities: Network providers collect all copayments, coinsurance and deductibles from beneficiaries and may not waive or fail to pursue collection of copayments. The network provider should not impose any fees or surcharges on a Health Net beneficiary for covered services provided. If Health Net receives notice of any additional charge, the network provider must Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 15 of 27

16 fully cooperate with Health Net to investigate such allegations and promptly refund the beneficiary any payment deemed improper by Health Net. Informing Beneficiaries about Non-Covered Services: Before delivering care, network providers must properly inform beneficiaries in advance if services are not covered. The beneficiary must agree in advance and in writing to receive and accept financial responsibility for non-covered services. The agreement must document the specific services, dates, estimated costs and other information. Certain government programs may not allow payment for non-covered services unless the provider has a written agreement that documents the specific services, dates, estimated costs and other information and signed in advance by the beneficiary. A general agreement to pay, such as one signed by the beneficiary at the time of admission is not sufficient to prove a beneficiary was properly informed or agreed to pay. If the beneficiary does not sign a specific written agreement as described above, the provider may be financially responsible for the cost of non-covered services he or she delivers. See the benefit program requirements for the programs applicable to you for any specific requirements for each benefit program. Coding Edits: Health Net will process provider claims that are accurate and complete in accordance with Health Net s normal claims processing procedures and applicable state and/or federal laws, rules and regulations with respect to the timeliness of claims processing. Such claims processing procedures and edits may include, without limitation, automated systems applications which identify, analyze and compare the amounts claimed for payment with the diagnosis codes and which analyze the relationships among the billing codes used to represent the services provided to beneficiaries. These automated systems may result in an adjustment of the payment to the provider for the services or in a request, prior to payment, for the submission for review of medical records that relate to the claim. Providers may request reconsideration of any adjustments produced by these automated systems by submitting a timely request for reconsideration to Health Net. A reduction in payment as a result of claims policies and/or processing procedures is not an indication that the service provided is a non-covered service. Claims Adjustment Procedures Claims adjustment procedures are programspecific and requests must be made in writing. Adjustment determinations are made on a claim-by-claim basis. Before submitting a request for claim adjustment, first review your Health Net PPN PPA and the applicable rate exhibits. Key pieces of information to include with your request: Provider Tax Identification Number (or SSN, as appropriate) Provider name and group name Legal point of contact name, address, telephone number, fax number, and address Single claim: Copy of disputed claim Copy of Remit Advice Reason for dispute Multiple claims (must be submitted in an MS Excel spreadsheet to include): Provider TIN/SSN Provider name Claim number Page 16 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

17 Date of service Billed amount Paid amount Reason for dispute Note: Communications containing claims detail are confidential and must be marked as such and managed, appropriately. Timely Filing Criteria If a claim is denied for timely filing, but the provider can demonstrate good cause for the delay, Health Net may choose to accept and adjudicate the claim as if it were submitted in a timely manner. Health Net considers and determines whether or not there is a good cause for the delay using standardized guidelines. Good Cause for Delay Guidelines: Good cause for claim submission delays for providers who receive misinformation from beneficiaries or Health Net that causes timely filing claim denials must fall under the following guidelines: The delay was not reasonably in the provider s sole ability to control. For example: The provider received misinformation from the beneficiary and the provider is submitting one of the following: Patient information form and/or beneficiary identification (ID) card presented by the Health Net beneficiary Explanation of Benefit from incorrect carrier The provider has followed Health Net instructions. Circumstances existed that the provider could not foresee or prevent. The delay was not the result of the provider s negligent or willful action or inaction. Adjustment Guidelines: For providers who can show proof of timely claim filing, Health Net gives consideration to other provider claim adjustments. Other adjustment policy guidelines include: The provider submits proof in the form of one of the following: Electronic Data Interchange (EDI) confirmation that Health Net received and accepted the claim Delivery confirmation evidence (e.g., registered receipt or certified mail receipt to a Health Net address) Reimbursement Payments made to network providers for medical services rendered to PPN program beneficiaries will not exceed 100 percent of the payment terms defined in the PPA. All reimbursement methodologies are impacted by a network provider s negotiated discount rate. A provider will not receive 100 percent of a program s allowable charge if they have a negotiated discount. The amount of payment for services provided is affected not only by the terms in the PPA, but also by the following: Beneficiary s eligibility at the time of service Whether services provided are covered services under the beneficiary s plan Whether services provided are medically necessary as required by the beneficiary s plan Whether services were without the prior approval of Health Net, if prior approval is required by the benefit program Amount of the provider s billed charges Beneficiary copayments, coinsurance, deductibles, and other coinsurance amounts due from the beneficiary and coordination of benefits with third-party payors as applicable Adjustments of payments based on coding edits described above Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 17 of 27

18 Note: With some claims, additional information may justify additional payment. For example, a provider s clinical notes may establish that a procedure code judged incidental to another in Health Net s automated process actually involved a distinct and significant provider effort, in the circumstances of the provider s encounter with his or her patient. If a provider believes that Health Net s automated process has adjudicated a claim incorrectly, the provider should follow the procedures for appealing the denial described above under Coding Edits, or if applicable, any laws or programspecific guidelines regarding grievance and appeals processes. Please include a copy of the applicable clinical notes with physician/ provider appeal. Nothing contained in the PPA or this manual is intended by Health Net to be a financial incentive or payment which directly or indirectly acts as an inducement for providers to limit medically necessary services. Note: Health Net applies the Centers for Medicare & Medicaid (CMS) site-of-service payment differentials in its fee schedules for CPT codes based on the place of treatment (physician office services versus other places of treatment). Network providers are to accept payment from Health Net for covered services provided to health plan beneficiaries in accordance with the reimbursement terms outlined in the PPA. Beneficiaries are responsible for their outof-pocket expenses including deductible, coinsurance and/or copayment amounts. For covered services, providers may not balance bill beneficiaries for a monetary amount over or above the fee schedule provided in their PPA; however, they are not prohibited by the PPA from collecting from beneficiaries for any services not covered under the terms of the applicable beneficiary plan. A reduction in payment as a result of claims policies and/ or processing procedures is not an indication that the service provided is a non-covered service. Fee Schedule: Fee Schedule information may be found at Reimbursement methodologies for your Health Net Provider Participaton Agreement (PPA) are found in the applicable PPA rate exhibits. Services Which Are Not Medically Necessary: Provider agrees that in the event of a denial of payment for services rendered to beneficiaries determined not to be medically necessary by Health Net, that provider will not bill, charge, seek payment or have any recourse against beneficiary for such services, unless specifically agreed to in writing by beneficiary, as described above. Provider Overpayments: If a provider is aware of receiving an overpayment from Health Net, including but not limited to, overpayment caused by incorrect or duplicate payment, errors on or changes to provider billing, or payment by another payer who is responsible for primary payment, the provider must promptly refund the overpayment amount to Health Net at the following address: Health Net Federal Services, LLC ATTN: CLAIMS ADMINISTRATION OVERPAYMENT 2025 Aerojet Rd Rancho Cordova CA The refund should contain a copy of the applicable Remittance Advice (RA) and a information indicating why the amount is being returned. If the RA is not available, provide beneficiary name, date of service, payment amount, Health Net beneficiary Page 18 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

19 identification (ID) number, provider Tax Identification Number (TIN) and National Provider Identifier (NPI). When Health Net determines that an overpayment has occurred, Health Net notifies the provider of services in writing within 365 days of the date of learning of the overpaid claim through a separate notice that includes the following information: Beneficiary name Claim ID number Explanation of why Health Net believes the claim was overpaid Amount of overpayment, including interest and penalties The 365 day time period does not apply to overpayments caused in whole or in part by fraud or provider misrepresentation. The provider of service has 30 business days to submit a written dispute to Health Net if the provider does not believe an overpayment has occurred. In this case, Health Net treats the claim overpayment issue as a provider dispute. Health Net may recoup uncontested overpayments by offsetting overpayments from payments for a provider s current claims for services if: The provider s PPA authorizes it to offset overpayments from payments for current claims for services Otherwise permitted under state laws A written notification is sent to the provider of service if an overpayment is recouped through offsets to claims payments. The notification identifies the specific overpayment and the claim identification (ID) number. Office Procedures This section provides policies and procedures that pertain to the daily operations of a provider office. Health Net provider representatives shall be permitted access to the provider s office records and operations. This access allows Health Net to monitor compliance with regulatory requirements. Medical Records Health Net may review medical records on a random basis to evaluate patterns of care and compliance with performance standards. Each provider should have policies and procedures in place to help ensure the information in each patient s medical record is kept confidential and is appropriately organized. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis and describe the patient s progress and response to medications and services. The provider s medical records must be available for utilization, risk management, peer review studies, customer service inquiries, grievance and appeal processing, and other initiatives Health Net may be required to conduct. To comply with accreditation and regulatory requirements, periodically Health Net may perform a documentation audit of some provider medical records. Note: The network provider must respond to the Health Net grievance and appeal unit expeditiously with submission of the required medical records. Only those records for the time period designated on the request should be sent. A copy of the request letter should be submitted with the copy of the record. The submission should include test results, office notes, referrals, telephone logs, and consultation Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 19 of 27

20 reports. Medical records should not be submitted by fax unless provider can ensure confidentiality of those medical records. To be compliant with HIPAA, providers should make reasonable efforts to restrict access and limit routine disclosure of protected health information (PHI) to the minimum necessary to accomplish the intended purpose of the disclosure of beneficiary information. Note: Charges for copying medical records are considered a part of office overhead and are to be provided at no cost to beneficiaries and Health Net, unless state regulations or municipal ordinances stipulate differently. Clinical Information Submission Health Net does not routinely require or request clinical information at the time of claim submission. Provider Inquiries An inquiry is a verbal or written question for clarification (such as a request for information), without an expression of dissatisfaction or request for reconsideration. Providers may contact Health Net or its designee, as applicable when wanting to: Inquire regarding the status of a claim or obtain payment calculation clarification Resubmit contested claims with the missing information requested by Health Net Submit a corrected claim (additional charges previously not submitted) Clarify member responsibility Provider inquiry contact information is program-specific and can be located at Health Net reserves the right to request clinical records before or after claim payment to comply with program requirements or to identify possible fraudulent or abusive billing practices, as well as any other inappropriate billing practice not compliant with the AMA CPT codes or guidelines. Note: Refer to the benefit program requirements for the programs applicable to you for Clinical Information Submission requirements. Page 20 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

21 Grievances and Appeals/Disputes The grievance and appeal/dispute processes apply to providers and beneficiaries who are dissatisfied with the health care services received, or any aspect of the program. These processes are designed to resolve complaints or disputes regarding adverse determinations. If the initial grievance or appeal is denied, the resolution letter will provide next level rights as applicable. Certain states and federal programs may have specific processes for physician grievance or appeal requests. Physicians may utilize the beneficiary s grievance or appeal process by obtaining authorization from the beneficiary. The fact that a member submits a grievance or appeal to Health Net or the network provider should not affect in any way the manner in which the member is treated by the network provider. If Health Net discovers that any improper action has been taken against such a member by the network provider, Health Net will take immediate steps to prevent such conduct in the future. These steps involve appropriate sanctions, including possible termination of the applicable Provider Participation Agreement (PPA). Grievances A grievance is a written complaint or concern about a medical provider, Health Net or Health Net associate, or a PPN program, in general. Appeals, disputes and claim review issues are separate from grievances. View the Appeals/Disputes section to the right and the Claims Procedures section on page 15 for additional information. Note: If a program attachment or addendum is applicable, providers should follow those program-specific grievance processes. The Health Net grievance process allows full opportunity for any program beneficiary, beneficiary s representative, and network or non-network provider to report in writing any concern or complaint (grievance) regarding health care quality or service. Note: Beneficiaries submit grievances through the applicable program-specific grievance process. Required Information for Grievances: A description of the issue or concern must include: The date and time of the event Name of the provider(s) and/or person(s) involved Location of the event (address) The nature of the concern or complaint Details describing the event or issue Any appropriate supporting documents Submit an HNFS PPN Grievance Form or a letter outlining the grievance information Fax [email protected] The HNFS PPN Grievance Form is located at listed above in one of the following ways: Appeals/Disputes An appeal or dispute is a verbal or written request to change a previous service decision or adverse determination (a determination that a health care service is not covered or is not medically necessary). The request can be from a network provider, beneficiary or a beneficiary representative. Note: Programspecific guidelines dictate whether a service decision or determination is appealable and by whom. Refer to the dispute/appeal requirements for the programs applicable Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 21 of 27

22 to you. Disputes/appeals regarding claims or prior authorizations and referrals must be submitted through the program-specific appeals process. Dispute Submission: Health Net complies with all applicable state and federal law with respect to providers disputes. The dispute resolution process may vary by Program and/or as mandated by applicable state or federal law. Refer to the benefit program requirements for the programs applicable to you. In the absence of applicable state, federal or program specific requirements, Health Net accepts disputes, including appeals, from network providers if they are submitted within 90 calendar days of receipt of Health Net s decision (for example, denial or adjustment), except as described below. If the network provider does not receive a decision from Health Net within 60 calendar days, the dispute is deemed rejected. Rejected claims may be resubmitted within 90 calendar days contesting Health Net s decision. If the network provider s PPA provides for a dispute-filing deadline that is greater than 90 calendar days, this longer time frame continues to apply until the agreement is amended. The provider dispute must comply with the following: The dispute must include the provider s name, identification (ID) number, contact information, including telephone number, and the original claim number. If the dispute is regarding a claim or a request for reimbursement of an overpayment of a claim, the dispute must include: clear identification of the disputed item, the date of service, and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment or other action is incorrect. If the dispute is not about a claim, the provider must include a clear explanation of the reason for the dispute, including if applicable, relevant references to the PPA. A provider dispute submitted on behalf of a beneficiary is considered a beneficiary appeal and is processed through the beneficiary appeal process. Health Net resolves provider disputes within 60 business days following receipt of the dispute and sends the provider a written determination stating the reasons for the determination. If the provider dispute submission does not include all pertinent details of the dispute, it will be returned to the provider with a request detailing the additional information required to resolve the issue. The amended dispute must be submitted with the missing information within 30 business days from date of receipt of the request for additional information. Providers are not asked to resubmit claim information or supporting documentation previously submitted to Health Net as part of the claims adjudication process, unless Health Net returned the information to the provider. If the provider dispute involving a claim for a provider s services is resolved in favor of the provider, Health Net pays any outstanding money due, including any required interest or penalties, within 21 business days of the decision. Accrual of the interest and penalties, if any, commences on the day following the date by which the claim or dispute should have been processed. Network providers who have an agreement to work directly with Health Net and disagree with Health Net s determination may refer to their PPA for other available means of resolution. Page 22 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

23 Contractual Disputes Health Net strives to informally resolve issues raised by providers on initial contact whenever possible. If issues cannot be resolved informally, Health Net offers an internal appeal process for resolving contractual disputes. Following the internal Health Net process, arbitration may be used as a final resolution step. Contractual disputes must be submitted in writing within 90 calendar days of the date of the occurrence. Submit your contractual dispute by fax or to: Health Net Federal Services, LLC ATTN: Provider Network Management Fax: [email protected] If a decision is made to uphold the initial decision, an appeal-denial letter will be sent to the provider outlining any additional appeal rights. Health Care Management and Administration Network providers must participate in and cooperate with the health care management programs required by the benefit plan. Medical records requested in connection with these programs must be provided at no charge and within the time frames requested which time frame must be reasonable under the circumstances, unless otherwise required by your provider agreement. Unless otherwise required by law or your PPA, payment may be denied for failure to comply with health care management requirements, and providers cannot bill beneficiaries for any such denied payments. In addition, failure to comply may result in disciplinary action up to and including removal from the network and/ or termination of the PPA. Utilization Management Utilization Management (UM) is a process that manages the beneficiary at the point of care through prospective review, concurrent review, retrospective review, case management and discharge-planning activities. Health Net may conduct UM activities on covered services subject to benefit program requirements. Case Management The Case Management Program, if applicable, coordinates all aspects of medical and behavioral health treatment by directing at-risk beneficiaries who require extensive, complex and/or costly services to the most appropriate levels of care necessary for effective treatment. By linking many services, including the government program resources, the case manager can coordinate treatment to provide cost-effective, quality care. Health Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 23 of 27

24 Net conducts case management activities on covered services subject to benefit program requirements. Clinical Quality Management Health Net is committed to providing the highest quality health care possible to PPN program beneficiaries by partnering with network providers who share this goal. In compliance with government program requirements, Health Net has a CQM program for assessing and monitoring care and services rendered to PPN program beneficiaries throughout the health care delivery system. Health Net conducts clinical quality management (CQM) activities on covered services subject to benefit program requirements. Discharge Planning As the patient s illness decreases in severity and/or begins to stabilize, the intensity of services will reflect that. If care may be delivered in a less emergency-oriented setting, the medical management staff will coordinate efforts with the physician directing the care (and the patient and family members) to facilitate timely and appropriate discharge. Refer to the benefit program requirements for the programs applicable to you to determine if Discharge Planning is required. Policy on Separation of Medical Decisions and Financial Concerns Health Net has a strict policy: UM decisions are based on medical necessity and medical appropriateness Health Net does not compensate physicians or nurse reviewers for denials Health Net does not offer incentives to encourage coverage or service denial Special concern and attention should be paid to underutilization risk Medical decisions regarding the nature and level of care to be provided to a beneficiary, including the decision of who will render the service (e.g., primary care physician versus specialist, network provider versus nonnetwork provider), must be made by qualified medical providers, and unhindered by fiscal or administrative concerns. Health Net monitors compliance with this requirement as part of its quality-improvement process. Page 24 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

25 Rights and Responsibilities Beneficiary Rights and Responsibilities Health Net adheres to certain rules of accrediting and regulatory agencies concerning beneficiary rights. PPN program beneficiaries have certain rights and responsibilities when being treated by network providers. The rights and responsibilities statement reminds beneficiaries and providers of their complementary roles in maintaining a productive relationship. PPN program beneficiaries have the right to: Get information Beneficiaries have the right to receive accurate, easy-to-understand information from written materials, presentations and program representatives to help them make informed decisions about PPN programs, medical professionals and facilities. Choose providers and programs Beneficiaries have the right to a choice of health care providers sufficient to ensure access to appropriate, high-quality health care. Emergency care Beneficiaries have the right to access emergency health care services when and where the need arises. Participate in treatment Beneficiaries have the right to receive and review information about the diagnosis, treatment and progress of their condition. Beneficiaries have the right to fully participate in all decisions related to their health care, or be represented by family members, conservators or other duly appointed representatives. Respect and nondiscrimination Beneficiaries have the right to receive considerate, respectful care from all members of the health care system without discrimination based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. Confidentiality of health information Beneficiaries have the right to communicate with health care providers in confidence and to have the confidentiality of their health care information protected as required by law. They also have the right to review, copy, and request amendments to their medical records. Complaints and appeals Beneficiaries have the right to a fair and efficient process for resolving differences with their health plans, health care providers and the institutions that serve them. PPN program beneficiaries have the responsibility to: Maximize health Beneficiaries have the responsibility to maximize healthy habits, such as exercising, not smoking and maintaining a healthy diet. Make smart health care decisions Beneficiaries have the responsibility to be involved in health care decisions. This means working with providers to develop and carry out agreed-upon treatment plans, disclosing relevant information and clearly communicating wants and needs. Be knowledgeable about benefit program requirements Beneficiaries have the responsibility to be knowledgeable about benefit program requirements and options. PPN program beneficiaries also have the responsibility to: Show respect for other patients and health care workers Health Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 25 of 27

26 Make a good-faith effort to meet financial obligations Use the disputed claims process when there is a disagreement Report wrong doing and fraud to appropriate resources or legal authorities Pay copayments, coinsurance and deductibles Pay for non-covered services (if the beneficiary agreed in advance and in writing to pay for these services) Pay all charges if ineligible for program benefits at the time of service Professional Conduct during Physical Examination of Program Beneficiaries: The beneficiary or provider may request a chaperon to be present during any office examination. The chaperon may be a family beneficiary or friend of the beneficiary, or the physician s/provider s assistant. Prior to an examination of a minor, the physician should obtain a parent or guardian s consent in the manner specified by the state. Note: Some states have regulations that may conflict with these guidelines. In those incidences, state regulations, if more stringent, shall take precedence over these guidelines. [REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK] Page 26 of 27 Health Net Preferred Provider Network (PPN) Provider Manual March 2015

27 Index Abuse...6, 7, 8 Address Change... 5 Appeal...18, 21, 22 Balance Billing Beneficiary Identification (ID) Card... 9 Beneficiary Rights and Responsibilities CAQH... 5, 10 Case Management Claims Adjudication Claims Adjustment Claims Procedures Clinical Information Submission Clinical Quality Management Coding Edits Comments... 4 Conditions of Participation Contact Us... 6 Covered Services... 9 Credentialing... 3, 10 Delegation Discharge Planning Dispute Submission Electronic Claims Submission Fee Schedule Fraud...6,7, 19, 26 Good Cause for Delay Guidelines Grievance Health Net Federal Services, LLC... 3 Health Net Products... 4 Health Net Program Integrity Department... 7 Health Net, Inc Liability Insurance Medical Records Non-Covered Services Office Procedures Other Adjustments Guidelines PIF...See Provider Information Form PPN...See Preferred Provider Network Preferred Provider Network... 3 Prior Authorization Prompt Payment of Claims Provider Demographics Update Form... 5 Provider Directory... 6 Provider Information Form... 5 Provider Overpayments Questions... 4 Recredentialing Referrals Reimbursement Requests for Review of Denied Claims Separation of Medical Decisions and Financial Concerns Termination without Cause Timely Filing Criteria Updates... 6 Utilization Management VH0215x033 Health (02/15) Net Preferred Provider Network (PPN) Provider Manual March 2015 Page 27 of 27