Neighborhood Health Partnership
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1 Neighborhood Health Partnership Answers to Frequently Asked Questions Q. Whom do I call for assistance or if I need information in another language? A. Call Customer Service at the phone number on your NHP health plan ID card. Language assistance is available through Customer Service. Q. Does NHP have a website, and can I my questions? A. Our website address is Our website offers helpful information about NHP and your coverage. The NHP homepage offers a useful link for contacting us (click on contact us ), with addresses and telephone number for other NHP departments. Q. What s included on the NHP website? A. NHP s website provides members with useful tools and guidelines. The website contains our members rights and responsibilities statement, notice of privacy practices, preventive health guidelines, preferred drug list, behavioral health benefit information and provider lookup. If you would like a summary of the tools and/or guidelines, please contact Customer Service at the phone number on your NHP health plan ID card. Q. How do I order a new ID Card, change my Primary Care Physician (PCP) or order a new Provider Directory? A. Please call Customer Service at the phone number on your NHP health plan ID card or access mynhp.com. Q. How can I add a dependent to my NHP coverage? A. You need to coordinate adding dependents through the HR department of the employer group through which you are covered. Your HR department can provide you with an NHP enrollment form. There are special rules regarding when dependents can be added. Your HR department can help you with this. Q. How do I get a referral? A. Unless your health benefit plan includes a Direct Access Rider, you must coordinate all of your care through your PCP. You will need a referral from your PCP to visit a NHP specialist. However, you can see the following specialties without a referral from your PCP: Podiatry Chiropractic Dermatology (first five visits) Gynecology Alcohol/substance use treatment (services must be provided by NHP s Behavioral Health Network) Mental health (services must be provided by NHP s Behavioral Health Network) Q. What is included in a referral? A. A referral is a written recommendation from your PCP for you to see a specialist or receive certain health care services. Your PCP must issue the referral through NHP s automated referral system or by contacting NHP directly prior to your visit. Please discuss with your practitioner the tests and services which are included in the referral. Test and services not included in the referral or performed outside the specialist s office may require a separate authorization. 1
2 Q. Whom do I contact if I have a complaint? A. If you have an inquiry or complaint about the service you received, your coverage or a provider, you may call Customer Service at the phone number on your NHP health plan ID card. Q. What if I m still not satisfied with the resolution of the complaint? A. If you are not satisfied with the resolution of your complaint you may file a formal written appeal within 180 days of the occurrence of the incident. Written appeals must be mailed to: Neighborhood Health Partnership, Inc. PO Box 5210 Kingston, NY Attention: Appeal Coordinator If you need assistance preparing your appeal, you may call Customer Service at the phone number on your NHP health plan ID card. Q. How do I add my newborn baby to my coverage? Q. Does NHP have a Quality Improvement program? A. To request a summary of the NHP Quality Improvement program s progress and achievements, call Customer Service at the phone number on your NHP health plan ID card, Monday through Friday between 8:00 am and 6:00 pm. For the hearing impaired (TTY), call the National Relay Center at Q. What drugs generally are not covered? A. In general, the following categories of drugs are either excluded, or have limitations: Appetite suppressants Erectile dysfunction drugs Infertility drugs Drugs used for cosmetic purposes Smoking cessation products Some injectables A. Please complete and return an NHP enrollment form within 60 days of your baby s date of birth, even if you already have family coverage. You may obtain enrollment forms through your employer group HR department. If NHP receives your baby s enrollment form within 30 days of birth, NHP will not charge an additional premium for the first 30 days of coverage. NHP must receive your completed enrollment form within 60 days of your baby s date of birth. 2
3 Q. How do I get care after my doctor s office hours? A. If it is not an emergency, you may call your doctor s office and work with his/her answering service to put you in contact with your doctor. If you are sick or injured and you re not sure if you should go to the emergency room, visit an urgent care center, make a doctor s appointment or use selfcare, call NurseLine SM Services. An experienced NurseLine nurse can give you information to help you decide and provide you information, support and education for any health-related question or concern. You can call the NurseLine toll free number anytime. If you have an emergency, go to the nearest emergency room. If you need urgent care services (minor injuries or illnesses that require immediate attention, but are not severe enough to go to the emergency room), go to one of the urgent care centers in NHP s network. If you are not sure if you are experiencing an emergency, go to the nearest emergency room or call 911. Q. Does NHP have a Utilization Management program? A. NHP has a Utilization Management (UM) program to ensure that utilization decisions affecting members health care are done in a fair, impartial and consistent manner. The UM components are prior authorization, concurrent review, retrospective review and case management. The UM program is designed to make health care services available to members medically appropriate, accessible and costeffective by evaluating service and care, and making decisions regarding benefit coverage. The following are brief summaries of each component: Prior authorization is the process of health services being reviewed before services are approved through the referral process. Concurrent review is the process of continuous medical monitoring while the member is in an inpatient facility or under a plan of care. This review assures that all the days in the facility are medically appropriate. If services are needed after discharge, NHP assists with the coordination of care in an alternative setting. Retrospective review is the review of care rendered to a member without providing NHP appropriate clinical data. NHP reviews clinical information obtained from the provider or facility. The review assures that services provided would have been approved as through the prior authorization process. Case management is the process whereby medical cases that are serious or medically complex are flagged and reviewed to assure that appropriate care is rendered to the member through a plan of treatment and the status of the member s condition is updated. Close communication with the practitioner and the member is maintained. The NHP Medical Management staff is available to practitioners and members to discuss UM issues, including UM decisions and questions about the program and process. The Medical Management staff is available during normal business days. Calls received after hours, weekends and holidays are forwarded to an after-hours line. You may also call Customer Service at the phone number on your NHP health plan ID card. Q. How can I get copies of my medical records? A. You may request copies of your medical records from your PCP and your other providers. 3
4 Q. What are the rules for changing my PCP? A. You may change your PCP once every month, and the change will be effective the first of the month following the request of the change. Q. How does NHP make sure that all of my Protected Health Information (PHI) stays confidential? A. NHP takes many steps to ensure that your Protected Health Information (PHI) remains confidential. Our routine notifications of our privacy practices include: our commitment to your privacy, how NHP uses and discloses your PHI, other uses and disclosures permitted or required by law, your rights regarding your PHI, how to obtain further information and how to file a complaint. NHP must ask for your authorization before disclosing your PHI for non-routine purposes. NHP also allows you access to your PHI upon written request. Employees of NHP receive education and training to ensure that your written, oral and electronic PHI is kept confidential. PHI transmitted electronically is encrypted and any documents containing your PHI are stored in a secure area with access limited to designated individuals. NHP uses, discloses and requests only the minimum amount of information necessary. NHP does not disclose PHI to your employer for employment-related purposes without your authorization, but may disclose PHI for plan administrative purposes. To obtain a complete Privacy Notice outlining all of NHP s privacy practices, call Customer Service at the phone number on your NHP health plan ID card or at mynhp.com Q. How does NHP evaluate new technology for inclusion as a covered benefit? A. UnitedHealthcare s Medical Technology Assessment Committee evaluates the strength of clinical evidence supporting the use of new and existing health services. Conclusions of this committee help to determine whether new technology and health services will be covered. Q. How do I obtain information about practitioners that participate in the NHP network (i.e., professional qualifications, specialty, and address)? A. Call Customer Service at the phone number on your NHP health plan ID card or at mynhp.com. Q. Does NHP provide incentives for Utilization Management decisions? A. NHP does not use incentives that encourage barriers to care and/or service, or that reward inappropriate restriction of care. Rather, NHP encourages appropriate utilization while discouraging any under-utilization. NHP affirms that utilization management decisionmaking is based only on appropriateness of care and services and existence of coverage. NHP does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage of service or care. No incentives are offered to encourage decisions that might result in under-utilization. 4
5 Q. Why have an Advance Medical Directive? A. You can plan ahead by writing an Advance Medical Directive, also called an Advance Directive. This statement outlines the medical treatment you would want, or names the person you would want, to make health care decisions for you if you can no longer express your wishes. You can get additional information by contacting your Primary Care Physician s office or by calling our Customer Service at the phone number on your NHP health plan ID card. These materials are for informational purposes only. If there are any conflict of terms between this communication and the NHP Handbook, the Handbook will prevail. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare of Florida, Inc United HealthCare Services, Inc. UHCFL
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Member Handbook. For questions and Gold Coast Health Plan information, Please call 1-888-301-1228. GCHP_Mbr_English 6/2011
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TotalIndependence Silver Plan: Health Republic Insurance of New York Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
Enrollment Application. Senior Blue Traditional Blue Medicare PPO
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Sharon M. Galup Vice President Provider and Member Services 008360 (2003-0018) 4/03
We would like to thank you for joining the Keystone Direct POS program. Carrying a Keystone Direct POS Identification Card (ID Card) entitles you to access a large network of providers, our friendly service,
Important Questions Answers Why this Matters: $3,000/ person $6,000/family Benefits not subject to deductible include: preventive care.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
CHAPTER 7: UTILIZATION MANAGEMENT
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Trustmark Life Insurance Company: LewerMark Coverage Period: Beginning on or after Aug 1, 2015
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AIG/HealthSmart Managed Health Care Plan
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National Guardian Life Insurance Company Maine College of Art Student Health Insurance Plan Coverage Period: 09/01/2015-08/31/2016
J3A59 National Guardian Life Insurance Company This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com
National Guardian Life Insurance Company: Kuyper College Student Health Insurance Plan
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
NEWSPAPER GUILD HEALTH AND WELFARE FUND : Aetna HealthFund Health Network Option SM
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-800-370-4526.