NEMS Medical Group Provider Manual

NEMS Medical Group Provider Manual Revised October 2011 NEMS-MSO 1520 Stockton Street San Francisco, CA 94133 Tel: 415-391-9686 Fax: 415-398-2895

I. Introduction TABLE OF CONTENTS I. INTRODUCTION 1-1 II. IMPORTANT QUESTIONS AND ANSWERS 2-1 III. MEMBER ELIGIBILITY VERIFICATION & ENROLLMENT 3-1 Verifying Eligibility 3-1 Sample Identification Cards 3-4 Determining Medi-Cal Eligibility 3-8 Managed Care Plan Hold Status 3-10 Determining Healthy Families Eligibility 3-11 Determining Healthy Kids Eligibility 3-12 Medi-Cal Member SFHP Enrollment 3-13 Healthy Families Member SFHP Enrollment 3-15 Healthy Kids Member SFHP Enrollment 3-19 IV. BENEFITS AND EXCLUSIONS 4-1 Medical Necessity 4-1 Medi-Cal Covered Benefits 4-2 Medi-Cal Limitations and Exclusions 4-8 Healthy Families Covered Benefits 4-11 Healthy Families Limitations and Exclusions 4-20 Healthy Families Program Co-payment 4-23 Healthy Kids Covered Benefits 4-24 Healthy Kids Limitations and Exclusions 4-33 Healthy Kids Program Co-payment 4-36 V. PCP REFERRAL/ AUTHORIZATION POLICY 5-1 Primary Care Physician and Service Provider Responsibilities 5-1 Initial Health Assessment 5-2 Authorizations to Medical Services 5-5 Referral Authorization Form (RAF) 5-6 Specialist Extension Form 5-8 Treatment Authorization Request (TAR) 5-9 Turn Around Time (TAT) 5-10 Approval / Denial Procedure 5-10 Appeals Process 5-10 Emergency Care Procedures 5-11 After-Hours Availability 5-12 Emergency Services Out-of-Area 5-13 Hospital Utilization 5-14 NEMS-MSO Authorization Listing 5-16 Revised October 2011 1-1

I. Introduction VI. SENSITIVE SERVICES 6-1 Abortion Services 6-1 Family Planning Services 6-1 Sterilization 6-2 Sterilization Consent Form Instructions 6-5 VII. COORDINATION OF CARE & SERVICES 7-1 Case Management 7-1 Facility Site and Medical Record Review 7-4 Medical Group Credentialing 7-7 Provider Orientation and Training 7-9 Second Opinions and Independent Medical Review 7-11 Cultural and Linguistic Services 7-14 Community Resources 7-16 VIII. QUALITY IMPROVEMENT PROGRAM 8-1 Quality Improvement Committee & Program Activities 8-1 Quality Indicator Collection and Case Management Review 8-2 Case Management Review Process 8-2 Quality Improvement Method and Peer Review 8-3 Quality Improvement Plan 8-4 IX. CLAIMS PROCESSING AND PAYMENT DISPUTE 9-1 Timely Filing Limit 9-1 Turn Around Time (TAT) 9-2 Claims Processing 9-2 Reimbursement Rate and UCR Pricing Methodology 9-4 Claims Payment Dispute Resolution Mechanism 9-5 X. PROVIDER COMPLAINT AND MEMBER GRIEVANCE 10-1 Provider Grievance Process 10-1 Member Grievances 10-6 XI. ATTACHMENTS A. UM Authorization Grid and RAF / TAR forms B. Provider Dispute Form / Member Grievance Form C. SFHP Reimbursable Immunization List D. CHDP Periodicity and Immunization Schedule E. California Children Services F. Reportable Diseases and Conditions G. Medi-Cal Aid Codes Master Chart H. Glossary of Terms Revised October 2011 1-2

I. Introduction I. INTRODUCTION NEMS-MSO (North East Medical Services-Management Services Organization) performs administrative services for Managed Care members (including Medi-Cal, Healthy Families and Healthy Kids members) who have selected the San Francisco Health Plan (SFHP) as their Health Maintenance Organization (HMO). Our Primary Care Providers (PCP) include North East Medical Services clinics, the Family Healthy Center at California Pacific Medical Center, Bayview Child Health Center, and some contracted private practices. San Francisco Health Plan is a City-sponsored health plan providing health insurance to more than 55,000 San Franciscans. For over 10 years, NEMS Medical Group and its partner hospital, California Pacific Medical Center (CPMC), have contracted with SFHP to provide quality medical services to Medi-Cal Managed Care, Healthy Families, and Healthy Kids members. Members assigned to NEMS Medical Group are able to access our broad physician network in the city and county of San Francisco. Medi-Cal Managed Care Program The Medi-Cal Managed Care Division (MMCD) provides high quality, accessible, and costeffective health care through managed care delivery systems. MMCD contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care. Managed care plans are a costeffective use of health care resources that improve health care access and assure quality of care. Today, approximately 3.4 million Medi-Cal beneficiaries in 25 counties receive their health care through three models of health care plans: Two-Plan, County Organized Health Systems (COHS) and Geographic Managed Care (GMC). Medi-Cal providers who wish to provide services to managed care enrollees must participate in the managed care plan s provider network. In San Francisco, a Two-Plan model is established by Blue Cross California (BCC) and San Francisco Health Plan which is sponsored by the San Francisco Health Authority. BCC has been operating Medi-Cal health plan business since July 1, 1996; San Francisco Health Plan has been in operation since January 1, 1997. Mandatory Medi-Cal Managed Care participants will be automatically assigned to a PCP in one of these two plans even if they do not choose one for themselves. Healthy Families Program The Healthy Families Program is administered by the Managed Risk Medical Insurance Board (MRMIB). It is a low cost insurance for children ages 18 years or younger. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for nocost Medi-Cal. It is a State Children s Health Insurance Program (SCHIP) for children whose family income is between 100% and 250% of the Federal Poverty Level. SFHP is the Community Provider Health Plan for the Healthy Families program in San Francisco County. The monthly premium for children is determined by income category, which includes family size, family income, and the health plan is chosen. In addition to the monthly premium, member pays a $5 co-payment for non-preventive services. Revised October 2011 1-1

I. Introduction Healthy Kids Program Healthy Kids Program is jointly administered by the California Department of Health Services and the Managed Risk Medical Insurance Board (MRMIB). Children under the age of 19 years, family income does not exceed 300% of the federal poverty level may enroll into this program. Provider Resources Information related to Medi-Cal Managed Care, Healthy Families, and Healthy Kids may be found at the Department of Health Care Services website or the Department of Health and Human Services website. Providers may visit these websites to retrieve background information and/or obtain updates to enrollment eligibilities and requirements. Medi-Cal Managed Care: http://www.dhcs.ca.gov/services/pages/medi-calmanagedcare.aspx Healthy Families: http://www.healthyfamilies.ca.gov/home/default.aspx Healthy Kids: http://www.dhhs.state.nh.us/dhhs/medassistelig/eligibility/d4.htm Provider may also access the San Francisco Health Plan website at www.sfhp.org to find information related to member enrollment information in the City and County of San Francisco. San Francisco Health Plan has also provided our physicians many useful resources through the SFHP website such as: SFHP Drug Formulary: http://www.sfhp.org/providers/provider_resources/drug_formulary.aspx Clinical Guidelines: http://www.sfhp.org/providers/provider_resources/clinical_guidelines.aspx Community Resources: http://www.sfhp.org/providers/provider_resources/community_resources.aspx Health Education for Providers and patients: http://www.sfhp.org/providers/health_education/healthedlibrary.aspx San Francisco Health Plan also provides periodic group trainings to deliver updates related to the different lines of businesses. The training schedule can be found by visiting the website at: http://www.sfhp.org/community/trainings.aspx Additionally, Primary Care Physicians may register with San Francisco Health Plan to download the monthly member roster from the website. For information on how to use the SFHP secure provider website, please visit: http://www.sfhp.org/providers/provider_resources/secure_website.aspx Revised October 2011 1-2

I. Introduction Important Telephone Numbers Membership Eligibility SFHP General questions about member benefits, eligibility, covered services, etc. Automated Verification System 415-547-7805 or 800-288-5555 415-547-7810 NEMS-MSO Christina Ng 415-391-9686 x 5860 PCP Assignment San Francisco Health Plan 415-547-7810 Medical Director Daniel Chan, MD 415-352-5300 Referral and Authorization Suzanne Lee Dorothy Fung 415-352-5345 Case Management Olin Lau, FNP 415-352-5051 Claim Payment and Dispute Provider Credentialing Provider Contracting Patricia Tse Wendy Miao Winnie Choy Wendy Miao Sandy Chiang 415-352-5043 415-352-5041 415-352-5349 415-352-5041 415-352-5047 NEMS-MSO Address: 1520 Stockton Street San Francisco, CA 94133 Telephone: 415-391-9686 Fax: 415-398-2895 Hours: Monday to Friday: 8:30 a.m. to 5:30 p.m. San Francisco Health Plan (SFHP) Address: 201 Third Street, 7th Floor San Francisco, CA 94103 Telephone: 415-547-7800 Fax: 415-547-7824 Revised October 2011 1-3

II. Important Questions and Answers II. IMPORTANT QUESTIONS AND ANSWERS 1. How do I know if a patient is eligible for the San Francisco Health Plan (SFHP) benefits and if I am the Primary Care Provider? You must verify the following information when seeing SFHP members: Eligibility: Is the patient eligible for Medi-Cal / Healthy Families / Healthy Kids benefits for the present month? Health Plan Enrollment: Is the patient enrolled in SFHP? PCP Assignment: Is the member assigned to you (if you are a PCP) or do you have a referral from the member s PCP (if you are a specialist)? Medical Group Assignment: Which medical group is the PCP affiliated with? The SFHP Eligibility Verification & Fax Back System verifies Eligibility, SFHP Enrollment, PCP Assignment and Medical Group Affiliation. Information can be accessed 24 hours a day by calling (415) 547-7810. (Please also refer to Section III -- Member Eligibility Verification & Enrollment) 2. How do I find out if a service is covered? Please refer to the Benefits and Exclusions section in this manual for detailed information on the scope of benefits. The scope of benefits for Medi-Cal beneficiaries enrolled in SFHP is identical to Fee-for-Service Medi-Cal recipients. However, there are several benefits and diseases carved out by the Medi-Cal Managed Care Program, such as Chiropractic and Acupuncture services. Medi-Cal members may also be disenrolled from the Managed Care Program to receive Fee-for-Service benefits, such as Long Term Care and Major Organ Transplant services. Pharmacy and Optometry benefits are covered and provided by SFHP directly. Mental Health benefits are covered through the San Francisco Mental Health Plan. Benefits and service exclusions for the Healthy Families and Healthy Kids program are set according to the regulations set forth by the Managed Risk Medical Insurance Board (MRMIB). Co-payments are required for non-preventive services. See Section 4-11 for more detail. (Please also refer to Section IV -- Benefits and Exclusions) 3. Which doctor should I refer my patients to when they need specialty care? SFHP PCPs must refer members for specialty care within their affiliated Medical Group network. For members who have selected a NEMS Medical Group s affiliated PCP, a Specialist provider must be selected from the SFHP Provider Directory. Please visit the SFHP website at www.sfhp.org for a detail provider listing and their specialties. 4. What are the referral/authorization guidelines? PCPs may authorize consultations with specialists by filling out a Referral Authorization Form (Attachment A). Specialists may request additional visits for the patient from the PCP by completing the Specialist Extension Form (Attachment A). Certain services require prior authorization from the NEMS-MSO Utilization Management Department. Services Revised October 2011 2-1

II. Important Questions and Answers providers will need to submit a Treatment Authorization Request (Attachment A) form and obtain approval before the procedure can be performed. A listing of procedures requiring the TAR form is in this Provider Manual, including the method of submission of the TAR form. Extra supplies of RAFs, TARs and Specialist Extension Forms may be requested from the NEMS-MSO UM Department, or by visiting the NEMS MSO Portal at http://nems.org/mso. (Please also refer to Section V -- PCP Referral/ Authorization Policy) 5. What kinds of services do not require a referral or prior authorization? Under federal and state law, Medi-Cal beneficiaries may access certain services (family planning, diagnosis/treatment of sexually transmitted diseases, HIV testing, sexual abuse counseling) in or out of network, without referral or prior authorization. Though abortion services are not considered family planning services; they do not require PCP or Medical Group prior authorization. Medi-Cal members may access these services through any willing providers. Healthy Families and Healthy Kids subscribers may access these services within network without referral or prior authorization. The provider shall document the service(s) provided in a treatment record and then bill the members medical group for the above services using the HCFA-1500 form. A copy of the treatment record must accompany the claim for payment. (Please also refer to Section VI -- Sensitive Services) 6. How do I submit a claim? NEMS Medical Group encourages all providers to submit claims for services rendered as soon as practical using a HCFA-1500 or UB-92 form. Hard copy claims should be mailed to the NEMS-MSO Claims Department at 1520 Stockton Street, San Francisco, California 94133. NEMS MSO does not accept electronic claims submission at the current moment. 7. How soon will I received payment after submitting claims? In general, the turn around time (TAT) for a clean claim is thirty (30) calendar days; the TAT for an unclean claim is forty-five (45) business days (63 calendar days). (Please also refer to Section IX -- Claims Submission and Payment Dispute.) 8. Which hospital should I admit my patient to? Patients should be referred to the California Pacific Medical Center (CPMC) for hospital care. In certain emergency care situations, the provider should direct the member to the nearest or most appropriate hospital facilities. Revised October 2011 2-2

III. Eligibility Verification & Enrollment III. MEMBER ELIGIBILITY VERIFICATION & ENROLLMENT VERIFYING ELIGIBILITY When a SFHP member seeks medical care, it is essential that the provider office verify the member s eligibility, assigned PCP, and medical group. Failure to verify eligibility may result in non-payment of claims. SFHP makes final determination of a member s eligibility for the date of service at the time of receipt of the claim. Note: Possession of a SFHP ID Card does not guarantee eligibility. However, once eligibility is confirmed, the SFHP ID Card can identify the member s assigned PCP and medical group. The following table provides a summary of the methods to verify eligibility. TO VERIFY ELIGIBILITY AND ENROLLMENT: Ask for the member s SFHP ID Card Check eligibility using the Provider Secure Website at www.sfhp.org/providers/ OR Call the SFHP Interactive Voice Response system (IVR) at (415) 547-7810, 24 hours a day 7 days a week. OR Call the SFHP Member Services Department at (415) 547-7800 Monday-Friday, 8:30 a.m.-5:30 p.m. SFHP systems will report: SFHP Enrollment Status Medical Group Affiliation PCP Assignment Note: Do not rely upon POS or other non-sfhp systems to determine member assignment, as they will not identify medical group or designated PCP. Revised October 2011 3-1

III. Eligibility Verification & Enrollment How to Verify Member Eligibility On-line THE SFHP SECURE PROVIDER WEB SITE San Francisco Health Plan s Provider Secure Website, www.sfhp.org/providers/ is a fast and sure way for providers and their staffs to verify a member s eligibility, download member rosters, and check claims status for their practice. To access the web site, follow these easy steps to creating a unique user ID and password. DESIRED ACTION Go to www.sfhp.org/providers/ Select Provider Secure Login Registration for User ID and Password Basic Feature you can Verify Member Eligibility & PCP and Search for Claims: Additional Features you can: View Current Member Roster Download Current Member rosters in Excel format To obtain access to these features, submit the form at the bottom of page with additional feature requests. Checking Member Eligibility Click on Sign up here Fill in requested information for steps 1-6 Choose a USERNAME for step 7 Click Finish. Your password will be sent to you via the e- mail that you submitted in the registration process. Enter Username and Password Click on Login Click on Verify member Eligibility & PCP Choose Search by ID or Search by Last name and Date of Birth Complete requested information Click on Check Eligibility Download Patient Roster in Excel Format Enter Username and Password Click on Login Click on View Current Patient Roster Click on Download Excel Spreadsheet If you have questions regarding this web site please contact Rebecca Lim, SFHP Provider Relations at (415) 615-4256; If you are experiencing technical difficulties, please contact Ying Li, SFHP Information Systems at (415) 615-4227 Revised October 2011 3-2

III. Eligibility Verification & Enrollment How to Use the Interactive Voice Response (IVR) System The SFHP Interactive Voice Response (IVR) system allows 24-hour access to member eligibility, medical group and PCP assignment. Provider may access the IVR system by dialing the SFHP Automated Verification of Coverage (AVC) line at (415) 547-7810, 24 hours a day, 7 days a week. To verify eligibility, providers must provide: Member s first and last name. ID Number from the front of the member s SFHP ID card; if SFHP ID Card is not available, use the member s Social Security number, client index number (CIN) or Medi- Cal ID number. Provider name and contact telephone number. Note: Each SFHP member receives an ID card to present to providers as a means of verifying eligibility for covered services. In addition, Medi-Cal members are issued a state Basic Identification Card (BIC). As neither card guarantees eligibility, SFHP recommends that where possible providers first use the SFHP ID card to determine eligibility. Point of Service (POS) Swipe Devices Use of a Point of Service (POS) swipe device will only alert the provider that the member has enrolled into San Francisco Health Plan as a Managed Care member, and will not indicate member s medical group and/or PCP assignment. San Francisco Health Plan does not issue or participate in the use of POS Swipe devices for verifying eligibility. Revised October 2011 3-3

III. Eligibility Verification & Enrollment SAMPLE IDENTIFICATION CARDS Medi-Cal Benefits Identification Card (BIC) The BIC is a small plastic card, similar to a credit card, which is issued to every Medi-Cal beneficiary. Only one permanent BIC is issued, although it may be replaced through the county welfare department if lost or stolen. Cards are not sent monthly. The following fields are present on the BIC: 1. Recipient ID Number a 10-character client index number (CIN), a unique identifier assigned to each beneficiary by the state, followed by a check digit. The check digit should be ignored for eligibility purposes. 2. Beneficiary s first name, middle initial and last name. 3. Gender Code male or female. 4. Beneficiary s date of birth. 5. BIC issue date required for access to the beneficiary eligibility information via the computerized point of service (POS) network. Note: Payment will not be guaranteed for care provided if eligibility is not verified. Providers, Professionals, and Institutions must use their best judgment in deciding whether to provide treatment for an individual whose eligibility could not be verified. Revised October 2011 3-4

III. Eligibility Verification & Enrollment SFHP Member Identification Card for Medi-Cal Members Each SFHP member receives a member card to present as identification when requesting services. This card must be shown in addition to the State Medi-Cal Benefits Identification Card (BIC) shown previously. Medi-Cal members are instructed to keep both cards with them. Member Name: Jane Doe Effective Date: Jan. 1, 1997 SFHP ID #: 12345678910 Member Medi-Cal #: 38305551212011 Member SSN #: 123-45-6789 Primary Care Provider: John Williams, MD Provider Phone #: 415-391-9686 Clinic Name: North East Medical Service Address: 1520 Stockton Street IPA/MG code: NEMS Members: Call your Primary Care Provider (PCP) when you need medical care. Keep this card with you at all times and present to all doctors and hospitals that treat you. If you lose Medi-Cal eligibility or disenroll from SFHP, your Membership is invalid. Prescription Plan: To get a prescription filled, take your doctor s written prescription to a SFHP-PCN participating pharmacy. Vision Plan: To find a SFHP Vision Service Plan (VSP) doctor and get an eye exam or glasses call 800-877-7195. FRONT OF CARD (Actual card has blue logo.) FRONT OF CARD WITH FOLD Members: For Urgent Care call your Primary Care Provider (PCP) 24 hours a day 7 days a week. For Emergency Care when you are in extreme pain or there is threat of death or disability, go to the nearest hospital or call 911. Members and Providers: Please notify the SFHP of all emergency related care or admissions within 24 hours or as soon as possible. Emergency services rendered by non-affiliated providers will be reimbursed by SFHP/affiliated contractor. BACK OF CARD Providers: This card is for identification only. Use member BIC card for verifying eligibility or call SFHP at 415-547-7810. Contact your IPA/MG for pre-authorization for required services and referrals. Prior authorization for emergency services is not required. Pharmacy Provider Questions: Call PCN at 1-800-777-0074 Use Account Number 00670, BIN Number 610011, SFHP Member Services Call 415-547-7805 or 1-800-288-5555 BACK OF CARD WITH FOLD Independent Physician Associate/Medical Group (IPA/MG) Codes CHN = Community Health Network CHI = Chinese Community Health Care Association KSR = Kaiser Permanente NEMS = North East Medical Services Medical Group STL = Integrated Medical Group at St. Luke s Hospital UCS = UCSF Medical Group San Francisco Revised October 2011 3-5

III. Eligibility Verification & Enrollment SFHP Member Identification Card for Healthy Families Members Each SFHP member receives a member card to present as identification when requesting services. LISA LEWIS Healthy Families ID# 00001234 SFHP ID #: 12345678910 Effective date: 050298 Primary care provider: John Smith, MD #11809 Provider Phone #: 415-391-9686 Clinic: North East Medical Service Address: 1520 Stockton Street IPA/MG code: NEMS *co-payments: $5 office visit, waived for preventive visits and children under 24 months; $5 emergency room visit; $5 prescription medicine Pharmacy: use account # 00671, bin # 610011 FRONT OF CARD (Actual card has red logo.) SUBSCRIBERS: Call your PCP when you need medical care. Keep this card with you at all times and present to all doctors and hospitals that treat you. PRESCRIPTIONS To get a prescription filled, take your doctor's written prescription to an SFHP participating pharmacy. FOR URGENT CARE: Call your PCP 24 hours a day, 7 days a week. FRONT OF CARD WITH FOLD EMERGENCY CARE Go to the nearest hospital or call 911 if you are in extreme pain or there is threat of death or disability. Prior Authorization is not required. If you are outside of San Francisco, go directly to the nearest hospital emergency room for treatment and notify your medical group and physician as soon as possible. SUBSCRIBERS AND PROVIDERS Please notify SFHP of all emergency related care or admissions within 24 hours or as soon as possible. Providers: This card is for identification only. To verify member eligibility, call SFHP at 415-547-7810. Contact your IPA/MG for pre-authorization for required services and referrals. Prior authorization for emergency services is not required. PHARMACY PROVIDER QUESTIONS: Call PCN at 1-800-777-0074 SFHP MEMBER SERVICES Call 415-547-7805 or 1-800-288-5555 BACK OF CARD BACK OF CARD WITH FOLD *Members will not have to pay more than $250 in co-payments during the course of one benefit year (July 1 to June 30). SFHP sends a new ID card to each Healthy Families subscriber who meets his or her co-payment maximum for the benefit year. The co-payments field in the new ID card will state none. Revised October 2011 3-6

III. Eligibility Verification & Enrollment SFHP Member Identification Card for Healthy Kids Members Each SFHP member receives a member card to present as identification when requesting services. LISA LEWIS Healthy Kids ID# 00001234 SFHP ID #: 12345678910 Effective date: 050298 Primary care provider: John Smith, MD #11809 Provider Phone #: 415-391-9686 Clinic: North East Medical Service Address: 1520 Stockton Street IPA/MG code: NEMS *co-payments: $5 office visit, waived for preventive visits and children under 24 months; $15 emergency room visit; $5 prescription medicine Pharmacy: use account # 00671, bin # 610011 FRONT OF CARD (Actual card has red logo.) SUBSCRIBERS: Call your PCP when you need medical care. Keep this card with you at all times and present to all doctors and hospitals that treat you. PRESCRIPTIONS: To get a prescription filled, take your doctor's written prescription to an SFHP participating pharmacy. FOR URGENT CARE: Call your PCP 24 hours a day, 7 days a week. FRONT OF CARD WITH FOLD EMERGENCY CARE Go to the nearest hospital or call 911 if you are in extreme pain or there is threat of death or disability. Prior Authorization is not required. If you are outside of San Francisco, go directly to the nearest hospital emergency room for treatment and notify your medical group and physician as soon as possible. SUBSCRIBERS AND PROVIDERS Please notify SFHP of all emergency related care or admissions within 24 hours or as soon as possible. Providers: This card is for identification only. To verify member eligibility, call SFHP at 415-547-7810. Contact your IPA/MG for pre-authorization for required services and referrals. Prior authorization for emergency services is not required. PHARMACY PROVIDER QUESTIONS: Call PCN at 1-800-777-0074 SFHP MEMBER SERVICES Call 415-547-7805 or 1-800-288-5555 BACK OF CARD BACK OF CARD WITH FOLD **Members will not have to pay more than $250 in co-payments during the course of one benefit year (July 1 to June 30). SFHP sends a new ID card to each Healthy Families subscriber who meets his or her co-payment maximum for the benefit year. The co-payments field in the new ID card will state none. Revised October 2011 3-7

III. Eligibility Verification & Enrollment Electronic Eligibility Verification Options for Medi-Cal Members To obtain eligibility information, you may use the information on the BIC to verify eligibility through the computerized point of service (POS) network. In addition, the POS network can be used to clear share of cost and report Medi-Services. Listed below are the services available to access the POS Network: CERTS A claims and eligibility real-time software system which allows access to the POS when the card is swiped or the card number is input. You can also print results on a receipt. A sample POS readout will read like this: Sample Readout Meaning John Recipient Patient name A764908571 EVC# - (Verification #) 38 County code 82 Primary aid code Medi-Cal for dental Dental coverage Medi-Cal eligible - Health Plan enrollment Call 800-288-5555 Health Plan phone number AEVS the Automated Eligibility Verification System allows access using a touch-tone telephone. A computerized voice will guide the caller through the transactions and provide the most current Medi-Cal eligibility information available. Note: The above listed systems are free to qualified Medi-Cal providers. Access to these devices must be approved by the DHS through insurance of two authorization numbers. Call the San Francisco Health Plan customer service for more information on AEVS, CERTS or the POS Devise. Determining Medi-Cal Eligibility Individuals apply for Medi-Cal in person through the Department of Health Care Services (DHCS). Children and pregnant women may also apply through the joint Medi-Cal and Healthy Families on-line One-E-App system. The State creates a computer record for each eligible Medi-Cal member in the FAME system. The County Welfare Department supplies eligibility information on the Medi-Cal population to the State, and the Social Security Administration supplies eligibility information on the SSI/Fiscal Intermediary Access to the Medi-Cal eligible population. These agencies are responsible for correcting any discrepancies regarding Medi-Cal eligibility information. FAME information is the basis for the computerized point of service (POS) network that you may access directly to verify member eligibility, and it is updated on a daily basis. Revised October 2011 3-8

III. Eligibility Verification & Enrollment What is Contained in a FAME Record The FAME system identified a Medi-Cal beneficiary by Social Security number, Medi-Cal ID number, and a unique Client Index number (CIN). The CIN has replaced the SSN as the primary beneficiary identifier. The Medi-Cal ID number is a 14-digit number as listed below: Digit What they designate 1 st & 2 nd County of responsibility; SF is 38 3 rd & 4 th Aid category code; identifies the assistant program; 5 th 11 th County case number, a 7 digit number; 12 th Family budget number; 13 th & 14 th Person number Most Medi-Cal eligible family members have the same number from 1-12, except for SSI beneficiaries who have individualized numbers based on their SSN as listed: 1 st & 2 nd 3 rd & 4 th 5 th 6 th to 14th County Code Aid code Always 9 SSN or MEDS pseudo number FAME Monthly Update Every month, approximately five days prior to the end of the month, FAME is modified to reflect eligibility for the following month. Health Care Options (HCO) enrollment information is matched against MEDS eligibility to produce health plan enrollment files for Medi-Cal members throughout the State. A member s enrollment that is processed by HCO by the 25 th of the month will be enrolled into a health plan on the first day of the next month that they are eligible. If a form is entered after the FAME cut-off date, the beneficiary will not be enrolled until the first of the second following eligible month. Eligibility data received from the state is processed by SFHP before distribution to IPA/MGs and other contracted providers. Medi-Cal Mandatory Aid Codes Aid codes are indicators of Medi-Cal eligibility and are used by the DHCS to classify beneficiaries by the type of Medi-Cal services for which they qualify. In San Francisco County, Medi-Cal beneficiaries with the following aid codes must enroll in a managed care plan, either SFHP or the Commercial Managed Care plan (Blue Cross): Mandatory Aid Category Codes: 0A, 0I, 3L, 01, 02, 08, 30, 32, 33, 34, 35, 38, 39, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 3R, 54, 59, 5X, 7A, 7X, 82. Exceptions in the mandatory aid categories include: Individuals who have been approved by the Medi-Cal Field Office or the California Children s Services Program for bone marrow, heart, heart-lung, liver, lung, combined liver and kidney, or combined liver and small bowel transplants; Individuals who elect and are accepted to participate in the following Medi-Cal waiver programs: In-Home Medical Care Waiver Program, Skilled Nursing Facility Waiver Program, AIDS or AIDS-Related Conditions Waiver Program. Revised October 2011 3-9

III. Eligibility Verification & Enrollment Individuals determined by the Medi-Cal Field Office to be in need of long-term care who have been residing in a Skilled Nursing Facility (SNF) for thirty (30) days past the month of admission; and Individuals who have received a Medical Exemption. Managed Care Plan Hold Status Each month FAME renewal re-evaluates current and pending health plan enrollments to determine if beneficiaries qualifications for enrollment have changed. If a beneficiary still qualifies for health plan enrollment, he or she will appear on the health plan s monthly eligibility reports as a capitated member. However, if a beneficiary s qualifications for health plan enrollment have changed, he or she will appear on the health plan s report with a hold status. Capitation is not paid for a health plan member with hold status. The following changes would cause a hold on enrollment: 1. Change in aid code to one not covered by the managed care plan; 2. Change in county code not covered by the health plan. These individuals are disenrolled once brought to the attention of DHCS; 3. Loss of Medi-Cal eligibility; or 4. Hold placed on Medi-Cal eligibility In the first two cases (change in aid code or change in county code), the beneficiary may still be entitled to benefits under the Medi-Cal fee-for-service program. Under the last two cases (loss of Medi-Cal eligibility and hold placed on Medi-Cal eligibility), the beneficiary would not be entitled to Medi-Cal benefits. An enrollee may remain in hold status for up to two months. If enrollment is not reinstated within two consecutive months, FAME will automatically disenroll the beneficiary from the health plan. If the beneficiary again becomes eligible, he or she will be processed as a new eligible. Supplemental Eligibility (Retroactive Enrollment) Enrollments are effective on the first of a future month. Supplemental eligibility enrollments are the only enrollments applied retroactively. Supplemental eligibility is the reinstatement of a member for the month(s) when the member was on hold or lost eligibility. If the enrollment was placed on hold because of a change in aid code or county code, health plan eligibility can only be reinstated for a future month. This occurs because once eligibility has been established for a given month. It cannot be changed until the following month. The effective month in which an enrollment is reinstated is determined by the process date. If supplemental eligibility is reinstated before the FAME cut-off date, the enrollment is effective the first of the current month. Example: On hold for August, reinstated August 20, enrollment effective August 1. In this example, the health plan is responsible for all services provided to the enrollee during August, and receives later capitation for the full month. If supplemental eligibility is reinstated after the FAME cut-off date, but before the end of the month, enrollment is for the current month and future month. Example: On hold for August, reinstated August 28, enrollment for August and September. Revised October 2011 3-10

III. Eligibility Verification & Enrollment Determining Healthy Families Eligibility Electronic Data Systems Healthy Families (HF) provides health, dental and vision insurance at low cost to eligible children who do not have insurance and are not eligible for no-cost Medi-Cal. Once deemed eligible by HF enrollment contractor Electronic Data Systems (EDS), the child is covered for at least 12 months. Even if family circumstances change during this period, eligibility continues unless the applicant requests disenrollment or fails to pay the monthly premium. For requests to add additional children to the program, an applicant must complete a new application and forward it to EDS. The HF application may be used to apply for either HF or Medi-Cal. If an applicant is eligible for no-cost Medi-Cal, the application is forwarded to Medi-Cal for review. Help in completing the document is available by calling the NEMS Member Services Department at (415) 391-9686 for application assistance from our Member Services representatives. Once an application is received, EDS determines eligibility for the Healthy Families program within twenty (20) business days. The applicant is then notified in writing of the application status. The notice tells the date on which coverage begins for each enrolled child. The first day of insurance coverage begins 10 days from the date that EDS determines the child s eligibility. If an applicant wants an update on the status of an application, he or she can call toll free (800) 880-5305, between 8 a.m. and 8 p.m., Monday through Friday. If a child is found to be ineligible, the applicant will be informed in writing of the reason. If the applicant gave permission to forward the application to Medi-Cal, EDS will forward the application, without the payment for the first month s premium, to Medi-Cal. If not, the application and money order will be returned to the applicant. Healthy Families Premiums The HF program requires subscribers to pay a monthly fee to retain insurance coverage. The monthly premium is determined by income category, which in turn includes family size, family income, and the health plan chosen. Subscribers pay a monthly premium between $4 and $15 for each child, up to a maximum of $45 for all children in the family enrolled in the program. The first month s premium must be mailed with the application and paid with a cashiers check or money order. Once a child is enrolled in the program, the subscriber is billed monthly. Subscribers have two methods of saving money on the payment of insurance premiums: 1. Choosing the Community Provider Plan saves the subscriber $3 per child on the monthly premium. The Community Provider Plan includes the most traditional and safety net providers in its network. SFHP is the Community Provider Plan in San Francisco County. 2. After paying in advance for three consecutive months of premiums, the fourth month of coverage is free. If a premium payment is sixty (60) days late, the child s insurance coverage ends. Coverage termination is effective at the end of the last month in which the premium was paid in full. The subscriber is then responsible for any health care received by the covered child in the last Revised October 2011 3-11

III. Eligibility Verification & Enrollment month after coverage ended. Partial payments of the premium are not allowed, and are considered non-payment and will be returned to subscriber. In addition to monthly premiums, the subscriber must pay a co-payment for certain services. Although some services, such as preventive care, are free, the usual individual charge is $5 per visit. There is a $250 maximum co-payment limit for a family during each benefit year (July 1 to June 30). After the $250 maximum is met, no more co-payments are required for the benefit year. At this point, SFHP will send the subscriber a new ID card noting that the maximum copayment has been met. Annual Eligibility Review Each year the subscriber is asked to renew the child s eligibility for Healthy Families (HF). The HF program notifies the subscriber by mail of the Annual Eligibility Review (AER) process. The subscriber will receive a notice about sixty (60) calendar days before the end of the family s anniversary date in the Healthy Families Program. If the enrolled child still qualifies for the Program, coverage will continue for another twelve (12) months. Each time the subscriber enrolls a new child in the Program, the subscriber re-qualifies all the children who are enrolled in the Healthy Families for another twelve (12) months. The AER date for all children will be twelve (12) months from the date the last child is enrolled. The monthly premium will be recalculated. The new premium may change depending on the household income. Subscribers may contact the Healthy Families Program by: Phone: Call (800) 880-5305 Monday to Friday 8:00am to 8:00pm, Saturday 8:00am to 5:00pm. E-mail: Send question by e-mail to HealthyFamilies@MAXIMUS.com, or Write to: P.O. Box 138005, Sacramento, CA 95813-8005. Determining Healthy Kids Eligibility The Healthy Kids Program offers complete medical, dental and vision insurance to children at a very affordable cost, regardless of immigration status. Subscribers must be under the age of 19 years, not eligible for no-cost, full-scope Medi-Cal or the Healthy Families Program, with family income within 300% of Federal Poverty Level (FPL). Depending on income and family size, Healthy Kids members pay an annual premium ranging from $48 to $126. Each member will be re-evaluated annually prior to his or her anniversary date in the program to determine continued eligibility for the Program. The continued eligibility of each member is contingent upon the availability of public funds from the City and County of San Francisco ( CCSF ) to pay the premium costs of the program. At or before each member s anniversary date, SFHP shall determine whether funds are available from CCSF to cover the premiums for the member s next year of enrollment. Applicants shall be notified of the annual eligibility review process at least sixty (60) days prior to the anniversary date. It is the member s, or where the member is a minor, the applicant s, responsibility to notify SFHP within thirty-one (31) days of all changes in eligibility affecting member s enrollment in the Healthy Kids Program. Contact the SFHP Healthy Kids renewal team at (800)558-5858. Revised October 2011 3-12

III. Eligibility Verification & Enrollment SFHP ENROLLMENT AND DISENROLLMENT Throughout the State, families with children under the age of 19 who may be eligible for no-cost Medi-Cal or low-cost Healthy Families Program may complete a mail-in application to enroll into a managed care health plan. Trained application assistants may include SFHP staff, providers and community-based organizations. These qualified sites offer assistance to families with the applications. Applications can be ordered through Richard Health and Associates, by calling (888) 237-6248, or call SFHP for help in ordering applications. Medi-Cal Member SFHP Enrollment All enrollments and disenrollments are handled by the State Department of Health Services (DHS) Health Care Options (HCO) contractor. Health Care Options can be reached at (800) 430-4263. How a Medi-Cal beneficiary Choose a Health Plan In San Francisco, current Medi-Cal beneficiaries in the mandatory aid code categories (those who must choose a managed card plan) receive an enrollment packet in the mail from the HCO contractor. New applicants and beneficiaries re-determining Medi-Cal eligibility are also informed of the health plan enrollment process. Beneficiaries receive enrollment materials through the mail or from an enrollment presentation conducted by the HCO contractor. Medi-Cal health plan enrollment requirements for the mandatory population differ from the enrollment requirements for the voluntary population. The mandatory population is informed that they must enroll in a health plan unless specific exemption criteria are met. NOTE: DHS no longer allows providers to distribute Medi-Cal managed care enrollment materials and Medi-Cal Health Plan Choice Forms. Exemption from Medi-Cal Health Plan Enrollment In certain cases, the State allows a beneficiary in a mandatory aid category to avoid enrollment, or allows dis-enrollment from a health plan. The beneficiary may be allowed to remain in the fee-for-service program for the duration of the treatment, if the beneficiary has a complex medical problem and is in the middle of a treatment program with a provider that is not participating anywhere within the health plan s provider network. The doctor must verify in writing that changing providers would be harmful, and state the duration of the treatment. Medical conditions that fall into this category include: Complex cancer treatment; Organ transplant (when certified for organ transplant except for kidney member would be disenrolled from SFHP even if he or she did not request enrollment exemption); HIV - positive status; or Participation in any Medi-Cal Waiver Program (i.e. AIDS Waiver Program) In addition, certain Medi-Cal beneficiaries, including Native Americans, Alaska Natives and non-indians currently receiving services from an Indian Health Service Program, may request Revised October 2011 3-13

III. Eligibility Verification & Enrollment an alternative to plan enrollment and continue to receive services from that facility through regular Medi-Cal. Members and providers may contact SFHP at (415) 547-7805 or (800) 288-5555 for additional details and/or assistance. Problems with Health Care Options (HCO) DHS has established an Office of the Ombudsman. The Office handles the full range of problems that Medi-Cal managed care members/providers experience, and is one avenue that providers and the health plans may use to address enrollment and disenrollment problems. You can call the Office of the Ombudsman at 1-800-452-8609. In addition, providers are encouraged to contact SFHP customer Service at 415-547-7805 about enrollment/disenrollment problems. Member Disenrollment Members may leave San Francisco Health Plan (SFHP) at any time and switch to another Medi-Cal managed care health plan. In these cases, the member must complete a Medi-Cal Choice Form, provided by the HCO Contractor, not SFHP, processes disenrollments. Members should obtain a Choice Form through the health plan according to State policy, or call Health Care Options at 1-800-430-4263 to request a Medi-Cal Health Plan Choice Form. Disenrollments based upon DHS Criteria In some cases, members may be involuntarily disenrolled from the Health Plan based upon DHS State guidelines. Reasons why members may be disenrolled include: A move out of San Francisco County (our health plan area); Loss of State Medi-Cal eligibility (the Plan does not determine Medi-Cal eligibility); A change in Medi-Cal aid code category to one that is not eligible for Medi-Cal Managed Care; When a member s condition meets criteria for excluded services such as major organ transplants, waiver programs, and long term care; Enrollment was in violation of State regulations; The contract between the State DHS and SFHP ends; Services Requiring Disenrollment. There are certain medical conditions that may meet the criteria for disenrollment (i.e., major organ transplants, waiver programs and long-term care). These situations warrant member disenrollment. These disenrollments become effective on the first day of the second months following receipt by DHS of all documentation necessary to process the disenrollment. Disenrollments related to major organ transplants will be effective the beginning of the month in which the transplant is approved. Disenrollment for any of the above reasons will not affect the individual s Medi-Cal eligibility. Re-enrollment with the San Francisco Health Plan is at the discretion of the California Department of Health Services and the San Francisco Health Plan. Effective Date of Disenrollment Except as described above for excluded service disenrollment, if a member loses eligibility, coverage will terminate at midnight on the day specified by the Department of Health Services, but no later than the last day of the month in which Medi-Cal eligibility is lost. If a member moves out of the county, coverage will terminate at midnight on the last day of the month for Revised October 2011 3-14

III. Eligibility Verification & Enrollment which the State Department of Health Services has paid monthly premiums to the San Francisco Health Plan on the member s behalf. SFHP initiated disenrollments that are approved by DHS will become effective on the first day of month following the approval of the disenrollment request. Member initiated disenrollment from the San Francisco Health Plan, for whatever reason, takes fifteen (15) to forty-five(45) days for the HCO Contractor to process. Emergency Disenrollments SFHP can request emergency disenrollments. The HCO Contractor will process emergency disenrollments within two (2) working days of receipt. Emergency disenrollment guidelines are being finalized by DHS and in draft form include the following circumstances: Members who were assigned to SFHP and contact the Plan or the HCO Contractor within 60 days of enrollment who meet criteria for Exemption from Health Plan enrollment; Members who are in foster care; Members enrolled while in a long term care facility; Members enrolled that are incarcerated; Members that have moved out of the county; or Other reasonable cause (i.e. breakdown in doctor-patient relationship). Contact SFHP Customer Service at (415) 547-7805 to initiate/report appropriate member emergency disenrollments. SFHP staff will work with providers, the HCO enrollment contractor and DHS staff to the greatest extent possible to ensure appropriate and timely emergency disenrollments. Foster Care Disenrollments SFHP works with the County s Department of Human Services to identify members placed in the Foster Care system. These members must be disenrolled from Managed Medi-Cal to Feefor-service Medi-Cal. However, until such disenrollment becomes effective, it is the appropriate IPA/MG s responsibility to authorize and pay for emergency services and medically necessary urgent services. (This includes the medical screening examination, a requirement of every child in San Francisco County who is removed from his or her home.) Healthy Families Member SFHP Enrollment Electronic Data Systems (EDS), the Healthy Families contractor, reviews all applications for Healthy Families eligibility. Information on Healthy Families eligible members who choose San Francisco Health Plan (SFHP) as their health insurance plan is then electronically transmitted to SFHP on a nightly basis. Transfer between Health Plans Subscribers can request that their children be transferred from one health, dental and vision insurance plan combination to another. They can transfer in any of the following instances: Applicant requests in writing (one time for any reason) within the first 30 days of the original effective date of coverage in HF; Applicant requests in writing (one time for any reason) within the first 30 days of the effective date of coverage in a new insurance plan following open enrollment; Revised October 2011 3-15

III. Eligibility Verification & Enrollment The covered child has moved out of the area served by the chosen insurance plan; The applicant or insurance plan requests a transfer in writing because the child and the insurance plan cannot maintain a good relationship, and the MRMIB Executive Director determines that the transfer is in the best interest of the child and the Program; MRMIB does not renew the contract with the participating insurance plan where the child is enrolled, or the contract is cancelled; or At least one other participating insurance plan serves the area in which the child lives. Annual Open Enrollment Each year the subscriber can choose a new health, dental and vision insurance plan combination for their child during Annual Open Enrollment, which is held from April 15 to May 31 each year. The Healthy Families Program mails open enrollment information in early April to each eligible member. If the subscriber chooses a new health insurance plan combination, all enrolled children in the household are transferred to the new insurance plan combination. The transfer takes place on July 1 of the transfer year. Healthy Families Member Disenrollment Disenrollment from Healthy Families means a loss of insurance coverage for the covered child. Disenrollment can be initiated by the subscriber or the HF program because: The child is found ineligible during the Annual Eligibility Review; The subscriber does not provide the information needed for the child s annual review; The child reaches age 19 years; The subscriber does not pay the child s insurance premium for sixty (60) days after the due date; The subscriber writes to the Healthy Families Program asking to end enrollment; or The subscriber makes false declarations about eligibility. If any of the above occurs, the subscriber will receive a written disenrollment notice before the child is disenrolled from the program. The child s health, dental and vision coverage ends when the child is disenrolled. A disenrolled child cannot join Healthy Families again for six months from the date of disenrollment if: The child was disenrolled for non-payment of the premium; The subscriber requested disenrollment; or The subscriber does not provide information needed for the annual eligibility review. The six-month exclusion period does not apply if the reason for disenrollment is one of the following: The person responsible for payment of the premiums looses a job, suffers a catastrophic illness and is unable to work, or is unable to work for more than two weeks; or The child became eligible for no-cost full-scope Medi-Cal. Health Insurance Portability and Accountability Act (HIPAA) Notice Under HIPAA, creditable coverage occurs when a member receives credit for previous health coverage. This credit is important when the member has a pre-existing condition and is moving from the Healthy Families Program to a new health insurance plan. In these cases, the Revised October 2011 3-16

III. Eligibility Verification & Enrollment credit may cancel any pre-existing condition exclusions or waiting periods of the new health insurance plan. Within ten (10) days of disenrollment, the Healthy Families contractor sends the member a HIPAA notice. This notice lists the child s eligible months of creditable coverage while enrolled in the HF Program. If the subscriber has questions, he or she should call the Healthy Families Program at (800) 880-5305, between 8 a.m. and 8 p.m., Monday through Friday. The subscriber will need to report a SFHP/Healthy Families number C080 if the subscriber chose Denticare, C081 if the subscriber chose Delta Dental. Healthy Families Eligibility Data The Healthy Families Program is updated with member identification and eligibility information on a nightly basis. Updates to the Healthy Families Program eligibility primarily come from the Managed Risk Medical Insurance Board (MRMIB) enrollment contractor, EDS, where eligibility for Healthy Families is determined and prepared for the plan on a daily basis. Eligibility files will be available from EDS by 2 a.m. of the day following the first day of the 10-day window prior to the member s actual Healthy Families eligibility date. For example, if a member is eligible for HF Program on the 20 th of the month, the Plan would be notified of the new member 10 days prior, or the 10 th of the month. This means that the Plan would have access to the file containing the member s information at 2 a.m. on the 11 th of the month. Information on eligibility for the Healthy Families Program is as current and accurate as provided by MRMIB. Any discrepancies in Healthy Families eligibility must be corrected by this agency. Once Healthy Families eligibility has been granted, it becomes effective until SFHP is notified by MRMIB and EDS of a member s change in status. Eligibility and termination dates will be provided in the monthly eligibility/enrollment file and must be monitored by the IPA/MG or vendor providing service. The eligibility and termination dates will be generated on a daily basis by MRMIB and EDS and passed to the IPA/MG or vendor by SFHP. Because of the logistical complexities of coordinating and providing daily eligibility files to all of IPA/MGs and vendors, SFHP provides eligibility on a weekly basis to coincide with the EDS weekly eligibility file. PCP Selection/Assignment SFHP Provider Directories list the PCPs, clinics, hospitals, pharmacies and other health care professionals that participate with SFHP. Listed information includes PCP addresses, telephone numbers, office hours, languages spoken, and hospital and IPA/MG affiliations. There are separate Provider Directories for each line of business. A PCP may be a Pediatrician, a General Practitioner, a Family Practitioner, an Internist, and in some cases an OB/Gyn. PCPs may practice in Federally Qualified Health Centers (FQHC), hospital-based clinics, a Native American Health Services Facility or in a private practice. Nurse Practitioners and Certified Nurse Midwives may assume the role of a PCP under the supervision of a SFHP doctor. However, at the present time only participating doctors can be designated as PCPs. Revised October 2011 3-17

III. Eligibility Verification & Enrollment During the Health Care Options (HCO) enrollment process, each family member enrolling in a Health Plan is asked to choose a PCP from the Plan s Provider Directory. Members are allowed to choose a different PCP for each family member. Member selections are designated on the Medi-Cal Health Plan Choice Form as described in Section 1-1. When a member is enrolled with SFHP and a PCP selection is not indicated, SFHP will assign a PCP to the member based upon the member s preferred language, address, and other member demographic information. How to Change PCPs A member can request to change PCPs at any time. There is no annual limit to the number of times a member can request a new PCP. To request a change of Primary Care Provider, a member may call SFHP Member Services at (415) 547-7800 or (800) 288-5555, complete a PCP Change Form. A new member ID card with the name and phone number of the new PCP will be mailed to the member. If the member wishes to see a PCP before getting the new card, he or she may contact SFHP Member Services. A representative will tell the member which PCP to see. If a member decides to choose a different PCP, the Plan will do its best to meet the request. If the PCP of the member chooses is unavailable for some reason, SFHP Customer Service will contact the member by phone or in writing. Effective Date of PCP Change SFHP s standard operating policy is that all PCP change requests received (phone or written) by the 25 th day of the month will be effective on the 1 st day of the following month, Except: Members that are assigned to a PCP by SFHP and seek services at another PCP site during their first effective month of SFHP enrollment may request an immediate PCP change. If approved, PCP assignment would be retroactively applied to the first day of the member s effective month. Retroactive PCP assignments are approved by SFHP if the member warrants that they have not previously received any services from their assigned PCP or other network provider during that month. If the request comes after the 25 th day of the month, retroactive PCP changes may be approved on a case-by-case basis by SFHP or the change will take place on the 1st of the following month (within 8 days.) PCP Initiated Reassignment or Disenrollment of Members Based on reasonable cause and SFHP Medical Director approval, a member may be removed from a Primary Care Provider s (PCP) membership list if requested by the PCP. Reasonable cause includes communication problems, inappropriate behavior, multiple missed appointments and non-compliance. SFHP will review requests for reassignment on a case-bycase basis, and may consider other issues in addition to those above listed. All requests for reassignments must be coordinated through SFHP. The requesting PCP should not send the member a written termination letter. The PCP may initiate the process by calling SFHP, but must follow-up by faxing or mailing a letter, describing the reason for the proposed reassignment. Both the member and the provider are advised in writing of the Plan s decision regarding the reassignment and the member is offered assistance selecting and establishing a relationship with a new PCP. Revised October 2011 3-18

III. Eligibility Verification & Enrollment SFHP has the right to recommend to DHS the disenrollment of a member in the event of a complete breakdown in the doctor-patient relationship which makes it impossible for SFHP and SFHP providers to render services adequately to a member. Except in cases of violent behavior or fraud, SFHP and SFHP providers must make significant effort to resolve the problem with the member. If efforts to reassign a member to a new PCP do not resolve the member s problem, other efforts at resolution or assistance may be attempted. Member education and referrals to services such as mental health or substance abuse programs are a few examples. SFHP initiated disenrollment could occur for any of the following reasons: The member is repeatedly verbally abusive to SFHP providers or administrative staff or to other SFHP members. The member physically assaults a SFHP provider or staff person or member; or threatens another individual with a weapon on SFHP or provider premises. In this instance a police report must be filed against the member. The member is disruptive to SFHP operations. The member habitually uses providers not affiliated with SFHP for non-emergency services without required prior authorization (causing SFHP and providers to be subjected to repeated provider demands for payment for those services or other degradation in SFHP s relations with community providers). The member has allowed the fraudulent use of Medi-Cal coverage under SFHP, which includes allowing others to use their SFHP member ID to receive services. The member s failure to follow prescribed treatment (including failure to keep established medical appointments) will not, in and of itself, be reasonable cause for disenrollment by DHS. Disenrollment will not be approved unless SFHP can demonstrate that as a result of the failure, SFHP and SFHP providers are exposed to a substantially greater and unforeseeable risk than otherwise contemplated under DHS rate-setting assumptions. Providers must contact the SFHP Provider Relations Department to report all incidences of member abuse or fraud. SFHP will initiate disenrollment proceedings in accordance with policies and procedures outlined by the DHS. A member s health status or uses of services are not reasons for disenrollment. Disenrollment for either of the above reasons will not affect the individual s Healthy Families eligibility. Re-enrollment with SFHP is at the discretion of the California Department of Health Services and the San Francisco Health Plan. Healthy Kids Member SFHP Enrollment Initial Enrollment The acceptance of any application for enrollment in the Healthy Kids program is contingent upon the availability of public funds from the City and County of San Francisco ( CCSF ) to pay the premium costs of the program. Upon initial enrollment and payment of one year s premium, members shall be guaranteed one year of participation in the program. At or before each member s anniversary date, SFHP shall determine whether funds are available from CCSF to cover the premiums for the member s next year of enrollment. Revised October 2011 3-19

III. Eligibility Verification & Enrollment Upon determination that funds are available to cover the potential member, an individual shall be all of the following: Ineligible for no-cost full-scope Medi-Cal or Medicare or the Healthy Families Program at the time application. A resident of San Francisco County. In a family with an annual or monthly household income under 300% of the Federal Poverty Level. Not covered by employer-sponsored health insurance or any other publicly sponsored health insurance plan and has not been covered within the last 90 days. Pregnant minors may be eligible for pregnancy-related services under the Healthy Kids program. If the pregnant minor becomes a member of the Healthy Kids program, the baby will automatically be covered for the first thirty (30) days of its life. After this initial 30 day period, the baby will be eligible to enroll as a member if he/she meets all of the eligibility criteria. To learn more about the health coverage options, including the Healthy Kids program, please contact SFHP Member Services at (800) 288-5555. Annual Eligibility Review Each member will be re-evaluated annually prior to his/her anniversary date in the program to determine continued eligibility for the program. The continued eligibility of each member is contingent upon the availability of public funds from the City and County of San Francisco ( CCSF ) to pay the premium costs of the program. At or before each member s anniversary date, SFHP shall determine whether funds are available from CCSF to cover the premiums for the member s next year of enrollment. Applicants shall be notified of the annual eligibility review process at least sixty (60) days prior to the anniversary date. It is the member s, or where member is a minor, the applicant s, responsibility to notify SFHP within thirty-one (31) days of all changes in eligibility affecting member s enrollment in the Healthy Kids program. Contact San Francisco Health Plan Healthy Kids Renewal Team at (800)558-5858. Selecting a PCP Members are required to have a PCP and are encouraged to select a PCP at the time of enrollment. The PCP, along with the Medical Group, is responsible for coordinating and directing all of the member s medical care needs, arranging referrals to specialists and other providers (including hospitals), and providing the required prior authorization the member will need to obtain health care services. If a member does not select a PCP at the time of enrollment, SFHP will designate one and the member will be notified. This designation will remain in effect until the member notifies SFHP of his/her own selection. Enrolled members may call (415) 547-7800 or (800) 288-5555, Monday through Friday, 8:30am to 5:30pm, to select a PCP. Changing a PCP or Medical Group Members may change PCPs or medical groups by calling the SFHP Member Services Department. The change is effective the first day of the next month when the request is received by the 22 nd day of the previous month, following notice of approval by SFHP. If the Revised October 2011 3-20

III. Eligibility Verification & Enrollment request is received after the 22 nd day of the previous month, the member may not be able to make the change until the month after. Disenrollment SFHP will provide at least fifteen (15) days prior written notice to any member before disenrollment becomes effective, except in cases where a member is being disenrolled due to fraudulent use of Healthy Kids benefits. A member may be disenrolled from participation in the program if any of the following occur: The member is found by the Health Plan to no longer be eligible. The member attains the age of 19 years. Disenrollment for this reason shall be effective on the last day of the month the member attains the age of 25 years. The required annual premium is not paid for the member for 30 consecutive days after the due date. Disenrollment for this reason shall be effective 45 days from the date of the non-payment notice. Death of a member. The member, or applicant on behalf of the member, fails to provide the necessary information to be re-qualified during the annual eligibility review. The member or his/her legal representative to request in writing. Disenrollment for this reason shall be effective at the end of the month in which the request is made. Members who are disenrolled for non-payment may reapply for coverage. SFHP requires a full year of premium payment or premium assistance (if eligible) for reinstatement. Members who are disenrolled due to their age-out status are not eligible to reapply. In the event of disenrollment prior to the last day of the period for which payment has been made, SFHP will return to the applicant the prorated portion of the premium paid to the Health Plan which corresponds to any unexpired period for which payment has been received by the Health Plan. Revised October 2011 3-21

IV. Benefits and Exclusions IV. BENEFITS AND EXCLUSIONS COVERED BENEFITS The benefit packages for SFHP Medi-Cal enrollees, Healthy Families and Healthy Kids subscribers are distinct. Please see the following sub-sections for the benefits covered and excluded within each benefit package. The member benefits can also be accessed or downloaded from the SFHP website at www.sfhp.org. The services described in this section are covered services only if all of the following are true: The services are medically necessary; and Are provided, prescribed by the member s PCP and/or authorized by the State laws and regulations, Health Plan and IPA/MG policies. If members disagree with a decision on medical necessity as defined below, they can request a review by SFHP through the Plan s Grievance Procedure. SFHP and participating IPAs/MGs are not required to pay for care that members obtain from a provider other than a primary care provider, unless: There is a medical emergency; The Plan s Evidence of Coverage indicates that a referral is not needed (e.g., direct access to OB/GYNs or Sensitive Services for Medi-Cal members); or The primary care provider authorizes a visit to another provider before services are obtained. MEDICAL NECESSITY In the area of physical health, Medi-Cal defines medical necessity as those services to protect life, to prevent significant illness or significant disability or to alleviate severe pain. In the area of mental health, Medi-Cal defines medical necessity as meeting ONE of the following impairment criteria: Significant impairment in an important area of life functioning; Probability of significant deterioration in an important area of life functioning; or Probability of a child not progressing developmentally as individually appropriate; and meeting all the conditions below for intervention related criteria: Focus of proposed intervention is to address the condition identified in the impairment criteria above. Individual will benefit form the proposed intervention by significantly diminishing the impairment, or preventing significant deterioration in an important area of life function, and/or for children it is probable the child will progress developmentally as individually appropriate. The condition would not be responsive to physical health care-based treatment. Revised October 2011 4-1

IV. Benefits and Exclusions MEDI-CAL COVERED BENEFITS The scope of benefits for Medi-Cal beneficiaries enrolled in SFHP is identical to fee-for-service Medi-Cal. However, there are several benefit and disease category exceptions that require the member to receive services outside of SFHP. In some instances, beneficiaries receive Medi-Cal benefits through fee-for-service Medi-Cal, (i.e. chiropractic, acupuncture, dental, drug and alcohol services) and in other instances, beneficiaries are disenrolled and convert to fee-forservice Medi-Cal to receive Medi-Cal services (long-term care, certain waiver programs, major organ transplants). Mental health services are provided through the San Francisco Mental Health Plan. Please call 1-888-246-3333 for more information. One difference between fee-for-service Medi-Cal and SFHP is the authorization process. Under managed care, the treatment authorization request (TAR) was eliminated and replaced with an internal, and, in some instances, more comprehensive authorization process administered in accordance with the standards of SFHP by each contracted IPA/MG. All referrals to specialists, in and out of the network, and some diagnostic services, specified in the Provider Manual, must be authorized through the IPA/MG. Covered Services do not include the Limitations and Exclusions set forth in Section 4-8 of this chapter. Following is the list of covered services and benefits for Medi-Cal members of SFHP. All services must be medically necessary, and provided in accordance with the Plan s Rules and Benefits Booklet. A) Chemical Dependency Services Services for alcohol or drug addiction are covered in an SFHP hospital for medically necessary management of withdrawal symptoms. Exclusions: Any other chemical dependency services are covered or obtained through the San Francisco Mental Health Plan. Call (888) 246-3333 for more detail. B) Durable Medical Equipment (DME) DME includes medically necessary oxygen and equipment for its administration, blood glucose monitors, apnea monitors, pulmoaides and related supplies, nebulizer machines, tubing and related supplies, spacer devices for metered dose inhalers, insulin pumps and necessary related supplies, ostomy bags, and urinary catheters and supplies. Exclusions: The following DME is NOT a SFHP covered benefit: Comfort, convenience or luxury items; Corrective shoes and arch supports (except therapeutic footwear for diabetics); Dental appliances; Disposable supplies, except ostomy bags, urinary catheters, and supplies consistent with Medicare coverage guidelines; Electronic voice producing machines; Experimental or research equipment; Non rigid devices (such as elastic knee supports, corsets, elastic stockings and garter belts); Revised October 2011 4-2

IV. Benefits and Exclusions More than one device for the same part of the body. If there are two or more professionally recognized appliances equally appropriate for a condition, SFHP will provide benefits based on the most cost effective appliance. Surgically implanted devices, such as pacemakers, are covered. C) Emergency Medical Care Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; (c) serious dysfunction of any bodily organ or part. Services for an emergency medical condition, in any Emergency Room, both in and out of the medical group s provider network, without prior authorization from the Plan or the member s PCP, are covered. However, follow-up care for the illness, injury or condition that caused the emergency medical service must be provided, referred and/or authorized according to the rules described in the PCP Referral and Authorization section. D) Family Planning Services Family planning services are medically necessary services that prevent or delay pregnancy. Family planning services are available from a member s PCP or any qualified family planning agency, clinic or doctor who accepts payment from SFHP or the IPA/MG. Members do not need a referral for family planning services. Services include the cost of fitting and/or inserting birth control devices (e.g., diaphragms, IUDs, Norplant), and the devices themselves, family planning drugs, and treatment for complications resulting from past family planning care. These services are available for male and female health plan members. Family planning does not include abortions. Elective abortions are covered when provided or arranged by a participating IPA/MG provider. Prior authorization is not required. Voluntary sterilization services are covered only if: The individual is at least 21 years old at the time the consent is obtained; The individual is mentally competent; The individual is not institutionalized; and at least 30 days, but not more than 180 days, have passed between the date the Sterilization Consent Form (PM-330 form) was signed and the date of the sterilization service was obtained. Exception: Sterilization may be performed at the time of emergency abdominal surgery or premature delivery if the written informed consent to be sterilized was given at least thirty (30) days before the individual intended to be sterilized, and at least seventy-two (72) hours have passed since written informed consent to be sterilized was given. Revised October 2011 4-3

IV. Benefits and Exclusions E) Food/Vitamins/Diet Items Nutritional supplements and formulas, including those for the treatment of Phenylketonuria (PKU), are covered only when prescribed by the member s PCP or specialist. Enteral formula is also covered if the member is in need of tube feedings. F) Hearing Services Monaural or binaural hearing aids, including ear molds, the hearing aid instrument, the initial battery, cords and other ancillary equipment are covered. Visits for fitting counseling, adjustments and repairs are provided at no charge for one year following the provision of a covered hearing aid. Other covered services include internally implanted hearing aids, additional batteries or other ancillary equipment, replacement parts for hearing aids, repair of hearing aid after the covered one-year warranty period. Exclusions: Any replacement after the first replacement a 36-month period and surgically implanted hearing devices are excluded from coverage. G) Home Health Care Home health care is covered when services are provided in lieu of staying in the hospital for an extended period of time. Home health care may include intermittent nursing care, parttime skilled nursing care, part-time home health aide, respiratory care, speech and/or occupational therapies, and medical social services. Exclusions: Personal care, comfort and/or convenience items are not covered. H) Hospital Inpatient Care Covered inpatient hospital services include: Semi-private room and board, unless a private room is medically necessary and authorized. If a private room is used without authorization, the member is responsible for the difference between the hospital s customary charge for a two-bed room and the private room. General nursing care and special duty nursing when medically necessary and authorized. Intensive care services. Operating room, special treatment room, delivery room, newborn nursery and related facility services. Meals (and special diets when authorized). Hospital ancillary services, including diagnostic laboratory, x-ray services, and shortterm therapy services. Medications, intravenous fluids, biologicals, and oxygen administered in the hospital and approved by the Food and Drug Administration (FDA). Up to three days supply of drugs as directed upon discharge during transition from hospital to home. Surgical and anesthetic supplies, dressings and cast materials, surgically implanted devices and prostheses (not including surgically implanted hearing aids), other medical supplies, medical appliances, and equipment administered in the hospital. Prosthetic devices for a patient having a mastectomy (to restore and achieve symmetry for the patient) or for a patient having a laryngectomy (to restore speech). Administration of blood and blood plasma including hospital blood processing, the cost of blood, blood plasma, and other blood products. Includes the collection and storage of autologous blood when medically indicated. Revised October 2011 4-4

IV. Benefits and Exclusions Radiation therapy, chemotherapy and renal dialysis. I) Hospice Care Hospice care is covered when a member has a terminal illness and the physician determines that life expectancy is 12 months or less. Hospice care is subject to Health Plan and the member s IPA/MG approval, and may be provided in home or at a hospice facility. Services include medications, supplies, nursing care, home health aide and homemaker services, counseling and bereavement services. J) Maternity Care Medically necessary professional and hospital services including routine prenatal and postpartum care, nutritional counseling, labor and delivery care, follow-up visit(s) and care for complications or conditions resulting from pregnancy or childbirth are covered. Care for the newborn child is covered for the month of birth and the month after, up to 60 days, based on the mother s eligibility. The newborn should receive an eligibility determination independent of the mother s and must be enrolled separately. K) Medical Supplies, Equipment and Prosthetic Devices Devices, such as artificial limbs and eyes, are covered when the device is necessary to treat an injury, illness or birth defect that occurs while the patient is a member of SFHP. Braces or other devices used primarily for sports or recreational activities are not covered. Other covered prosthetic services include: Mammary prostheses - artificial breast or breast implant following a mastectomy; Blood and blood products; Durable Medical Equipment such as crutches, wheel chairs, walkers and home oxygen equipment prescribed by a participating provider. Common household items for convenience purposes are not included. L) Medical Transportation Non-emergency ambulances, litter vans and wheelchair vans are covered when members need transportation to obtain medically necessary health care services, and their medical and physical condition is such that transportation by a car, bus or BART is not medically advisable. Non-emergency medical transportation requires prior approval from the IPA/MG. M) Mental Health Services Short-term mental health care services provided by member s PCP in a primary care setting are covered. Inpatient mental health care is covered when authorized and performed by a participating mental health professional, but limited to: The treatment of an acute phase of a mental health condition; Care provided at a participating hospital; A maximum of thirty (30) days per benefit year. Outpatient visits for mental health care must be authorized and performed by a participating mental health professional. It is limited to evaluation, crisis intervention and treatment for Revised October 2011 4-5

IV. Benefits and Exclusions conditions that are subject to significant improvement through relatively short-term therapy. Services not subject to short-term therapy, such as chronic psychosis, chronic brain syndrome, or intractable personality disorder are not covered. Benefits are limited to a maximum of twenty (20) visits per benefit year. With the agreement of the subscriber, member, applicant, or other responsible adult, SFHP may substitute the following for a day of inpatient hospitalization: two days of residential treatment, three days of day care treatment, or four outpatient visits. Exclusions: Specialty mental health services and Short-Doyle Mental Health services are not covered. These services may be provided through the San Francisco County Mental Health Plan. Authorizations can be requested through the SFMHP Access Line at (415) 255-3737 or toll-free at (888) 246-3333. Services for the treatment of mental retardation are not covered. Subscribers determined by the County Mental Health Department to be seriously emotionally disturbed (SED) will be treated by the County for these conditions. Once eligibility is established and treatment has begun by the County Mental Health Department, the member will still receive primary care services that are not related to SED conditions through SFHP. N) Out-of-Area Services If a member is admitted to a hospital as the result of an emergency and the facility is not within the member s IPA/MG s network, the Plan may elect to transfer the member to a hospital within the IPA/MG s network. This transfer will occur when the patient s condition is medically stable. Any service provided by the hospital after SFHP has deemed the transfer safe is not a covered service. Non-emergency care provided outside of San Francisco is not covered unless referred and authorized in accordance with Health Plan rules in the Member Handbook. O) Pharmacy Services SFHP covers approved outpatient prescription drugs and some over-the-counter medications. Orders for drugs must be written by a participating provider, mental health provider or dentist. Members must use Plan participating drug stores and pharmacies. A member leaving the hospital after inpatient or emergency room care must be given a sufficient quantity of each medically necessary medication to ensure adequate supply until the member can reasonable expect to fill his/her prescription. In no event should the member receive less than a 12-hour supply. P) Physician and Preventive Care General physician and preventive care covered services include: Office visits for examinations and surgical procedures; Preventive medical care, such as well-baby care, immunizations and physical examinations; Referrals for special needs such as allergy, dermatology, cardiology and podiatry; Physician home visits when medically necessary; Revised October 2011 4-6

IV. Benefits and Exclusions Physician visits and examinations during a stay in a hospital or skilled nursing facility; Health promotion and education programs such as healthy eating, smoking cessation and parenting skills. Q) Rehabilitation Center Services Inpatient and outpatient rehabilitation services, including cardiac rehabilitation, and physical, speech, hearing and occupational therapy, whether provided in a specialized rehabilitation hospital or as part of a rehabilitation program in an acute general hospital, are covered only when such services are expected to result in the significant improvement of the member s condition within a reasonable period of time. R) Reconstructive Surgery Reconstructive surgery corrects or repairs problems with parts of the body that are caused by birth defects, abnormal development, trauma, infection, tumors, or diseases. This is covered if an SFHP provider finds that it will make your body work better or make the appearance more normal to the member. Reconstructive surgery of the breast is covered after the medically-necessary removal of all or part of a breast (mastectomy). S) Sensitive Services Sensitive services, includes sexually transmitted disease counseling/treatment/services, HIV/AIDS services, services for sexual assault, abortions services, and family planning services are covered. Members are allowed to seek medical care for sensitive services within the medical group s physician network referral from PCP and/or authorization from the IPA/MG. T) Skilled Nursing Facility/Intermediate Care Facility Services in a skilled nursing facility or intermediate care facility are covered for the month of admission and the following month. Members who need extended skilled nursing services may continue on Medi-Cal, but must disenroll form SFHP. As soon as practical, the provider should notify the member s Medical Group when they have a patient who is expected to remain in a SNF/ICF beyond the month following admission. The Medical Group should call Health Care Option and/or SFHP to initiate the disenrollment process. U) Therapy and Rehabilitation Services Special therapy is covered when such services are expected to result in a significant improvement to the patient s condition within a reasonable period of time. Special therapy may be subject to restrictions and may include: Physical therapy Respiratory therapy Speech therapy Occupational therapy V) Transplant Services Transplant services for kidney and corneal are covered if: Revised October 2011 4-7

IV. Benefits and Exclusions The member when receiving services is age 21 or older; and There is prior authorization from the member s PCP and IPA/MG; and The transplant services are done at a SFHP transplant facility. Exclusions: If a member is under the age of 21, the transplant services will be provided by California Children Services (CCS). Other transplant services such as lung, heart, liver, heart/lung, or any other organ transplant. Members may get these services through regular Medi-Cal or CCS. W) Vision Services An annual retinal exam is covered as health promotion and prevention for diabetic patients. MEDI-CAL LIMITATIONS AND EXCLUSIONS a) Acupuncture Services Eligible members may receive acupuncture services through fee for service Medi-Cal. b) Adult Day Health Care Services which a member gets through the adult day health care program are not covered. c) CCS Services California Children Services is a medical program that treats children with certain physically handicapping conditions and who need specialized medical care. As part of the services provided through the Medi-Cal Program, children needing specialized medical care may be eligible for the CCS Program. A Medi-Cal member must be under the age of 21 and their PCP must suspect or identify a possible CCS-eligible condition. The PCP must refer the member to the local CCS Program to be eligible for the Program. If the CCS Program determines the member s condition is eligible for CCS services, the member will continue to stay enrolled with SFHP, but will receive treatment for the CCSeligible condition through the specialized network of CCS providers and CCS approved specialty centers. SFHP will continue to provide primary care and preventive services that are not related to the CCS-eligible condition. SFHP will also work with the CCS program to coordinate care provided by both the CCS Program and SFHP. The CCS Program will provide all of the services necessary to treat the CCS-eligible condition and SFHP will provide all medically necessary covered services not covered by CCS. d) Chiropractic Services Eligible members may receive Chiropractic services through fee for service Medi-Cal. e) Cosmetic Services Plastic surgery or other cosmetic services to change the member s appearance are not covered. This exclusion does not apply to services covered under Reconstructive Surgery in Section 4-7. Revised October 2011 4-8

IV. Benefits and Exclusions f) Custodial care Services primarily for custodial, maintenance, or domiciliary care or rest or to change a person s environment are not covered. g) Dental Care Services that are normally done by a dentist, orthodontist, or oral surgeon, and dental appliances are not covered. The exclusion does not apply to medically necessary covered services, such getting the member s jaw ready for radiation treatment, where the member s PCP may refer the member to a dentist. Children under age 21 may receive dental care through Denti-Cal. h) Diets/Vitamins/Food Special foods or diet items, including vitamins, minerals, food supplements, nutritional services and food item for special diets are not covered. i) Experimental or Investigational Services Experimental or Investigational cares are services that: Are not seen as safe and effective by generally accepted medical standards to treat a condition; or Require approval by a governmental authority prior to use and such approval has not been granted when the service is to be rendered. Experimental or Investigational services are not covered, unless the conditions of Title 22 of the California Code of Regulations, Section 51303 (h) are met and prior authorization is received. Members may request an Independent Medical Review (IMR) for denied requests for Experimental or Investigational services. See Section 5-8 for more information. j) Hair Loss or Growth Treatment Services to make hair grow or for hair loss are not covered benefits. k) Infertility Services and Conception by Artificial Means Infertility services and treatments including in-vitro fertilization, gamete intrafallopian transfer (G.I.F.T), embryo transport, donor semen, and non-medically necessary amniocentesis are not covered. l) Personal Care Services Services that are not medically necessary, such as help with activities of daily living are not covered. Or, services that can be done by people whom do not need a medical license or do not have to be supervised by a nurse. This exclusion does not apply to services covered under Skill Nursing Facility Care in section 4-7. m) Prayer Healing Eligible members may receive prayer healing services through fee-for-service Medi-Cal. Revised October 2011 4-9

IV. Benefits and Exclusions n) Reversal of Sterilization Services to reverse voluntary surgical birth control (tubal-ligation for women and vasectomy for men) are not covered. o) Routine Foot Care Services Routine foot care services that are not medically necessary are not covered benefits. p) Sexual Reassignment Surgery Sexual reassignment surgery, including hormone therapy associated with sexual reassignment surgery, is not a covered benefit. q) Surrogacy A surrogacy arrangement occurs when a woman (the surrogate ) agrees to become pregnant and give the baby to someone else to rise. Services for anyone related to the member in a surrogacy arrangement, except for services covered in this manual that are provided to a member who is a surrogate, are not covered. r) Testing Any examinations, testing or treatments for purposes of obtaining or maintaining a career, education, employment or insurance, marriage or adoption, are not covered, even if it is prescribed by a participating provider. s) Travel and Lodging Costs Travel and lodging costs related to covered services are not covered. This exclusion does not apply if the member s medical group authorizes care from a non-sfhp provider and SFHP authorizes the costs ahead of time. This exclusion does not apply to services covered under Medical Transportation in Section 4-5. t) Limitations and Reductions The California Department of Managed Health Care (DMHC) has the right to recover money from a third party payer, such as: Services covered by an employer; Services covered by government agencies; Services covered by Medicare; Services covered by the veteran s administration; Services covered by other health insurance plan as their primary insurance; The amount recovered by DHS will never be more than the amount a third party pays. Revised October 2011 4-10

IV. Benefits and Exclusions HEALTHY FAMILIES COVERED BENEFITS MEDICAL NECESSITY For all services (including physical and mental health), Healthy Families defines medical necessity as services, supplies and equipment that are: Established as sage and effective; Furnished in accordance with generally accepted professional standards to treat illness or injury; Determined by SFHP to be consistent with the symptoms or diagnosis; Not furnished primarily for the convenience of the patient, the attending physician or other providers; Furnished at the most appropriate level that can be provided safely and effectively to the patient. Benefits and service exclusions for the Healthy Families program are determined according to the regulations set forth by the Managed Risk Medical Insurance Board (MRMIB). Copayments are required for non-preventive services. Please see Section 4-23 for additional information. Following is the list of covered services and benefits for Healthy Families members of SFHP. All services must be medically necessary, and provided in accordance with the Plan s Rules and Benefits Booklet. A. Acupuncture and Chiropractic Services Acupuncture and Chiropractic benefits are administered by American Specialty Health Plans, and an HMO licensed by the State of California. American Specialty Health Plans (ASHP) is an independent contractor to San Francisco Health Plan that provides and administers these benefits. ASHP has established a network of participating Chiropractors and participating Acupuncturists to provide and arrange the Acupuncture and Chiropractic benefits members may receive under the Healthy Families Evidence of Coverage. Members can self-refer for initial Acupuncture or Chiropractic exams. Treatment may be authorized by SFHP for up to 20 visits per benefit year each for Acupuncture and Chiropractic care. Members must pay a co-payment for each visit. Exclusions: Those not customarily considered part of acupuncture or not provided by licensed acupuncturist services are not covered. Chiropractic examinations and/or treatments for conditions that are not associated with spinal, muscle or joint manipulation are also not covered. B. Alcohol and Drug Abuse Services Inpatient hospitalization as medically necessary for alcohol and drug detoxification is covered. Up to 20 outpatient visits per benefit year are also covered for medically appropriate crisis intervention and treatment of alcoholism or drug abuse. This benefit is provided through the County Mental Health Plan. SFHP contracts with San Francisco Revised October 2011 4-11

IV. Benefits and Exclusions Mental Health Plan (SFMHP) to provide these services. Authorizations can be requested through the SFMHP Access Line at (415) 255-3737 or toll-free at (888) 246-3333. Exclusions: Treatment and rehabilitation on an inpatient or day care basis, whether or not court-ordered, except for inpatient detoxification are not covered. C. Biofeedback A maximum of eight (8) visits for biofeedback are covered if referred by a PCP or participating specialist. D. Blood and Blood Products The processing, storage, and administration of blood and blood products in inpatient and outpatient settings are covered. The collection and storage of autologous blood is also covered when medically indicated. E. Clinical Cancer Trials If a member is recommended to participate in a cancer clinical trial by his/her physician, and the treating physician determines that participation will have a meaningful potential to the member, the clinical cancer trails, phase I through IV, are covered. Benefits include the payment of costs associated with the provision of routine patient care, including drugs, items, devices and services that would otherwise be covered if they were not provided in connection with an approved clinical trial program. F. Diagnostic X-ray and Laboratory Services Diagnostic laboratory services, diagnostic imaging and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, treat and follow-up on the care of members are covered. Benefit includes other diagnostic services including Electrocardiography, Electroencephalography, and Mammography for screening or diagnostic purposes; and Laboratory tests appropriate for the management of diabetes, including at a minimum: cholesterol, triglycerides, microalbuminuria, HDL/LDL, and Hemoglobin A-1C (Glycohemoglobin). G. Durable Medial Equipment (DME) DME includes medically necessary oxygen and equipment for its administration, blood glucose monitors, apnea monitors, pulmoaides and related supplies, nebulizer machines, tubing and related supplies, spacer devices for metered dose inhalers, insulin pumps and necessary related supplies, ostomy bags, and urinary catheters and supplies. Exclusions: The following DME are NOT covered benefits by SFHP: Comfort, convenience or luxury items; Corrective shoes and arch supports (except therapeutic footwear for diabetics); Dental appliance; Disposable supplies, except Ostomy bags, urinary catheters, and supplies consistent with Medicare coverage guidelines; Electronic voice producing machines; Experimental or research equipment; Revised October 2011 4-12

IV. Benefits and Exclusions Non rigid devices (such as elastic knee supports, corsets, elastic stockings and garter belts); More than one device for the same part of the body. If there are two or more professionally recognized appliances equally appropriate for a condition, SFHP will provide benefits based on the most cost effective appliance. Surgically implanted devices, such as pacemakers, are covered. H. Emergency Health Care Services Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain) such that a prudent lay person, who possesses and average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; (c) serious dysfunction of any bodily organ or part. Services for an emergency medical care, in any Emergency Room, both in and out of the medical group s provider network, without prior authorization from the Plan or the member s PCP, are covered. However, follow-up care for the illness, injury or condition that caused the emergency medical service must be provided, referred and/or authorized according to the rules described in Section 5-9. I. Family Planning Services Family planning benefits include family planning, counseling, professional services for sterilization as permitted by State and Federal Law, and prescription contraceptives, as listed in SFHP s Drug Formulary. Services include the cost of fitting and/or inserting birth control devices (e.g., diaphragms, IUDs, Norplant), and the devices themselves, family planning drugs, and treatment for complications resulting from past family planning care. Therapeutic abortions are covered when medically necessary. Infertility services, except treatment for medical conditions of the reproductive system, are not covered services. J. Inpatient Hospital Services Covered inpatient hospital services include: Semi-private room and board, unless a private room is medically necessary and authorized. If a private room is used without authorization, the member is responsible for the difference between the hospital s customary charge for a two-bed room and the private room. General nursing care and special duty nursing when medically necessary and authorized. Intensive care services. Operating room, special treatment room, delivery room, newborn nursery and related facility services. Meals (and special diets when authorized) Hospital ancillary services, including diagnostic laboratory, x-ray services, and shortterm therapy services. Medications, intravenous fluids, biological, and oxygen administered in the hospital and approved by the Food and Drug Administration (FDA). Up to three days supply of Revised October 2011 4-13

IV. Benefits and Exclusions drugs as directed upon discharge by the SFHP physician during transition from hospital to home. Surgical and anesthetic supplies, dressings and cast materials, surgically implanted devices and prostheses (not including surgically implanted hearing aids), other medical supplies, medical appliances, and equipment administered in the hospital. Prosthetic devices for a patient having a mastectomy (to restore and achieve symmetry for the patient) or for a patient having a laryngectomy (to restore speech). Administration of blood and blood plasma including hospital blood processing, the cost of blood, blood plasma, and other blood products. Includes the collection and storage of autologous blood when medically indicated. Radiation therapy, chemotherapy and renal dialysis. K. Hearing Care Monaural or binaural hearing aids, including ear molds(s), the hearing aid instrument, the initial battery, cords and other ancillary equipment are covered. Visits for fitting counseling, adjustments and repairs are provided at no charge for one year following the provision of a covered hearing aid. Other covered services include internally implanted hearing aids, additional batteries or other ancillary equipment, replacement parts for hearing aids, repair of hearing aid after the covered one-year warranty period. Replacement more than once in 36-month period and surgically implanted hearing devices are excluded from coverage. L. Home Health Care Home health care services are skilled medical services provided by SFHP s contracted licensed providers to a homebound member. The purpose of home care is to transition the member from institutionalization or to prevent institutionalization when the Subscriber does not require continuous skilled services in the home. A homebound member is unable to leave his or her home due to a medical condition except with considerable effort and assistance. Home health care services are provided according to an authorized home health treatment plan and only when medically necessary and authorized. Home health care services must be provided under the direct care and supervision of the member s PCP within the IPA/MG. Home Health Benefits include intermittent and part-time home visits by a home health agency to provide the skilled services of the professional providers described in this section. As authorized, home health visits are made by the following clinicians: Registered nurse Licensed vocational nurse Physical therapist Occupational therapist Speech therapist Respiratory therapist Certified home health aides provide services in conjunction with the services of the nurses and/or the therapists listed above. Licensed Medical Social Workers provide consultations and/or evaluations. Revised October 2011 4-14

IV. Benefits and Exclusions Physical therapy, occupational therapy, speech therapy and other rehabilitative therapy provided in this section are counted towards, and subject to, the SFHP maximums described in Short Term Therapy section. The following home health care services are also included: In conjunction with the professional services rendered by a home health agency, medical supplies and medications administered by the home health agency necessary for the home health care treatment plan, and related pharmaceutical and laboratory services to the extent that these services would have been provided if the member was an inpatient of a hospital; Medically necessary home visits by a SFHP physician; Durable Medical Equipment (DME) that if medically necessary under the members home health treatment plan. DME shall be rented or purchased, as determined by SFHP, and must be authorized by the member s IPA/MG. DME does not include equipment that is primarily for the convenience of the member or the person providing care. Replacement of lost equipment and repair due to misuse and damage of DME are not covered. Exclusions: The following are excluded services: Services that are not skilled services or those for lone-term physical therapy or rehabilitation; Non-skilled, convalescent, or domiciliary care (also called custodial ) as defined by SFHP. In the event that services are partially custodial care and partially skilled medical services benefits, SFHP will cover only that portion of the costs of the home health care that is directly attributable to the provision of the skilled medical services. IN the event that the member has been diagnosed with a terminal illness and has less than six months to live as determined by the member s PCP, authorized home health care services, subject to all limitation of this section, may be provided even if they are custodial services; Services that can safely be performed for the member by a family member or a nonmedical person without the direct supervision of a licensed health care professional (even if this person is unavailable), or that can safely be self-administered by the member; Services provided as a substitute for SNF benefits or for any other limited benefit exhausted by the member. M. Hospice In addition to the above home health care services, SFHP provides hospice care for members who are terminally ill. Care is provided through periodic visits to the member at home by licensed hospice staff under contract to SFHP, if the member elects this home-based treatment instead of the other benefits for terminal illness provided by the Plan. The member may change the decision to receive hospice care at any time and request other services offered by SFHP. A life expectancy of twelve months or less after being diagnosed indicates patient is terminally ill. Hospice care must be provided by a licensed hospice provider who contracts with the Health Plan. When ordered by a Plan physician, hospice benefits include: Physician services Revised October 2011 4-15

IV. Benefits and Exclusions Nursing care Medical social services Home health aid services Drugs, medical supplies and appliances Counseling and bereavement services Physical, occupational and speech therapy Short-term inpatient care for pain control and symptom management Homemaker services Short-term respite care Exclusions: Members who elect hospice care are not entitled to any other benefits under the plan for the terminal illness while the hospice election is in effect. N. Medical Transportation Services The SFHP will pay for the following ambulance services: Emergency Ambulance Services -- ambulance transportation to the nearest hospital is covered only if, as determined by SFHP, the transportation was required for the member to receive emergency services for a life-threatening emergency medical condition. Authorized Ambulance Services -- ambulance services to transfer the member to or from an SFHP hospital or SNF in connection with an authorized confinement/admission will be authorized only when transportation by other means would adversely affect the member s medical condition, whether or not such other means of transportation is available. Coverage for transportation by airplane, passenger car, taxi, or other form of public transportation is excluded. O. Mental Health Services Mental health care services when ordered and performed by a San Francisco Community Behavioral Health Plan provider are covered. For members with a Serious Emotional Disturbance (SED), inpatient mental health care is covered when authorized and performed by a participating mental health professional, but limited to: The treatment of an acute phase of a mental health condition; Care provided at a participating hospital; A maximum of thirty (30) days per benefit year. With the agreement of the subscriber, member, applicant, or other responsible adult, SFHP may substitute the following for a day of inpatient hospitalization: two days of residential treatment, three days of day care treatment, or four outpatient visits. Outpatient visits for mental health care must be authorized and performed by a participating mental health professional. It is limited to evaluation, crisis intervention and treatment for conditions that are subject to significant improvement through relatively short-term therapy. Revised October 2011 4-16

IV. Benefits and Exclusions Services not subject to short-term therapy (such as chronic psychosis, chronic brain syndrome, or intractable personality disorder) are not covered. The benefit is limited to a maximum of 20 visits per benefit year. Mental health services for Healthy Families members are provided through the County Mental Health Plan. SFHP contracts with San Francisco Mental Health Plan (SFMHP) to provide these services. Authorizations can be requested through the SFMHP Access Line at (415) 255-3737 or toll-free at (888) 246-3333. Services for the treatment of mental retardation are not covered. Subscribers determined by the County Mental Health Department to be seriously emotionally disturbed (SED) pursuant to Section 5600.3 of the Welfare and Institutions Code will be treated by the County for these conditions. Once eligibility is established and treatment has begun by the County Mental Health Department, the member still receives primary care services that are not related to SED conditions through SFHP. P. Maternity Care Medically necessary professional and hospital services including routine prenatal and postpartum care, nutritional counseling, labor and delivery care, follow-up visit(s) and care for complications or conditions resulting from pregnancy or childbirth are covered. Inpatient hospital care will be provided for 48 hours following a normal vaginal delivery and 96 hours following delivery by cesarean section. Q. Outpatient Hospital Services Services and supplies for treatment (including radiation and chemotherapy) or surgery in an outpatient hospital setting or ambulatory surgery center are covered. Hospital outpatient psychiatric care/alcohol and drug abuse treatment is not covered. Other Outpatient Services include diagnostic and therapeutic radiological services such as electrocardiography, electroencephalography, mammography and laboratory services that are necessary to evaluate, diagnose, and treat and follow-up on the care of children and adolescents. Tests for management of diabetes, cholesterol, triglycerides, microalbuminuria, HDL/LDL, and Hemoglobin A-1C (glycohemoglobin) are also included. Hospital services listed in this section are SFHP benefits when authorized and provided at a participating SFHP hospital and provided in accordance with SFHP rules. Hospital services in connection with dental procedures are covered when due to an underlying medical condition or because of the severity for the procedure. Services of the dentist or oral surgeon may be covered under the Healthy Families Dental Plan in which the member is enrolled. Note: Hospital benefits are not covered if the member refuses to be under the direct care and treatment of an IPA/MG physician or other physician whose services have been authorized. R. Preventive Health Services The following services are covered for Healthy Families members: Well baby care from birth through age 2. Revised October 2011 4-17

IV. Benefits and Exclusions Exams every year for children ages 3-18. Breast and pelvic exams and Pap tests every year for women. Mammography for screening for diagnostic purposes and annual cervical cancer screening test as recommended by the member s PCP or a qualified provider. Immunizations consistent with the most current Recommendations for Preventive Pediatric Health Care as adopted by the American Academy of Pediatrics, and the most current version of the Recommended Childhood Immunization Schedule/ United States, jointly adopted by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians. Immunizations required for travel as recommended by the U.S. Public Health Services and other age-appropriate immunizations as recommended by U.S. Public Health Services. Hearing screening by the PCP to determine the need for an audiogram for hearing correction. Screening for blood lead levels in children at risk for lead poisoning, as determined by the PCP. Health education and health promotion services provided by SFHP Vision screening by the PCP to determine the need for a refraction test for vision correction. S. Prescription Drug Program Medically necessary prescription drugs (including injectable) are covered when prescribed by a licensed practitioner acting within the scope of his or her license. Coverage includes needles and syringes, when medically necessary for the administration of the covered injectable medication. For diabetics, coverage includes medically necessary insulin, blood glucose testing strips, ketone urine testing strips, and lancets. Prenatal vitamins and fluoride supplements that require a prescription are covered only if medically necessary. SFHP shall determine the supply of drugs to be prescribed. Only genetic drugs are covered unless a generic equivalent for a brand-name drug does not exist and is medically necessary; up to a 24 to 30 days supply of these drugs will be given. Up to a 90 to 100 days supply of maintenance drugs, including oral and injectable contraceptives and insulin supplies are covered. (Maintenance drugs are those prescribed for 60 days or longer and are usually for chronic conditions). Smoking cessation drugs are covered for one cycle or course of treatment per benefit year. Please note, the member for whom smoking cessation treatment is prescribed must also attend a smoking cessation program. T. Reconstructive Surgery Medically necessary cosmetic and reconstructive surgery for congenital defects, sever burns and other medical conditions, as well as services related to cosmetic and reconstructive surgery, are covered to repair or alleviate bodily damage caused by illness or injury or following surgery. Additionally, cosmetic services are provided in connection with reconstructive surgery after a mastectomy to restore and achiever symmetry for the patient. Revised October 2011 4-18

IV. Benefits and Exclusions U. Skilled Nursing Care A Skilled Nursing Facility (SNF) is a facility which contracts with SFHP, provides continuous skilled nursing services, and is licensed as a SNF by the State of California. A SNF may be a distinct part of a hospital and use of such distinct part shall be counted towards the maximum number of days described below. This benefit is limited to 100 days during any benefit year. Subject to this limitation, the following SNF benefits are provided when medically necessary and authorized, and are not primarily for custodial, convalescent or domiciliary care: Semi-private room and board, unless a private room is medically necessary and authorized. If a private room is used without authorization, the member is responsible for the difference between the SNF s customary charge for a two-bed room and the private room General nursing care and special duty nursing, when authorized Special diets, when authorized Physical therapy, occupation therapy, speech therapy, and other rehabilitative services up to SFHP maximums Oxygen administered in the SNNF Administration of blood and blood plasma, including hospital blood processing, the cost of blood, blood plasma, and other blood products. Includes the collection and storage of autologous blood, when medically indicated Durable Medical Equipment utilized by the member during an authorized SNF stay. V. Therapy Services Short-term therapy services and benefits, whether provided on an inpatient or outpatient basis (including when provided in an acute care hospital, rehabilitation unit, SNF, outpatient office, or as part of home health care or hospice services), may be provided up to a combined maximum of 60 consecutive calendar days following the first such therapy treatment for any single illness or injury. As is in the case of all services, these services must be medically necessary and authorized. Short-term therapy benefits include physical therapy, occupational therapy, speech therapy and respiratory therapy. If the IPA/MG determines that extending short-term therapy services beyond the 60-day period on an outpatient basis will result in a significant improvement of the member s condition, a short-term extension of such outpatient therapy may be authorized. W. Transplant Services Hospital and professional services provided in connection with medically necessary and authorized human organ transplants are covered for recipients who are SFHP subscribers. All transplants must be pre-authorized and SFHP may require that the transplant be performed at a transplant center selected by SFHP. In no event will organ transplants be a covered benefit if experimental or investigational or for the transplant of non-human organs or artificial organs. When the transplant recipient is a member, services incident to obtaining the transplanted material from a living donor or an organ transplant bank are covered for the covered transplant. Prescribed post-surgical immune suppressive outpatient drugs following the Revised October 2011 4-19

IV. Benefits and Exclusions transplant are also covered. The costs of any transplant services are not covered when the recipient of the transplant is not a member. Note: Bone marrow and organ donor searches are covered benefits. However, SFHP is not responsible for assuring the availability of, or locating a bone marrow donor or donor organ. X. Vision Care Eye refraction tests to determine the need for corrective lenses, dilated retinal eye exams, cataract spectacles, cataract contact lenses, or intraocular lenses that replace the natural lens of the eye after cataract surgery are covered by SFHP. Also, one pair of conventional eyeglasses or conventional contact lenses is covered if necessary after cataract surgery with insertion of an intraocular lens. Vision Service Plan (VSP), the Healthy Families vision plan, covers an eye examination, lenses and one pair of frames once each 12 months. Through this program, each member is entitled to a comprehensive vision examination, including a complete analysis of the eyes and related structures. HEALTHY FAMILIES LIMITATIONS AND EXCLUSIONS Cosmetic services -- plastic surgery or other cosmetic services used primarily to improve the member s appearance that will not result in significant functional improvement; cosmetic products, health or beauty aids. Treatment of non-cosmetic complications of cosmetic surgery (e.g., infections or hemorrhages) may be a benefit, but only upon review and approval by SFHP Custodial care -- as part of services rendered in the home or after hospitalization or confinement in a health facility primarily for custodial, maintenance, or domiciliary care, rest, or to control or change a person s environment, such as confinement in an eating disorder unit. Dental care -- except hospitalization for a dental procedure, when required. Disabling condition, illness or injury -- related services for which the member is entitled to an extension of benefits or other coverage under a contract or policy providing hospital, medical or surgical expense or service benefits. Drug addiction -- drug abuse treatment or rehabilitation on an inpatient, or day care basis, except as medically necessary to remove toxic substances from the body. Durable medical equipment -- when used for comfort or convenience. Foot care -- routine care, including callus, corn paring or excision, toenail trimming, foot orthotics and treatment (other than surgery and therapeutic footwear for diabetics) of chronic conditions of the foot, including but not limited to weak or fallen arches, flat or pronated foot, pain or cramp of the foot, bunions, muscle trauma due to exertion or any type of massage procedure on the foot. Revised October 2011 4-20

IV. Benefits and Exclusions Investigational and Experimental care -- health care services, drugs, devices or treatments that are determined by SFHP to be experimental or investigational. A drug is not excluded under this section on the basis that the drug is prescribed for a use that is different from the use for which the drug has been approved for marketing by the Federal Food and Drug Administration, provided that each of the conditions set forth in Section 1367.21 of the California Health and Safety Code are met. Home/vehicle improvements -- modifications or attachments made to dwellings, property, or motor vehicles including ramps, elevators, stair lifts, swimming pools, air filtering systems, environmental control equipment, spas, hot tubs, or automobile hand controls. Infertility treatment -- including in-vitro fertilization, a G.I.F.T. (Gamete Interfallopian Transfer) procedure or any other form or induced fertilization, artificial insemination, or services incident to or resulting from procedures for or the services of a surrogate mother. Treatments for medical conditions of the reproductive system are not excluded. Intermediate care facility -- services that are received in an Intermediate Care Facility (ICF). Learning and self-improvement programs -- such as the treatment of hyperkinetic syndrome, learning disability, behavioral problems, developmental delay, mental retardation, and/or autism in childhood (other than diagnosis), or for or incident to reading, vocational, educational, recreational, art, dance or music therapy, weight control or exercise programs. Long-term care -- unless SFHP determines that it is a less costly, satisfactory alternative to covered benefits. Short-term, SNF and hospice care are covered. Mental health/psychiatric -- inpatient and outpatient services are limited. Members with serious mental disturbances will be referred to the County Mental Health Department for specialized treatment. Subscribers will remain with SFHP but will receive care for SED conditions through the County Mental Health Department. Military services related to military injuries or injuries or disabilities for which care is reasonably available from the Department of Veterans Affairs. Non-covered benefits -- including services or benefits not specifically listed in the Evidence of Coverage, the Member Handbook, or the Health Plan contract, or that is listed as exclusion. Non-skilled care -- that can be performed safely and effectively by family members or persons without licensure or certification or the presence of a supervising licensed nurse, except for authorized homemaker services for hospice care. Obesity surgery -- morbid obesity, unless determined medically necessary by SFHP. Organ transplant donor -- services for a member in connection with donor transplant services when the recipient of the transplant is not a member. Revised October 2011 4-21

IV. Benefits and Exclusions Orthopedic -- devices/other supplies, including orthopedic shoes (except for diabetics); elastic supports as listed in the exclusions for orthotic and prosthetics, disposable medical supplies, home testing devices, comfort items, environment control equipment, exercise equipment, selfhelp/educational devices, home monitoring equipment, any type of communicator, voice enhancer, voice prosthesis or any other language assistance devices, except as provided under orthotics and prosthetics. Over-the-counter -- drugs, supplies, and devices, including over-the-counter devices such as air filters, medications not requiring a prescription, vitamins, minerals, food supplements, or food items for special diets or nutritional supplements. Pain management -- defined as confinement in a pain management center to treat or cure chronic pain. SFHP covers pain management services in a regular SFHP hospital for intractable cancer pain or traction. Physical exams and immunizations -- required for licensure, employment, insurance, participation in school or participation in recreational sports, ordered by a court, or for travel, unless the examination corresponds to the schedule of routine physical examinations and immunizations. Prescriptions for drugs and medicines that have not received the marketing approval of the U.S. Food and Drug Administration (FDA), however, coverage for drugs and medicines which have received FDA approval for marketing for one or more uses will not be denied on the basis that they are begin prescribed for an off-label use if the conditions set forth in California Health & Safety Code Section 1367.21 have been met. Private duty nursing -- special duty nursing, if authorized, may be covered as part of an authorized hospital or SNF admission. Prostheses -- unless implanted by surgical means, other than prosthetic devices for members have mastectomies. Services -- not provided by, prescribed, or referred, by the member s PCP and not authorized in accordance with SFHP procedures except for emergency services, OB/GYN visits (including family planning), and initial acupuncture and chiropractic exams. Surgery -- for or incident to intersex surgery (transsexual operations) are excluded. Medically necessary services relating to complications of sex change surgeries are a covered benefit. Sexual dysfunction -- incident to non-physically related sexual dysfunction, including all services excluded under infertility treatment described in this section; penile implant devices, surgery and related services, except as penile devices and surgery are medically necessary for a non-psychiatric condition. Medically necessary services relating to complications of surgery area covered benefit. Skin Aging -- services relating to the diagnosis and treatment to retard or reverse the effects of aging of the skin. Revised October 2011 4-22

IV. Benefits and Exclusions Speech therapy -- relating to speech problems not related to surgery, trauma or stroke Substance abuse admissions (whether or not court-ordered) -- unless medically necessary for acute medical detoxification. Transportation -- other than provided under ambulance services Vasectomy and tubal ligation -- vasectomy and tubal ligation reversal, repeat vasectomy or tubal ligation, or the infertility resulting thereof Vision care -- except for services listed on page 4-12, which are provided through the Healthy Families Vision Plan Workers Compensation benefits -- including any injury arising out of, or in the course of, any employment for salary, wage or profit, or any disease covered, with respect to such employment, by any workers compensation law, occupational disease law or similar legislation. If SFHP pays for such services, it shall be entitled to establish a lien upon such other benefits up to the reasonable cash value of benefits provided by SFHP for the treatment of the injury or disease as reflected by the providers usual billed charges. Also, SFHP may recover the cash value of its benefits from the member to the extent that such benefits would have been covered or paid for as Workers Compensation Benefits if the member had diligently tried to establish his or her rights. HEALTHY FAMILIES PROGRAM CO-PAYMENT For non-preventive services, the member is responsible for paying a minimum charge (copayment) to the physician or provider of services when services are received. Specific copayments are listed in the Summary of Benefits. Because of a recent waiver from MRMIB, American Indians and Alaskan natives are exempt from all co-pays. The maximum aggregate co-payment per benefit year (July 1- June 30) is $250 per family, no matter how many children are enrolled. Members should ask for a receipt whenever they make a co-payment and keep the receipt and a record of all payments so that they can demonstrate when the maximum has been paid. When the limit is reached, members should contact SFHP s Customer Service Department at (800) 288-5555 to get a no co-pay identification card. Members are asked to present this card at each visit to the doctor s office or pharmacist to provide proof that the maximum co-payment amount has been reached. In the event a subscriber utilizes a significant number of health services which co-payments are required, and which causes a financial burden to the subscriber, SFHP requests that providers accommodate the subscribers in instituting a co-payment plan whereby the subscriber can reimburse the provider over an extended period of time which will be mutually determined by the subscriber and the provider. There are no deductibles under the program and there are no lifetime financial benefit maximums for any of the covered health benefits. Revised October 2011 4-23

IV. Benefits and Exclusions HEALTHY KIDS COVERED BENEFITS MEDICAL NECESSITY For all services (including physical and mental health), Healthy Kids defines medical necessity as services, supplies and equipment that are: Established as sage and effective; Furnished in accordance with generally accepted professional standards to treat illness or injury; Determined by SFHP to be consistent with the symptoms or diagnosis; Not furnished primarily for the convenience of the patient, the attending physician or other provider; Furnished at the most appropriate level that can be provided safely and effectively to the patient. Exclusions and limitations for the Healthy Kids program are determined according to the regulations set forth by the Managed Risk Medical Insurance Board (MRMIB). Co-payments are required for non-preventive services. Following is the list of covered services and benefits for Healthy Kids members of SFHP. All services must be medically necessary, and provided in accordance with the Plan s Rules and Benefits Booklet. 1) Alcohol and Drug Abuse Services Inpatient hospitalization as medically necessary to remove toxic substances from the system is covered. Up to twenty (20) outpatient visits per benefit year are also covered for medically appropriate crisis intervention and treatment of alcoholism or drug abuse. This benefit is provided through San Francisco Community Behavioral Health Plan. Authorizations can be requested through the SFCBHP s Access Help Line at (415) 255-3737 or toll-free at (888) 246-3333. Exclusions: Treatment and rehabilitation on an inpatient or day care basis, whether or not court-ordered, except for inpatient detoxification, are not covered. 2) Blood and Blood Products The processing, storage, and administration of blood and blood products in inpatient and outpatient settings are covered. The collection and storage of autologous blood is also covered when medically indicated. 3) Cancer Clinical Trials Routine patient care costs related to the member s participation in a cancer clinical trial which meets the requirements of Health and Safety Code Section 1370.6. The member must be diagnosed with cancer, and is recommended to participate in a cancer clinical trial by his/her physician, and the treating physician determines that participation will have a meaningful potential to the member, the clinical cancer trails, phase I through IV, are covered. Benefits include the payment of costs associated with the provision of routine Revised October 2011 4-24

IV. Benefits and Exclusions patient care, including drugs, items, devices and services that would otherwise be covered if they were not provided in connection with an approved clinical trial program. 4) Diagnostic X-ray and Laboratory Services Diagnostic laboratory services, diagnostic imaging and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, treat and follow-up on the care of members are covered. Benefit includes other diagnostic services including Electrocardiography, Electroencephalography, and Mammography for screening or diagnostic purposes; and Laboratory tests appropriate for the management of diabetes, including at a minimum: cholesterol, triglycerides, microalbuminuria, HDL/LDL, and Hemoglobin A-1C (Glycohemoglobin). 5) Durable Medial Equipment (DME) DME includes medically necessary oxygen and equipment for its administration, blood glucose monitors, apnea monitors, pulmoaides and related supplies, nebulizer machines, tubing and related supplies, spacer devices for metered dose inhalers, insulin pumps and necessary related supplies, ostomy bags, and urinary catheters and supplies. Exclusions: The following DME are NOT covered benefits by SFHP: Comfort, convenience or luxury items; Corrective shoes and arch supports (except therapeutic footwear for diabetics); Dental appliance; Disposable supplies, except Ostomy bags, urinary catheters, and supplies consistent with Medicare coverage guidelines; Electronic voice producing machines; Experimental or research equipment; Non rigid devices (such as elastic knee supports, corsets, elastic stockings and garter belts); More than one device for the same part of the body. If there are two or more professionally recognized appliances equally appropriate for a condition, SFHP will provide benefits based on the most cost effective appliance. Surgically implanted devices, such as pacemakers, are covered. 6) Emergency Health Care Services Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain) such that a prudent lay person, who possesses and average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; (c) serious dysfunction of any bodily organ or part. Services for an emergency medical care, in any Emergency Room, both in and out of the medical group s provider network, without prior authorization from the Plan or the member s PCP, are covered. However, follow-up care for the illness, injury or condition that caused Revised October 2011 4-25

IV. Benefits and Exclusions the emergency medical service must be provided, referred and/or authorized according to the rules described in Section 5-9. 7) Family Planning Services Family planning benefits include family planning, counseling, professional services for sterilization as permitted by State and Federal Law, and prescription contraceptives, as listed in SFHP s Drug Formulary. Services include the cost of fitting and/or inserting birth control devices (e.g., diaphragms, IUDs, Norplant), and the devices themselves, family planning drugs, and treatment for complications resulting from past family planning care. Therapeutic abortions are covered when medically necessary. Infertility services, except treatment for medical conditions of the reproductive system, are not covered services. 8) Inpatient Hospital Services Covered inpatient hospital services include: Semi-private room and board, unless a private room is medically necessary and authorized. If a private room is used without authorization, the member is responsible for the difference between the hospital s customary charge for a two-bed room and the private room. General nursing care and special duty nursing when medically necessary and authorized. Intensive care services. Operating room, special treatment room, delivery room, newborn nursery and related facility services. Meals (and special diets when authorized) Hospital ancillary services, including diagnostic laboratory, x-ray services, and shortterm therapy services. Medications, intravenous fluids, biological, and oxygen administered in the hospital and approved by the Food and Drug Administration (FDA). Up to three days supply of drugs as directed upon discharge by the SFHP physician during transition from hospital to home. Surgical and anesthetic supplies, dressings and cast materials, surgically implanted devices and prostheses (not including surgically implanted hearing aids), other medical supplies, medical appliances, and equipment administered in the hospital. Prosthetic devices for a patient having a mastectomy (to restore and achieve symmetry for the patient) or for a patient having a laryngectomy (to restore speech) Administration of blood and blood plasma including hospital blood processing, the cost of blood, blood plasma, and other blood products. Includes the collection and storage of autologous blood when medically indicated Radiation therapy, chemotherapy and renal dialysis. 9) Hearing Care Audiological evaluation to measure the extent of hearing loss and a hearing aid evaluation to determine the most appropriate make and model of hearing aid. Monaural or binaural hearing aids, including ear molds(s), the hearing aid instrument, the initial battery, cords and other ancillary equipment are covered. Other covered services include internally implanted hearing aids, additional batteries or other ancillary equipment, replacement parts for hearing aids, repair of hearing aid after the covered one-year warranty period. Replacement more Revised October 2011 4-26

IV. Benefits and Exclusions than once in 36-month period and surgically implanted hearing devices are excluded from coverage. 10) Home Health Care Home health care services are skilled medical services provided by SFHP s contracted licensed providers to a homebound member. The purpose of home care is to transition the member from institutionalization or to prevent institutionalization when the Subscriber does not require continuous skilled services in the home. A homebound member is unable to leave his or her home due to a medical condition except with considerable effort and assistance. Home health care services are provided according to an authorized home health treatment plan and only when medically necessary and authorized. Home health care services must be provided under the direct care and supervision of the member s PCP within the IPA/MG. Home Health Benefits include intermittent and part-time home visits by a home health agency to provide the skilled services of the professional providers described in this section. As authorized, home health visits are made by the following clinicians: Registered nurse Licensed vocational nurse Physical therapist Occupational therapist Speech therapist Respiratory therapist Certified home health aides provide services in conjunction with the services of the nurses and/or the therapists listed above. Licensed Medical Social Workers provide consultations and/or evaluations. Physical therapy, occupational therapy, speech therapy and other rehabilitative therapy provided in this section are counted towards, and subject to, the SFHP maximums described in Short Term Therapy section. The following home health care services are also included: In conjunction with the professional services rendered by a home health agency, medical supplies and medications administered by the home health agency necessary for the home health care treatment plan, and related pharmaceutical and laboratory services to the extent that these services would have been provided if the member was an inpatient of a hospital; Medically necessary home visits by a SFHP physician; Durable Medical Equipment (DME) that if medically necessary under the members home health treatment plan. DME shall be rented or purchased, as determined by SFHP, and must be authorized by the member s IPA/MG. DME does not include equipment that is primarily for the convenience of the member or the person providing care. Replacement of lost equipment and repair due to misuse and damage of DME are not covered. Exclusions: Covered home health care services DO NOT include the following: Revised October 2011 4-27

IV. Benefits and Exclusions Services that are not skilled services or those for lone-term physical therapy or rehabilitation; Non-skilled, convalescent, or domiciliary care (also called custodial ) as defined by SFHP. In the event that services are partially custodial care and partially skilled medical services benefits, SFHP will cover only that portion of the costs of the home health care that is directly attributable to the provision of the skilled medical services. IN the event that the member has been diagnosed with a terminal illness and has less than six months to live as determined by the member s PCP, authorized home health care services, subject to all limitation of this section, may be provided even if they are custodial services; Services that can safely be performed for the member by a family member or a nonmedical person without the direct supervision of a licensed health care professional (even if this person is unavailable), or that can safely be self-administered by the member; Services provided as a substitute for SNF benefits or for any other limited benefit exhausted by the member. 11) Hospice In addition to the above home health care services, SFHP provides hospice care for members who are terminally ill. Care is provided through periodic visits to the member at home by licensed hospice staff under contract to SFHP, if the member elects this home-based treatment instead of the other benefits for terminal illness provided by the Plan. The member may change the decision to receive hospice care at any time and request other services offered by SFHP. A life expectancy of twelve months or less after being diagnosed indicates patient is terminally ill. Hospice care must be provided by a licensed hospice provider who contracts with the Health Plan. When ordered by a Plan physician, hospice benefits include: Physician services Nursing care Medical social services Home health aid services Drugs, medical supplies and appliances Counseling and bereavement services Physical, occupational and speech therapy Short-term inpatient care for pain control and symptom management Homemaker services Short-term respite care Exclusions: Members who elect hospice care are not entitled to any other benefits under the plan for the terminal illness while the hospice election is in effect. 12) Medical Transportation Services The SFHP will pay for the following ambulance services: Emergency Ambulance Services -- ambulance transportation to the nearest hospital is covered only if, as determined by SFHP, the transportation was required for the member to receive emergency services for a life-threatening emergency medical condition. Revised October 2011 4-28

IV. Benefits and Exclusions Authorized Ambulance Services -- ambulance services to transfer the member to or from an SFHP hospital or SNF in connection with an authorized confinement/admission will be authorized only when transportation by other means would adversely affect the member s medical condition, whether or not such other means of transportation is available. Coverage for transportation by airplane, passenger car, taxi, or other form of public transportation is excluded. 13) Mental Health Services Mental health care services when ordered and performed by a San Francisco Community Behavioral Health Plan provider are covered. For members with a Serious Emotional Disturbance (SED), inpatient mental health care is covered when authorized and performed by a participating mental health professional, but limited to: The treatment of an acute phase of a mental health condition; Care provided at a participating hospital; A maximum of 30 days per benefit year. With the agreement of the subscriber, member, applicant, or other responsible adult, SFHP may substitute the following for a day of inpatient hospitalization: two days of residential treatment, three days of day care treatment, or four outpatient visits. Outpatient visits for mental health care must be authorized and performed by a participating mental health professional. It is limited to evaluation, crisis intervention and treatment for conditions that are subject to significant improvement through relatively short-term therapy. Services not subject to short-term therapy (such as chronic psychosis, chronic brain syndrome, or intractable personality disorder) are not covered. The benefit is limited to a maximum of 20 visits per benefit year. Mental health services for Healthy Families members are provided through the County Mental Health Plan. SFHP contracts with San Francisco Mental Health Plan (SFMHP) to provide these services. Authorizations can be requested through the SFMHP Access Line at (415) 255-3737 or toll-free at (888) 246-3333. Services for the treatment of mental retardation are not covered. Subscribers determined by the County Mental Health Department to be seriously emotionally disturbed (SED) pursuant to Section 5600.3 of the Welfare and Institutions Code will be treated by the County for these conditions. Once eligibility is established and treatment has begun by the County Mental Health Department, the member still receives primary care services that are not related to SED conditions through SFHP. 14) Maternity Care Medically necessary professional and hospital services including routine prenatal and postpartum care, nutritional counseling, labor and delivery care, follow-up visit(s) and care for complications or conditions resulting from pregnancy or childbirth are covered. Inpatient hospital care will be provided for 48 hours following a normal vaginal delivery and 96 hours following delivery by cesarean section. Revised October 2011 4-29

IV. Benefits and Exclusions 15) Outpatient Hospital Services Services and supplies for treatment (including radiation and chemotherapy) or surgery in an outpatient hospital setting or ambulatory surgery center are covered. Hospital outpatient psychiatric care/alcohol and drug abuse treatment is not covered. Other Outpatient Services include diagnostic and therapeutic radiological services such as electrocardiography, electroencephalography, mammography and laboratory services that are necessary to evaluate, diagnose, and treat and follow-up on the care of children and adolescents. Tests for management of diabetes, cholesterol, triglycerides, microalbuminuria, HDL/LDL, and Hemoglobin A-1C (glycohemoglobin) are also included. Hospital services listed in this section are SFHP benefits when authorized and provided at a participating SFHP hospital and provided in accordance with SFHP rules. Hospital services in connection with dental procedures are covered when due to an underlying medical condition or because of the severity for the procedure. Services of the dentist or oral surgeon may be covered under the Healthy Families Dental Plan in which the member is enrolled. Note: Hospital benefits are not covered if the member refuses to be under the direct care and treatment of an IPA/MG physician or other physician whose services have been authorized. 16) Preventive Health Services The following services are covered for Healthy Families members: Well baby care from birth through age 2. Exams every year for children ages 3-18. Breast and pelvic exams and Pap tests every year for women. Mammography for screening for diagnostic purposes and annual cervical cancer screening test as recommended by the member s PCP or a qualified provider. Immunizations consistent with the most current Recommendations for Preventive Pediatric Health Care as adopted by the American Academy of Pediatrics, and the most current version of the Recommended Childhood Immunization Schedule/ United States, jointly adopted by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians. Immunizations required for travel as recommended by the U.S. Public Health Services and other age-appropriate immunizations as recommended by U.S. Public Health Services. Hearing screening by the PCP to determine the need for an audiogram for hearing correction. Screening for blood lead levels in children at risk for lead poisoning, as determined by the PCP. Health education and health promotion services provided by SFHP. Vision screening by the PCP to determine the need for a refraction test for vision correction. Revised October 2011 4-30

IV. Benefits and Exclusions 17) Prescription Drug Program Medically necessary prescription drugs (including injectable) are covered when prescribed by a licensed practitioner acting within the scope of his or her license. Coverage includes needles and syringes, when medically necessary for the administration of the covered injectable medication. For diabetics, coverage includes medically necessary insulin, blood glucose testing strips, ketone urine testing strips, and lancets. Prenatal vitamins and fluoride supplements that require a prescription are covered only if medically necessary. SFHP shall determine the supply of drugs to be prescribed. Only genetic drugs are covered unless a generic equivalent for a brand-name drug does not exist and is medically necessary; up to a 24 to 30 days supply of these drugs will be given. Up to a 100 days supply of maintenance drugs, including oral and injectable contraceptives and insulin supplies are covered. (Maintenance drugs are those prescribed for 60 days or longer and are usually for chronic conditions). Smoking cessation drugs are covered for one cycle or course of treatment per benefit year. Please note, the member for whom smoking cessation treatment is prescribed must also attend a smoking cessation program. 18) Reconstructive Surgery Medically necessary cosmetic and reconstructive surgery for congenital defects, severe burns and other medical conditions, as well as services related to cosmetic and reconstructive surgery, are covered to repair or alleviate bodily damage caused by illness or injury or following surgery. Additionally, cosmetic services are provided in connection with reconstructive surgery after a mastectomy to restore and achieve symmetry for the patient. 19) Skilled Nursing Care A Skilled Nursing Facility (SNF) is a facility which contracts with SFHP, provides continuous skilled nursing services, and is licensed as a SNF by the State of California. A SNF may be a distinct part of a hospital and use of such distinct part shall be counted towards the maximum number of days described below. This benefit is limited to 100 days during any benefit year. Subject to this limitation, the following SNF benefits are provided when medically necessary and authorized, and are not primarily for custodial, convalescent or domiciliary care: Semi-private room and board, unless a private room is medically necessary and authorized. If a private room is used without authorization, the member is responsible for the difference between the SNF s customary charge for a two-bed room and the private room. General nursing care and special duty nursing, when authorized. Special diets, when authorized. Physical therapy, occupation therapy, speech therapy, and other rehabilitative services up to SFHP maximums. Oxygen administered in the SNNF. Administration of blood and blood plasma, including hospital blood processing, the cost of blood, blood plasma, and other blood products. Includes the collection and storage of autologous blood, when medically indicated. Durable Medical Equipment utilized by the member during an authorized SNF stay. Revised October 2011 4-31

IV. Benefits and Exclusions 20) Therapy Services Short-term therapy services and benefits, whether provided on an inpatient or outpatient basis (including when provided in an acute care hospital, rehabilitation unit, SNF, outpatient office, or as part of home health care or hospice services), may be provided up to a combined maximum of 60 consecutive calendar days following the first such therapy treatment for any single illness or injury. As is in the case of all services, these services must be medically necessary and authorized. Short-term therapy benefits include physical therapy, occupational therapy, speech therapy and respiratory therapy. If the IPA/MG determines that extending short-term therapy services beyond the 60-day period on an outpatient basis will result in a significant improvement of the member s condition, a short-term extension of such outpatient therapy may be authorized. 21) Transplant Services Hospital and professional services provided in connection with medically necessary and authorized human organ transplants are covered for recipients who are SFHP subscribers. All transplants must be pre-authorized and SFHP may require that the transplant be performed at a transplant center selected by SFHP. In no event will organ transplants be a covered benefit if experimental or investigational or for the transplant of non-human organs or artificial organs. When the transplant recipient is a member, services incident to obtaining the transplanted material from a living donor or an organ transplant bank are covered for the covered transplant. Prescribed post-surgical immune suppressive outpatient drugs following the transplant are also covered. The costs of any transplant services are not covered when the recipient of the transplant is not a member. Note: Bone marrow and organ donor searches are covered benefits. However, SFHP is not responsible for assuring the availability of, or locating a bone marrow donor or donor organ. 22) Vision Care Eye refraction tests to determine the need for corrective lenses, dilated retinal eye exams, cataract spectacles, cataract contact lenses, or intraocular lenses that replace the natural lens of the eye after cataract surgery are covered by SFHP. Also, one pair of conventional eyeglasses or conventional contact lenses is covered if necessary after cataract surgery with insertion of an intraocular lens. Vision Service Plan (VSP), the Healthy Kids vision plan, covers an eye examination, lenses and one pair of frames once each 12 months. Through VSP, each member is entitled to a comprehensive vision examination, including a complete analysis of the eyes, basic lenses, frame allowance of $75 toward the purchase of the frames, and supplementary testing or cares related the eye structures. Medical or surgical treatment of the eyes or any corrective eyewear required as a condition of employment is not covered. Revised October 2011 4-32

IV. Benefits and Exclusions HEALTHY KIDS LIMITATIONS AND EXCLUSIONS Acupuncture and Chiropractic Services are not covered under the Healthy Kids Program Alcoholism services for alcoholism treatment and rehabilitation on an inpatient or day care basis, whether or not court-ordered, except for inpatient detoxification. Convenience items such as telephones, TVs, guest trays, and personal hygiene items. Cosmetic surgeries -- plastic surgery or other cosmetic services that is performed to alter or reshape normal structures of the body solely for the purpose of improving the member s appearance that will not result in significant functional improvement; cosmetic products, health or beauty aids. Treatment of non-cosmetic complications of cosmetic surgery (e.g., infections or hemorrhages) may be a benefit, but only upon review and approval by SFHP Custodial care -- as part of services rendered in the home or after hospitalization or confinement in a health facility primarily for custodial, maintenance, or domiciliary care, rest, or to control or change a person s environment, such as confinement in an eating disorder unit Dental care -- except hospitalization for a dental procedure, when required Disabling condition, illness or injury -- related services for which the member is entitled to an extension of benefits or other coverage under a contract or policy providing hospital, medical or surgical expense or service benefits Drug addiction -- drug abuse treatment or rehabilitation on an inpatient, or day care basis, except as medically necessary to remove toxic substances from the body Durable medical equipment -- when used for comfort or convenience Foot care -- routine foot care, including callus, corn paring or excision, toenail trimming, foot orthotics and treatment (other than surgery and therapeutic footwear for diabetics) of chronic conditions of the foot, including but not limited to weak or fallen arches, flat or pronated foot, pain or cramp of the foot, bunions, muscle trauma due to exertion or any type of massage procedure on the foot. Investigational and Experimental care -- health care services, drugs, devices or treatments that are determined by SFHP to be experimental or investigational. A drug is not excluded under this section on the basis that the drug is prescribed for a use that is different from the use for which the drug has been approved for marketing by the Federal Food and Drug Administration, provided that each of the conditions set forth in Section 1367.21 of the California Health and Safety Code are met. Home/vehicle improvements -- modifications or attachments made to dwellings, property, or motor vehicles including ramps, elevators, stair lifts, swimming pools, air filtering systems, environmental control equipment, spas, hot tubs, or automobile hand controls. Revised October 2011 4-33

IV. Benefits and Exclusions Infertility treatment -- including in-vitro fertilization, a G.I.F.T. (Gamete Interfallopian Transfer) procedure or any other form or induced fertilization, artificial insemination, or services incident to or resulting from procedures for or the services of a surrogate mother. Treatments for medical conditions of the reproductive system are not excluded. Intermediate care facility -- services that are received in an Intermediate Care Facility (ICF). Learning and self-improvement programs -- such as the treatment of hyperkinetic syndrome, learning disability, behavioral problems, developmental delay, mental retardation, and/or autism in childhood (other than diagnosis), or for or incident to reading, vocational, educational, recreational, art, dance or music therapy, weight control or exercise programs. Long-term care -- unless SFHP determines that it is a less costly, satisfactory alternative to covered benefits. Short-term, SNF and hospice care are covered. Mental health/psychiatric -- inpatient and outpatient services are limited. Members with serious mental disturbances will be referred to the County Mental Health Department for specialized treatment. Subscribers will remain with SFHP but will receive care for SED conditions through the County Mental Health Department. Military services related to military injuries or injuries or disabilities for which care is reasonably available from the Department of Veterans Affairs. Non-covered benefits -- including services or benefits not specifically listed in the Evidence of Coverage, the Member Handbook, or the Health Plan contract, or that is listed as exclusion. Non-skilled care -- that can be performed safely and effectively by family members or persons without licensure or certification or the presence of a supervising licensed nurse, except for authorized homemaker services for hospice care. Obesity surgery -- morbid obesity, unless determined medically necessary by SFHP. Organ transplant donor -- services for a member in connection with donor transplant services when the recipient of the transplant is not a member. Orthopedic -- devices/other supplies, including orthopedic shoes (except for diabetics); elastic supports as listed in the exclusions for orthotic and prosthetics, disposable medical supplies, home testing devices, comfort items, environment control equipment, exercise equipment, selfhelp/educational devices, home monitoring equipment, any type of communicator, voice enhancer, voice prosthesis or any other language assistance devices, except as provided under orthotics and prosthetics. Over-the-counter -- drugs, supplies, and devices, including over-the-counter devices such as air filters, medications not requiring a prescription, vitamins, minerals, food supplements, or food items for special diets or nutritional supplements. Revised October 2011 4-34

IV. Benefits and Exclusions Pain management -- defined as confinement in a pain management center to treat or cure chronic pain. SFHP covers pain management services in a regular SFHP hospital for intractable cancer pain or traction. Physical exams and immunizations -- required for licensure, employment, insurance, participation in school or participation in recreational sports, ordered by a court, or for travel, unless the examination corresponds to the schedule of routine physical examinations and immunizations. Prescriptions for drugs and medicines that have not received the marketing approval of the U.S. Food and Drug Administration (FDA), however, coverage for drugs and medicines which have received FDA approval for marketing for one or more uses will not be denied on the basis that they are begin prescribed for an off-label use if the conditions set forth in California Health & Safety Code Section 1367.21 have been met. Private duty nursing -- special duty nursing, if authorized, may be covered as part of an authorized hospital or SNF admission. Prostheses -- unless implanted by surgical means, other than prosthetic devices for members have mastectomies. Services -- not provided by, prescribed, or referred, by the member s PCP and not authorized in accordance with SFHP procedures except for emergency services, OB/GYN visits (including family planning), and initial acupuncture and chiropractic exams. Surgery -- for or incident to intersex surgery (transsexual operations) are excluded. Medically necessary services relating to complications of sex change surgeries are a covered benefit. Sexual dysfunction -- incident to non-physically related sexual dysfunction, including all services excluded under infertility treatment described in this section; penile implant devices, surgery and related services, except as penile devices and surgery are medically necessary for a non-psychiatric condition. Medically necessary services relating to complications of surgery area covered benefit. Skin Aging -- services relating to the diagnosis and treatment to retard or reverse the effects of aging of the skin. Speech therapy -- relating to speech problems not related to surgery, trauma or stroke Substance abuse admissions (whether or not court-ordered) -- unless medically necessary for acute medical detoxification. Transportation -- other than provided under ambulance services Vasectomy and tubal ligation -- vasectomy and tubal ligation reversal, repeat vasectomy or tubal ligation, or the infertility resulting thereof. The plan covers medically necessary services necessary to treat complications arising out of any reversal or sterilization procedure. Revised October 2011 4-35

IV. Benefits and Exclusions Workers Compensation benefits -- including any injury arising out of, or in the course of, any employment for salary, wage or profit, or any disease covered, with respect to such employment, by any workers compensation law, occupational disease law or similar legislation. If SFHP pays for such services, it shall be entitled to establish a lien upon such other benefits up to the reasonable cash value of benefits provided by SFHP for the treatment of the injury or disease as reflected by the providers usual billed charges. Also, SFHP may recover the cash value of its benefits from the member to the extent that such benefits would have been covered or paid for as Workers Compensation Benefits if the member had diligently tried to establish his or her rights. HEALTHY KIDS PROGRAM CO-PAYMENT For non-preventive services, the member is responsible for paying a minimum charge (copayment) to the physician or provider of services when services are received. Specific copayments are listed in the Summary of Benefits. American Indians and Alaskan natives are exempt from all co-pays. The maximum aggregate co-payment per benefit year (July 1- June 30) is $250 per family, no matter how many children are enrolled. Members should ask for a receipt whenever they make a co-payment and keep the receipt and a record of all payments so that they can demonstrate when the maximum has been paid. When the limit is reached, members should contact SFHP s Customer Service Department at (800) 288-5555 to get a no co-pay identification card. Members are asked to present this card at each visit to the doctor s office or pharmacist to provide proof that the maximum co-payment amount has been reached. In the event a subscriber utilizes a significant number of health services which co-payments are required, and which causes a financial burden to the subscriber, SFHP requests that providers accommodate the subscribers in instituting a co-payment plan whereby the subscriber can reimburse the provider over an extended period of time which will be mutually determined by the subscriber and the provider. There are no deductibles under the program and there are no lifetime financial benefit maximums for any of the covered health benefits. Revised October 2011 4-36

V. PCP Referral / Authorization Policy V. PCP REFERRAL AND AUTHORIZATION Primary Care Physician and Service Provider Responsibilities Eligibility verification NEMS MSO reimburses claims only for individuals who are eligible SFHP members and have selected a NEMS Medical Group physician at the time the service is rendered. Payment for authorized services is based on the specific terms or rates set forth in each physician, hospital, or other providers contract. Prior to providing services, it is the responsibility of the PCP, hospital, or other health care provider to verify eligibility of the member in the month that the service will be provided. When claims for services are submitted to the NEMS MSO, the Claims Processing Department will again check member eligibility on the dates services were provided before making payment. PCP Rosters The PCP clinics and contracted PCPs should consult their member rosters to determine which members are assigned to them. This can be done through the SFHP secure web site. If the individual is not listed in the member roster, the provider should contact the SFHP Member Services Department or the NEMS MSO Member Services Department for member eligibility verification. Hospitals and other providers may call the Member Services Department to verify eligibility and determine the members PCP assignment. Primary Care Physician Responsibilities The PCP is the overall coordinator of care for the San Francisco Health Plan member. Responsibilities of the PCP include, but are not limited to: Assuring reasonable access and availability to primary care services Providing all preventive care and CHDP/EPSDT required services Providing access to urgent care Providing 24-hour coverage for advice and referral to care Making appropriate referrals for specialty care Providing coordination and continuity of care after emergency care, out-patient, in-patient, and tertiary care referrals, including Providing referral, coordination and continuity of care for members needing mental/behavioral health services, drug and alcohol detoxification and treatment services, or referrals for seriously medically impaired and seriously emotionally disturbed members to the San Francisco Community Behavioral Health Services Providing referral, coordination and continuity of care for members requiring Direct Observed Therapy for uncontrolled tuberculosis Providing referral, coordination and continuity of care for members requiring services from California Children Service (CCS), Early Start, Golden Gate Regional Center (GGRC), and Local Education Agency (LEA) Providing referral, coordination and continuity of care for members requiring hospice care Revised October 2011 5-1

V. PCP Referral / Authorization Policy Case managing members or referring members for case management services as necessary Requesting authorizations for specialty care or services as necessary from the medical group or outside the medical group s network as necessary Communicating authorization decisions to the member Assisting the member in making appointments or other arrangements for specialty care or procedures Tracking and following up on referrals that are made Primary care providers must have hospital admitting privileges with a network hospital. If a member is hospitalized emergently at a non-network hospital, the PCP arranges transfer to a network hospital once the member is medically stable. INITIAL HEALTH ASSESSMENT SFHP PCPs are required to schedule an Initial Health Assessment (IHA) with a new member within 120 days of enrollment in SFHP. Members are asked to arrange this appointment in the New Member Information Packet mailed to them upon enrollment. Additionally, at 45-60 days after enrollment, SFHP sends IHA reminder cards to members, as well as New Member Summary reports to PCPs, encouraging each party to contact the other to schedule IHA appointments. At each IHA or other well visit, the PCP follows the appropriate SFHP preventive health care guidelines. The visit includes: History and unclothed physical exam with vital signs Allergies flagged and listed (or none known at this time) Emergency contact information Anticipatory guidance Health education including the Health Education Behavioral Assessment ( Staying Healthy form) or other DHS approved tool Dental screening with referral Nutritional assessment with referral to WIC for pregnant women and children under 3 years of age or a registered nutritionist as appropriate Immunization screening and updates as appropriate Lead testing TB Mantoux testing Evaluation for need of obstetric or family planning services Assessment of language or cultural barriers Hearing screening Vision screening Laboratory, radiology, or other diagnostic tests as indicated Documentation of problems, medications and treatment plans Problems identified during screening should be treated or referred to the appropriate specialist. The Medical group and provider compliance in completing the IHA is monitored through an annual IHA rate, medical record audits and Health Employer Data Information Set (HEDIS) measures of well-child and well-adolescent visits. Revised October 2011 5-2

V. PCP Referral / Authorization Policy Staying Healthy Individual Health Behavior Assessment Tool The Staying Healthy individual health education behavioral assessment is designed to encourage communication between SFHP Medi-Cal members and their PCPs. It is designed to initiate appropriate health education referrals, services, and interventions to increase the use of preventive services and promote health. SFHP requires PCPs and/or clinic sites to implement Staying Healthy with the assessment tool provided by SFHP. Medical groups and providers who elect to use an alternative assessment tool must submit the tool to SFHP for approval based on Department of Health Services Medi-Cal Managed Care Division criteria. The Staying Healthy questionnaire must be offered to all new members at visits that occur within 120 days of enrollment or at the first scheduled non-acute visit. Existing members who have never answered the questionnaire must be offered the assessment tool at their next non-acute visit. The Staying Healthy assessment tool is a series of five, self-administered questionnaires designated for the following age groups: 0-3 years 4-8 years 9-11 years 12-17 years 18 years and older The Staying Healthy assessment tool must be re-administered when the member moves into the next age-designated category. However, for youth 12-17, it is recommended that the Staying Healthy too be re-administered at each annual visit. SFHP provides PCPs copies of the Staying Healthy assessment forms in English or Spanish. For monolingual members who speak a language other than English or Spanish, limited English proficient members, or low-literate Medi-Cal members, help should be offered in completing the questionnaire. The assistance must be documented in the appropriate place on the questionnaire and placed in the medical record. Member refusal to complete the questionnaire must also be documented in the medical record. PCPs are responsible for reviewing the Staying Healthy assessment questionnaire with the member on the visit in which the member or parent/guardian completes the questionnaire. All Staying Healthy assessment tools must remain in the member s confidential medical record. SFHP monitors compliance with the Staying Healthy program requirement using the Department of Health Services Facility Site and Medical Record Review process. A Staying Healthy Handbook that describes program requirements and includes copies of the assessment tool, tip sheets for patients, talking points for providers, and health education and community resources for referrals is distributed by SFHP and is available upon request. For additional information about the Staying Healthy program or to request training or copies of forms, contact SFHP s Manager of Health Education, Cultural, and Linguistic Services. Revised October 2011 5-3

V. PCP Referral / Authorization Policy SPECIALIST RESPONSIBILITIES Specialists are required to coordinate the member s care with the member s PCP. Specialists are required to communicate their assessments, care provided, and management recommendations to the member s PCP within one week of treating the referred patient. PROVIDER ACCESS AND AVAILABILITY Provider offices and clinics shall meet the following access and availability standards for scheduling appointments, and tracking telephone services. Members must have 24-hour access to PCP services at all times. Criteria Initial Health Assessment (members age 18 months and older) Initial Health Assessment (members age 18 months and younger) Initial prenatal care appointments Emergency Care Urgent care appointment for services that do not require prior authorization Urgent appointment for services that require prior authorization Non-urgent primary care appointments Non-Urgent appointment with a specialist Appointment Availability Standards Must be completed within 120 calendar days of enrollment Must be completed within 60 calendar days of enrollment Within 14 calendar days Immediately Within 48 hours of the request Within 96 hours of the request Within 10 business days of request Within 15 business days of request Non-urgent appointment for ancillary services Within 15 business days of request for diagnosis or treatment of injury, illness, or other health condition Triage or Screening (by phone) Provide or arrange for the provision 24/7 Telephone Triage or Screening Waiting Time Wait time to speak to a customer service representative during normal business hours Wait time in office to see provider for scheduled appointments Not to exceed 30 minutes Not to exceed 10 minutes Maximum of 30 minutes Extending Appointment Waiting Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has Revised October 2011 5-4

V. PCP Referral / Authorization Policy determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient. Telephone Triage SFHP providers must maintain standard protocols and guidelines for processing calls from patients that include: When the call should be immediately transferred to a physician on duty. When the patient should be instructed to go to the emergency room. Notification of emergency medical services (911) for life-threatening situations. After Hours Availability. SFHP providers must maintain reasonable hours of operation and provide 24-hour access to primary care via extended office hours, urgent care centers, emergency departments, and 24-hour physician on-call systems. 24-hour access to care must include: A physician or mid-level provider is available for contact after-hours, either in person or via telephone. All contacts must be documented in the member s permanent medical record. All documentation must be forwarded to the member s PCP of record. After-hours contact must include appropriate triage for emergency care. AUTHORIZATIONS TO MEDICAL SERVICES Procedures/Services Not Requiring Authorization Routine services provided by Primary Care Physicians do not require authorization. In addition, members may obtain other services which do not require prior authorization from NEMS Medical Group. These services are listed as follow: For NEMS-MSO Contracted Providers: 1. Abortion Services. 2. CHDP/EPSDT Preventive Services. Services are provided per CHDP/EPSDT periodicity schedules and guidelines. 3. Prenatal care. Members may seek prenatal care from a NEMS-MSO affiliated provider without prior authorization. Labor and Delivery should be arranged at California Pacific Medical Center. 4. Sensitive services for all members include pregnancy testing, family planning services. 5. Tuberculosis Care includes TB screening, testing, and treatment, unless hospitalization is needed. Revised October 2011 5-5

V. PCP Referral / Authorization Policy 6. Well Woman Care (as provided according to ACOG guidelines), with emphasis on preventive screening, pap smear, breast exam, and mammography. For All Providers: 1. Emergency care, in and out of area, includes hospital facility and ambulance services 2. Immunization members may go to DPH immunization clinics under urgent need conditions. i.e., a child is six months or more behind on any dose of vaccine according to DHS schedule; a child age 4.5 years or more with incomplete immunizations presents between July 1 and the starting date of school and is unable to obtain an appointment with the PCP prior to school start date. 3. HIV testing confidential testing from in or out of plan providers 4. Sensitive services for Medi-Cal members only, include pregnancy testing, family planning services. Members have freedom of choice to see out-of-network providers on a self-referred basis without prior authorization. Family planning services do not include abortion. 5. STD diagnosis and treatment - initial examination and follow-up visit. Second Opinion Consultations SFHP members may request a second opinion from any qualified health care provider (Primary Care Provider or specialist) contracted with NEMS-MSO, or with any other Medical Group within SFHP s physician network. NEMS Medical Group is responsible for authorizing and arranging the service for the second opinion, and will be financially responsible for the services provided. REFERRAL AUTHORIZATION FORM (RAF) General Provisions A Referral Authorization Form (RAF) is used by the Primary Care Physician to refer patients for services by a participating specialist. The PCP must initiate the referral process by completing a RAF. This is necessary in order for the specialist to make a claim for services provided. The PCP has the power to authorize (without Medical Group approval) a maximum of two (2) visits to a participating specialty physician or ancillary provider. For continuing specialist care after the initial two visits, the Specialist Extension Form is filled out. For treatments or other procedures which require the authorization by the NEMS-MSO, a Treatment Authorization Form (TAR) is filled out. These forms are described later. RAF Procedure This procedure describes the process for submitting and authorizing a RAF when a Primary Care Physician refers a member to a specialist or ancillary provider. The PCP must initiate the referral process by completing a RAF in order for specialist and/or ancillary services to be approved for payment by the NEMS-MSO. The RAF must contain all necessary member and referral information, including the type of service and the number of visits requested. Revised October 2011 5-6

V. PCP Referral / Authorization Policy Routing of RAF copies Option 1 Hard Copy Procedure: The RAF comes in quadruplicate (4 copies). 1. The PCP completes the required information on the RAF form, faxes a copy to the NEMS-MSO UM Department, and gives the remaining 3 copies to the member. 2. The member gives the form to the Specialist at the time of visit. Alternatively, the PCP may mail the form to the specialist. 3. The Specialist completes the Specialist Report section of the form, and returns a copy to the PCP. 4. The specialist or ancillary provider should retain a copy of the RAF for his/her files. In Summary: Copy 1 - Specialist returns to PCP after Specialist Report section is filled out. Copy 2 - Retained by the Specialist in member s record. Copy 3 - Specialist submits to the NEMS-MSO Claims Processing Department along with claim for services (optional). Copy 4 - Retained by PCP in Member's medical chart at time of referral. Option 2 Fax Procedure: The RAF can also be downloaded from the NEMS MSO web portal at www.nems.org/mso. 1. PCP fills out the form, faxes a copy to NEMS-MSO UM Department. 2. Member is given a copy of the RAF form to take to the specialist. 3. The Specialist completes the Specialist Report section, and faxes it back to the PCP. Upon completion of the initial evaluation of the member, the specialist or ancillary provider shall provide to the PCP within thirty (30) days of member s visit the following information: If "Consultation" or Second Opinion was requested by the PCP, advise the PCP of the member's condition and the proposed treatment plan. If "Treatment" was requested by the PCP, provide to the PCP a written report, and other oral reports as appropriate, regarding the members diagnosis, treatment, and prognosis. If a proposed service requires authorization, the specialist or ancillary provider must submit a TAR to the NEMS-MSO UM Department. Other Provisions 1. The PCP can designate an alternate physician practice in the same office who is also recognized by SFHP to submit a TAR if the PCP is unavailable or in absent. 2. Obstetrical providers: During the obstetrical care of a member, obstetrical providers may refer members directly for medically necessary obstetrical sub-specialty services. While the referral does not require a RAF, a TAR must be completed by the obstetrical sub-specialist for services on the Authorization Grid (see Appendix A). 3. Referrals to non-contracted providers will be authorized only when there is a compelling medical reason that prevents service performance by a contracted NEMS-MSO Specialist or provider. The RAF is not to be used for out-of-network referrals and for services on the prior authorization list (a TAR form is used for these referrals). 4. Approval of an RAF is limited to those services which have been requested by the PCP and are SFHP-covered benefits. Additional services not included in the initial RAF require either a new RAF or a TAR, based on the procedure or service needed. Revised October 2011 5-7

V. PCP Referral / Authorization Policy 5. Specialist or ancillary services must be initiated within sixty (60) days from the date authorized by the PCP on the RAF. It may be prudent for the Specialist to verify eligibility with the NEMS-MSO or the SFHP Member Services Department prior to giving services. Through the NEMS-MSO Provider Relations Department, the NEMS-MSO is responsible for giving provider training about RAF procedures. NEMS-MSO will print up and distribute RAFs to member clinics and contracted PCPs. PCPs or Specialists may have questions about RAF procedures, verification of submitted RAFs, or whether a RAF authorization has expired. The NEMS-MSO UM Nurse is available to assist providers about RAF inquiries. Payment of claims for authorized services is subject to verification of the member's eligibility and PCP assignment at the time services are rendered. The NEMS-MSO UM Department reserves the right to review and modify RAFs based on established criteria and/or community standards of practice. If a RAF is modified, the PCP and specialist provider will be notified by the UM Coordinator/UM Nurse. Expiration of Referral Authorizations In general, RAFs are valid for sixty (60) days after the PCP s authorization signature dates. An RAF may become expired prior to specialty services being performed by the rendering physician due to back log in appointment scheduling. The PCP may re-issue a new RAF to the specialist. Alternatively, the specialist can contact the NEMS-MSO UM Department to request an extension of the Referral Authorization. SPECIALIST EXTENSION FORM General Provisions The PCP will initiate a referral to a Specialist using the RAF form. It may be necessary for the Specialist to treat the referred patient beyond the initial two visits which have authorized by the PCP. The Specialist Extension Form is for use by specialists to request extension of office visits and office procedures. This form is not to be used for authorization of hospital admissions, outof-network referrals, or procedures listed on the required Prior Authorization list. Visits may be approved for up to six (6) visits or up to one year with the submission of a plan of treatment at the discretion of the PCP. Routing of Specialist Extension Form Option 1 Hard Copy Procedure: The Specialist s office submits the requested information on the Specialist Extension Form indicating the treatment plan and other pertinent medical information to the NEMS-MSO UM Department. The Specialist s office informs the member that additional appointments will be scheduled following approval of the request. A notation is made in the medical record that a request for additional visits has been made. Revised October 2011 5-8

V. PCP Referral / Authorization Policy The NEMS-MSO UM Nurse and/or the Medical Director will review the request. A medical decision will be made to authorize, modify or deny the visits and/or office procedures as appropriate by signing the form. A copy of the signed request will be forwarded to the PCP to file in the member s medical chart. The request will then be sent back to the Specialist s office. The Specialist retains a copy of the form in his/her office for the member file. In Summary: Copy 1 - Forwarded by NEMS-MSO UM Dept to PCP to be filed in the member s record. Copy 2 - Specialist retains a copy of the form containing the written decision. Copy 3 - Retained by NEMS-MSO UM Department for future audit purposes. Option 2 -- Fax Procedure: The Specialist Extension Form can be downloaded online at www.nems.org/mso. 1. Provider fills out the form, faxes a copy to NEMS-MSO UM Department. 2. NEMS-MSO UM Dept. faxes a reply to provider about Extension approval or denial. PCPs or Specialists may have questions about RAF procedures, verification of submitted RAFs, or need information about whether a RAF authorization has expired. The NEMS MSO UM Coordinator is available to assist providers about RAF inquiries. Payment of claims for authorized services is subject to verification of the member's eligibility and PCP assignment at the time services are rendered. TREATMENT AUTHORIZATION REQUEST (TAR) General Provisions Certain procedures, services, and medications require prior authorization from the NEMS-MSO UM Department. Providers must use the TAR form to request approval for these procedures and services. Please refer to the NEMS UM Authorization Grid (Appendix A) for the listing of procedures requiring treatment authorization. Drugs and Medications are regulated separately by SFHP, and are not included in the NEMS- MSO review process. Prescribed medications must be on the SFHP drug formulary. Certain medications on the formulary require prior authorization, which is submitted directly to SFHP. Treatment Authorization Requests (TAR) may be submitted by PCPs, Specialists and other service providers who actually perform the service. NEMS-MSO will pay for authorized services based on the specific terms rates set forth in each physician, hospital, or service provider s contract. Routing of Treatment Authorization Request (TAR) Option 1 Hard Copy Procedure As soon as a TAR is received, the UM Coordinator will begin the process of TAR review. Routing of the triplicate TAR Form: Copy 1 - Forwarded by NEMS UM Dept to PCP to be filed in the member s record. Copy 2 - Retained by NEMS-MSO UM Department for future audit purpose. Revised October 2011 5-9

V. PCP Referral / Authorization Policy Copy 3 - Specialist retains a copy of the form containing the written decision. Option 2 Fax Procedure 1. TAR can be downloaded from the NEMS-MSO web portal at www.nems.org/mso. 2. Provider fills out the TAR form, faxes a copy to NEMS-MSO UM Department. 3. NEMS-MSO UM Dept. faxes a reply to provider about TAR approval or denial. Other Provisions The PCP can designate an alternate physician practice in the same location who is also recognized by SFHP to submit a TAR if the PCP is unavailable or is absent. Through the NEMS-MSO Provider Relations Department, the NEMS-MSO is responsible for giving provider training about TAR procedures. NEMS-MSO will print up and distribute TAR forms to member clinics and contracted PCPs. PCPs or Specialists may have questions about TAR procedures, verification of submitted TARs, or need information about whether a TAR authorization has expired. The NEMS-MSO UM Nurse is available to assist providers about TAR inquiries. This will be available over the telephone during regular weekday business hours. Payment of claims for authorized services is subject to verification of the member's eligibility and PCP assignment at the time services are rendered. Turn Around Time (TAT) In general, the standard turn around time for processing a treatment authorization request is seventy-two (72) hours. Urgent TAR, when indicated by the requesting provider, will be processed within twenty-four (24) hours of receipt on regular weekdays. If an urgent TAR is submitted over a weekend or holiday, the PCP should be contacted and may be able to authorize the treatment and/or procedure and notify the MSO UM Department on the next working day. Approval / Denial procedure The NEMS MSO UM Department approves the TAR request if eligibility criteria are satisfied and the service is medically justified. The UM Dept. may request more data if necessary from the patient or the requesting provider. The member s Primary Care Physician may also be contacted if more information affecting justification of approval is needed, or if it is unclear if the PCP is aware that the TAR for the procedure is being made. Significant communications and concerns are recorded in dated sequence on the TAR Worksheet. Many denials are actually involving non-covered services. The UM Coordinator will check the SFHP non-covered services listing and note the TAR form before routing it to the Medical Director. Decision Notification to Provider/Member/Health Plan Requesting provider will be notified by telephone with authorization number given for approved or modified case; follow by fax or mail the signed TAR form. Revised October 2011 5-10

V. PCP Referral / Authorization Policy Requesting provider will be notified by telephone for denial case, verbally explain the reason of the denial; follow by fax or mail of the signed denied letter. Member will be notified by mail only if a TAR is denied. A signed copy of the denied letter will be sent to the member within two days of the denial, with explanation of reason(s) for the denial, and to inform the member of the appeal process. NEMS-MSO UM Department is required to report all denied referrals and/or treatment requests to the Health Plan in a monthly basis. NEMS-MSO UM Department will generate denial letter for each specific request. A signed copy of the denial letter will be sent to the PCP, the specialist, and the member. Members and/or providers can appeal denials of services. Appeals are made by submitting a written request for appeal to the Utilization Management Department. Appeals Process The requesting provider may appeal a denied treatment request to the NEMS-MSO Medical Director. Complaints and concerns may also be submitted directly to SFHP. The provider should contact the Grievance Coordinator at SFHP for instruction. NEMS-MSO makes the expedited appeal decision and notifies the member and practitioners as expeditiously as the medical condition requires, but no later than 3 calendar days after the request is made. All appeals will be reviewed by the NEMS-MSO Medical Director and/or the UM/QI Committee. The member also has the right to initiate a formal complaint or grievance directly to SFHP, or to request a Fair Hearing with the Department of Health Services. The member is instructed to call the Health Plan to initiate this process, or to call the NEMS-MSO Members Services Department for assistance. TAR Utilization Review Aggregate TAR data will be subject to retrospective analysis as by the Utilization Management Committee. The review is designed to identify the practice patterns of individual providers relative to standards of medical practice to evaluate for over or under utilization of services. A quarterly random sampling of TARs, both approved and denied, will be reviewed retrospectively by the Utilization Committee to ensure that appropriate utilization management has been performed. The member and provider grievance processes also will serve as an evaluation tool for appropriate utilization management policies. The Medical Director may present follow-up reports regarding this monitoring to the UM/QI Committee and the Health Plan as necessary. EMERGENCY CARE PROCEDURES Revised October 2011 5-11

V. PCP Referral / Authorization Policy Purpose This policy and procedure describes how the NEMS-MSO UM staff can assist providers and members in following the proper emergency department service utilization process which is aimed at the appropriate authorization of emergency department services. Definition Emergency Services An Emergency Service is a medical service to address a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in disability or death, i.e., a situation that: 1. Places the member s health in serious jeopardy. 2. May result in serious impairment to bodily functions. 3. May result in serious dysfunction of any bodily organ or part. Emergency services do not require authorization prior to treatment. Urgent Services Urgent Services are defined as those required to diagnosis and treat medical problems that require same day treatment. This may occur when the PCP is unavailable to treat the member in the office. Urgent services ordinarily require PCP authorization prior to treatment. Non-Urgent Services Non-Urgent Services are defined as those that do not require same day treatment and can be referred to the PCP for follow-up. After-Hours Availability Participating providers must maintain reasonable hours of operation and provide 24-hour access to primary care via extended office hours, urgent care centers, emergency departments, and 24- hour physician on-call systems. 24-hour access to care must include a physician or mid-level provider who is available for contact after-hours, either in person or via telephone. After hours is defined as the period between the close of regular business hours and the opening of the next regular business day. In-person contact includes care at urgent care facilities, or when a PCP attends members in an emergency room. It does not include emergency consultation by an emergency room physician. Telephone contact is when an answering service takes the initial call and then pages an on-call physician to contact the member. All contacts must be documented in the member s permanent medical record. All documentation must be forwarded to the member s PCP of record. After-hours contact must include appropriate triage for emergency care. Member Self Referral to Emergency Room In all instances when a member presents him/herself at an emergency room for diagnosis and treatment of illness or injury, pre-established guidelines for hospitals require appropriate triage of the severity of illness/injury. For cases determined to be true emergencies, diagnosis and Revised October 2011 5-12

V. PCP Referral / Authorization Policy treatment should start immediately. The Emergency Physician is expected to transmit documentation of the ER treatment to the patient s PCP, which include a plan for PCP consultation and follow-up care. For emergency situations as defined by the examining physician, assessment and treatment must proceed until the patient is stabilized-authorization is not required. The emergency room staff must conduct a psychiatric screening exam and treat, relieve or eliminate the psychiatric emergency. In routine and non-urgent situations, treatment authorization by the PCP is required after completing the medical screening exam and stabilizing the condition. If the PCP does not respond, the Emergency Room/Department will proceed with treatment. Documentation and proof of the Emergency Department s attempt to reach the PCP and IPA/Medical Group and failure to respond within 30 minutes of the first contact attempt will be accepted as authorization to diagnose and treat. PCP Referral of Member to Emergency Room The PCP provides 24-hour access to members. After hours, this may involve telephone advice or triage. In routine or urgent situations, the PCP may determine whether or not care in the emergency room is appropriate. The PCP is expected to arrange urgent or follow-up care with the member. Emergency Services Out of Area Should a member require medical attention outside of the San Francisco City and County area (including outside of the United States), they must obtain complete documentation of their condition and care provided. Complete documentation includes: Descriptions of the problem/complaint/symptoms/condition that you were experiencing that lead you to believe that you were having a medical emergency. Diagnosis of condition (copy of the emergency room/physician report). Treatment(s) occurred at the emergency room/center. Treatment(s) recommended as follow-up care, if any. (If the documentation arrives in a language other than English, SFHP will translate it provided the specific language has been written in.) If a member has paid for his emergency care, and is seeking for reimbursement from the NEMS- MSO Claims Department, the member must provide in addition to the above: Copies of the receipt indicating the currency in which it was paid. Amount paid for this care. Out-of-Area Emergency Hospital Admissions Revised October 2011 5-13

V. PCP Referral / Authorization Policy The NEMS-MSO UM Department will work to coordinate and manage the care of members admitted out-of-area for emergency medical problems. The UM Department will work to return the member to care within the Medical Group s network as soon as medically appropriate. This policy ordinarily applies to members admitted to the hospital, and can apply to members admitted at other levels of care, e.g., to a skilled nursing facility (SNF). After notification of an admission to an out-of-area hospital, The NEMS-MSO Case Manager or UM Nurse/Coordinator will begin follow-up with the admission. The UM Nurse records the daily concurrent reviews for the out-of-network member, and submits them to the Medical Director for evaluation. The goal of out-of-network UM is to monitor the course of medical care until the patient has stabilized or improved to the point that the patient can safely return to an innetwork facility. At all times, an appropriate level of services must be maintained. The member's PCP shall be communicated with during the transfer process as necessary. This may include arranging follow-up care to the in-network hospital or the PCP s office after the transfer is successfully facilitated. COBRA/OBRA Regulations 1. Every person who presents to an emergency department must receive a medical screening evaluation by a physician or person under the supervision of a physician regardless of whether authorization has been received from a health plan. 2. Medical screening must be performed prior to asking about the individual's ability to pay or before verifying health plan eligibility. 3. Each person who presents to the ER must be stabilized by medical treatment. 4. The ER physician has the obligation to treat a patient in the emergency department, if in the physician's judgment; adequate care will not be obtained at another facility. 5. Transfers between emergency departments are appropriate only if the emergency physician at the second hospital accepts the transfer. Otherwise, the initiating ER physician must contact the member's PCP, who is responsible for arranging the transfer to the second hospital. HOSPITAL UTILIZATION California Pacific Medical Center (CPMC) is the affiliated hospital facility with NEMS Medical Group. All SFHP members assigned to the NEMS Medical Group will be directed to CPMC for all in and out patient hospital care. Hospital utilization is divided into three phases: Prospective Review, Concurrent Review, and Retrospective Review. The NEMS-MSO UM/QI Committee will work in conjunction with CPMC in the hospital review process. Concurrent Review The tracking of hospital utilization is done by the NEMS-MSO UM Department. As soon as a hospitalization occurs, the UM Coordinator or Nurse will rely on the Clinical Resource Revised October 2011 5-14

V. PCP Referral / Authorization Policy Management (CRM) for concurrent review and discharge planning. CRM will follow the Case Management Department Policy guidelines set forth by CPMC. Concurrent Review includes: 1. Continued Stay Review The patient s status and the result of diagnostic and therapeutic procedures are evaluated to determine the reason for continued inpatient hospitalization. A continued stay review for each member s hospitalization will be based on the application of approved severity of illness and intensity of service criteria. Additional hospital days are justified and authorized accordingly, and indications for certain services are identified. Similarly, plans for discharge and the restriction of certain services are identified. 2. Level of Care Review -- Objective indicators of the patient s clinical status are assessed to ensure that care is being delivered at the appropriate resource level. Concurrent review should be done whenever a member is admitted to the hospital without a preadmission review or prior authorization, as may be the case with emergency admissions. Review should occur within 24 hours of admission and at a minimum once every other day, or more frequently as required. For authorized hospital admissions, concurrent review is conducted for all extended stay requests for reasons of medical necessity beyond the number of days originally authorized. Prospective Review Prospective review of hospitalization is completed prior to all elective admissions and designated hospital procedures. The admission is certified for medical necessity and length of stay assignments. Authorizations for elective admissions shall be handled according to the TAR process as described in previous sections. The PCP shall submit a TAR to the NEMS-MSO UM Department with referral to the NEMS-MSO Medical Director for approval or denial as necessary. Retrospective Review Retrospective review is conducted in cases that were emergency hospital admissions, delayed discharges, and other cases that involved complaints or complications with the delivery of care. The NEMS-MSO UM/QI Committee shall be responsible for implementing this review. Denial of Services The Clinical Resource Management (CRM) will follow guidelines to determine medical necessity for continued inpatient hospital stay. This will include review of available medical records, and consultation with a Physician Advisor and with the attending physician. The NEMS-MSO Medical Director will receive information from CRM and make an evaluation for medical necessity. If medical necessity for a continued hospital stay is not met, the denial notification is made. For problematic and/or difficult cases, the MSO Medical Director will consult with the CPMC Medical Director, and a joint decision will be made. The NEMS-MSO UM Department will initiate the denial process. The attending physician will be notified of the denial for a continued hospital stay. A denial letter is prepared, signed and delivered to the patient. The letter also instructs the patient on how the appeals process can be initiated. Revised October 2011 5-15

V. PCP Referral / Authorization Policy Revised October 2011 5-16

V. PCP Referral / Authorization Policy Procedures Requiring Treatment Authorization Requests (TAR) (This is not a complete list) Admissions to Hospital and SNF Ambulance Transport (non-emergency) Ambulatory Surgery Services Amniocentesis Angiography Assistant Surgeons (Other than Residents) Audiological Services Bone Density Studies Cardiac Catheterization Cardiac Rehabilitation Chemical Dependency Services Child Development Services Colonoscopy Procedures CT Scans / MRI / PET Scans Durable Medical Equipment (DME) Echocardiogram Endoscopic Procedures Gamma Immune Therapy Hearing Aids Hepatitis B Injections for > 18 yrs. old High-Risk Pregnancy Services Holter Monitoring Home Health/Home Infusions Services Hospice Care Hospital admissions (Elective) Infertility Services Laboratory Procedures (non-routine) Lithotripsy Magnetic Resonance Imaging (MRI scans) Maternity hospital admissions (non-standard) Mental Health Services Nuclear Medicine Studies Nutritional Counseling (all types) Obstetric Procedures (high risk) Occupational / Physical therapy (outpatient) Office Procedures (non-standard) Ophthalmic Procedures (non-office based) Orthotics and Prosthetics (O&P) Revised October 2011 5-17

V. PCP Referral / Authorization Policy Procedures Requiring Treatment Authorization Requests (TAR) (Continued) Out-of-Network Services (non-emergency) Pentamidine Treatment Plasmapheresis Podiatric Surgery (including office-based) Psychological Testing Pulmonary Function Tests (non-baseline) Radiation Therapy Radiology Procedures (non-routine) RAST Testing Rehabilitation Services Renal Dialysis Respiratory Therapy (outpatient) Skilled Nursing and Intermediate Care Sleep Monitoring/Sleep Studies Specialist to Specialist Referrals Surgeries (major) Therapeutic Abortions Therapy Services (include PT, OT, Speech) Treadmill Stress Test Ultraviolet Light Treatment Ultrasounds (office based - except first OB) Vasectomy/Tubal Ligation Revised October 2011 5-18

VI. Sensitive Services VI. SENSITIVE SERVICES Sensitive services are those services related to: Family planning Option counseling or pregnancy testing Abortion services Testing and treatment for sexually transmitted diseases Confidential HIV testing and counseling Minors and adult members have the right to timely access to confidential and sensitive services without pre-authorization. Minors and adolescents have the right to access sensitive services without parental consent. Members may go out of network for sensitive services except for abortion (see abortion services below). Information and records related to sensitive services is strictly confidential and shall not be released to any third party without the consent of the member involved, including adolescents. Abortion Services NEMS-MSO members may self-refer for outpatient abortion services, but must see a provider that is contracted with the NEMS Medical Group. Outpatient abortion services are not subject to prior authorization, medical justification or any other utilization management procedures, except when performed using general anesthesia. NEMS-MSO members must obtain prior authorization for the use of general anesthesia, regardless of whether the abortion is performed in an office, outpatient facility or a hospital. If the NEMS-MSO does not have a provider for abortion services, NEMS-MSO arranges for such services and pays all professional fees and facility fees. NEMS-MSO will assist any provider or member to access abortion services. Family Planning Services Family Planning is a benefit provided to Medi-Cal beneficiaries and, under federal law, members have the right to freedom of choice of any willing provider for the purpose of delaying or preventing pregnancy, including out-of-network providers on a self-refer basis and without prior authorization. Family planning may include: Health education and counseling necessary to make informed choices and understand contraceptive methods. A limited history and physical examination. Laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods. (Pap smear is included if performed in accordance with US Preventive Services Task Force Guidelines.) Diagnosis and treatment of STDs if medically indicated. Screening, testing and counseling of at-risk individuals for HIV and referral for treatment. Revised October 2011 6-1

VI. Sensitive Services Follow-up care for complications associated with contraceptive methods issued by the family planning provider. Provision of contraceptive pills/devices/supplies. Tubal ligation. Vasectomies. Pregnancy testing and counseling. Non-reimbursable services include: Routine infertility studies or procedures. Reversal of voluntary sterilization. Hysterectomy for sterilization purposes only. Transportation, parking, and child care. Sexually Transmitted Diseases Medi-Cal members can access services for sexually transmitted diseases from any willing provider, both in-network and out-of-network. NEMS-MSO will cooperate with the local health departments to promote the diagnosis and treatment of members with sexually transmitted diseases. Care provided for STDs include testing, diagnosis, immediate treatment and medications. The local health department and NEMS-MSO will collaborate to ensure members receive immediate care when the member presents with an STD. The local health department and other out-of-plan providers are to refer the member back to the Primary Care Physician for any conditions requiring ongoing care beyond the initial diagnosis and treatment of the STD. For Plan coverage of these services, members may sign a refusal of medical record release in lieu of releasing their medical records. Confidential HIV Testing Confidential HIV Testing is available through plan providers and confidential Department of Public Health sites. The Plan encourages members to seek these services from their PCP or to provide the information to their PCP to ensure continuity and quality of care. For Plan coverage of these services, members may sign a refusal of medical record release in lieu of releasing their medical records. Payment to Non-Medical Group Providers Based on the definition of family planning services listed above, NEMS-MSO are required to reimburse non-medical Group providers for those services at the Medi-Cal rates. Please also refer to Section IX, Page 9-4 for information related to Reimbursement and Pricing Methodology. Sterilization Under federal regulations, human reproductive sterilization is defined as any medical treatment, procedure or operation for the purpose of rendering an individual permanently incapable of reproducing. Sterilizations which are performed because pregnancy would be life-threatening to the mother ( therapeutic sterilizations) are included in this definition. The term sterilization, as used in Medi-Cal regulations, means only human reproductive sterilization, as defined above. Revised October 2011 6-2

VI. Sensitive Services Sterilization is covered only if the following conditions are met: The individual is at least 21 years old at the time written consent for sterilization is obtained. The age limit is an absolute requirement. There are no exceptions for marital status, number of children or for a therapeutic sterilization. At least 30 days, but not more than 180 days, have passed between the date of the written and signed informed consent and the date of the sterilization. The individual is mentally incompetent. The individual is able to understand the content and nature of the informed consent process. The individual is not institutionalized. The individual has voluntarily given informed consent in accordance with all the requirements prescribed in this section. A completed consent form must accompany all claims for sterilization services. This requirement extends to all providers, attending physicians or surgeons, assistant surgeons, anesthesiologists and facilities. The informed consent process for a sterilization procedure may be conducted either by a physician or by the physician s designee. The Consent Form must be signed and dated by the: individual to be sterilized, interpreter, if one is provided, individual who obtains the consent, and the physician who performed the sterilization procedure. The only sterilization consent form accepted by NEMS-MSO is the Department of Health Services Consent Form (PM 330). Claims submitted with a computer generated form or any other preprinted version of the PM 330 will not be reimbursed. A sample PM 330 and instructions for completing the form are included in this section. The sterilization Consent Form requirements are imposed by the Federal government and can be found in California Code of Regulations, Title 22, Section 51305.4. Prior authorization is required for inpatient sterilizations. Since elective sterilizations normally can be performed as an outpatient procedure, the TAR should clearly indicate why hospitalization is required. TARs need not include consent documentation. Revised October 2011 6-3

VI. Sensitive Services Sample Sterilization Consent Form -- English Sterilization Consent Form Instructions Revised October 2011 6-4

VI. Sensitive Services 1. Name of physician or clinic. Name of the doctor, group, clinic or hospital. If the provider is a physician group, all names may appear (for example, Drs. Miller and Smith), the professional group name may be listed (for example, Westside Medical Group ) or the phrase and/or his/her associates may be used. This line may be prestamped or typed. 2. Name of procedure. Enter the full name of the procedure. If completing the Consent Form in Spanish, the name of the procedure may be written in Spanish. Must be consistent throughout the Consent Form (numbers 2, 6, 13 and 20) and must match name of procedure on the claim. This line may be pre-stamped or typed. 3. Patient s birthdate. Month, day and year required and must match the patient s date of birth on the claim. The patient must be at least 21 years of age at the time consent is obtained. 4. Patient s name. Must be consistent throughout the Consent Form (numbers 4, 7, 12 and 18) and must match the patient s name on the claim. Print the last name first; use one letter per square. 5. Physician s name. If a group, all provider s names may be listed, or the phrase and/or his/her associates. This line may be pre-stamped or typed. 6. Name of procedure. Enter the full name of the procedure. If completing the Consent Form in Spanish, the name of the procedure may be written in Spanish. Must be consistent throughout the Consent Form (numbers 2, 6, 13 and 20). This line may be prestamped or typed. 7. Patient s signature. If the patient signs the consent form with an X, a symbol/character or in a non-arabic alphabet, the signature must be countersigned by a witness. Must be consistent throughout the Consent Form (numbers 4, 7, 12 and 18). 8. Date. Patient s signature must be dated with month/day/year. The required 30-day waiting period is calculated from this date. Interpreter s Statement: 9. Language. Indicate the language in which the patient was counseled, if other than English or Spanish. 10. Interpreter s signature. A signature is required if an interpreter was used. 11. Date. Interpreter s signature must be dated with month/day/year. Statement of person obtaining consent: 12. Patient s name. Patient s name must be consistent throughout the Consent Form (numbers 4,7,12 and 18) and must match the patient s name on the claim. 13. Name of procedure. Enter the full name of the procedure. If completing the Consent Form in Spanish, the name of the procedure may be written in Spanish. Must be consistent throughout the Consent Form (numbers 2, 6, 13 and 20). This line may be prestamped or typed. 14. Signature of person obtaining consent. Signature required from person providing sterilization counseling; it may be a physician or the physician s designee. 15. Date. Signature of the person obtaining consent must be dated with month/day/year. 16. Name of facility. Name of place where patient was given sterilization counseling, for example, a physician s office, clinic, etc. (Not necessarily the facility where the procedure was performed.) May be pre-stamped or typed. Revised October 2011 6-5

VI. Sensitive Services 17. Address of facility. Complete mailing address of facility identified in number 16. Must include street address, city, state and ZIP code. Once this section is completed, the patient must be given a copy of the consent form. May be prestamped or typed. Physician s statement: 18. Patient s name. Patient s name must be consistent throughout the Consent Form (numbers 4,7,12 and 18) and must match the patient s name on the claim. 19. Date. Enter month/day/year. This date must match the date of the procedure on the claim. 20. Name of procedure. Enter the full name of the procedure. If completing the Consent Form in Spanish, the name of the procedure may be written in Spanish. Must be consistent throughout the Consent Form (numbers 2, 6, 13 and 20). This line may be pre-stamped or typed. 21. Paragraph one. Do not cross off paragraph one if the minimum waiting period of 30 days has been met; cross off paragraph two if the minimum waiting period of 30 days has been met. 22. Paragraph two. Do not cross off paragraph two if the minimum waiting period of 30 days has not been met; cross off paragraph one if the minimum waiting period of 30 days has not been met. In addition, mark either box A for premature delivery or box B for emergency abdominal surgery. 23. Premature delivery. Mark box A if the minimum waiting period of 30 days has not been met due to a premature delivery. Complete date of premature delivery (number 24) and date delivery was expected (number 25). 24. Premature delivery date. Date of premature delivery with month/day/year. This date must be at least 72 hours from the date consent was given by the patient and the date of the sterilization procedure. Must be completed if box A is marked. 25. Individual s expected date of delivery. Date of patient s expected delivery with month/day/year as estimated by physician based on the patient s history and physical condition. Must be completed if box A is marked. This date must be at least 30 days from the date consent was given by the patient (as identified in number 8). 26. Emergency abdominal surgery. Mark box B if the minimum waiting period of 30 days was not met due to emergency abdominal surgery or if 72 hours has not passed between the date the patient gave consent and the date of the emergency abdominal surgery. Enter name of the operation performed and describe the circumstances. 27. Physician s signature. Signature of the physician who has verified consent and who actually performed the operation is required. 28. Date. Physician s signature must be dated with month/day/year. Date must be on or after the sterilization date (refer to number 19). Revised October 2011 6-6

VI. Sensitive Services Sample Sterilization Consent Form -- Spanish Revised October 2011 6-7

VII. Coordination of Care Services VII. COORDINATION OF CARE CASE MANAGEMENT NEMS Medical Group adopts the official SFHP definition of case management, as developed by the Case Management Society of America (CASA): Case management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes. Members with more complex medical and/or social needs may require a specific Case Manager, separate from the member's Primary Care Provider. This may occur under the following conditions: Medically complex or costly care; e.g., AIDS, terminal illness, high risk pregnancy; Coordination with out-of-plan services; e.g., drug treatment services, CCS eligible services; Members with potential access difficulties. e.g., member having unique linguistic needs; Transition with changing Medi-Cal coverage and benefits; e.g., during major organ transplant; The NEMS-MSO shall maintain a monthly log of case management activities, and a list of members being case managed, with documentation of their status (i.e., active, inactive, discharged with disposition). Documentation of plans should include PCP approval, and ongoing communication between case managers and PCPs. The case management log or summaries shall be available to the Utilization Management Committee and the Quality Improvement Committee for review. Direct Access to Obstetricians/Gynecologists A SFHP member may self direct to any SFHP network obstetrician/gynecologist or family practice physician within their medical group for gynecological and obstetric services. A SFHP member shall not be required to obtain prior approval from another provider prior to making an appointment and obtaining direct access to an obstetric and gynecological or family practice physician for obstetric services. The obstetrician/gynecologist or family practice physician is required to communicate with the member s primary care provider regarding the member s condition, treatment, and any need for follow-up care. SFHP and its medical groups shall reimburse any physician providing the above services according to their existing reimbursement policy. Adult Sterilization and Consent SFHP assures that reproductive sterilization services provided to its male and female members meet all federal requirements, including 1) services are provided only to members age 21 and older, and 2) an informed consent process and provisions for a waiting period (as determined by the member s insurance program) before services are rendered. Medi-Cal members are Revised October 2011 7-1

VII. Coordination of Care Services subject to a 30-day waiting period. Additionally, consent is not only voluntary and fully informed, but the individual must also be allowed to make a free selection of the method for sterilization. SFHP requires completion of the State of California Health and Welfare Consent Form (PM- 330) before providing a sterilization procedure to a SFHP Medi-Cal member. The physician performing the sterilization service must ensure that the Consent Form (PM 330) is signed and completed. The physician must document the informed consent process in the medical record and include the signed Consent Form (PM-330) in the medical record. Claims for sterilization must have a copy of the PM-330 attached or payment will be denied. The sterilization consent procedures and requirements are imposed by the Federal government and can be found in California Code of Regulations, Title 22 Section 51305.1-51305.8. (Please refer to Section 6-3 in this manual for additional information related to adult sterilization and consent) Voluntary Termination of Pregnancy Services SFHP members may self-refer for outpatient abortion services within their assigned or chosen medical group. Outpatient abortion services are not subject to prior authorization, medical justification or any other utilization management procedures except when performed using general anesthesia. SFHP members must obtain prior authorization from their medical group for the use of general anesthesia regardless of whether the abortion is performed in an office, outpatient facility, or a hospital. Note: If the member s medical group does not have a provider of abortion services, the medical group arranges for services and pays all professional fees, facility fees and the reasonable cost of related transportation or lodging if needed. SFHP will assist any provider or member to access abortion services. Care of Adolescents and Minors Minors have the right to control the disclosure of their medical records related to services for which they have the authority to consent. In California, minors 12 years to 18 years of age do not have the authority to consent to abortions or sterilization. For abortions and sterilization, the minor's guardian must consent and so must also be notified and can have access to those records. Under the Family Code, minors 12 years and older do have the right to consent to mental health services treatment for STDs, treatment for rape or sexual assault, and treatment for drug and alcohol abuse. Revised October 2011 7-2

VII. Coordination of Care Services Behavioral Health SFHP PCPs are responsible to provide behavioral health services, including diagnosis and treatment, within their scope of practice. Members with behavioral health needs beyond the scope of practice of the PCP or members who need substance abuse services are eligible for services at Community Behavioral Health Services (CBHS). SFHP members may self-refer for behavioral health and substance abuse services by calling the CBHS Access Hotline for triage. Members may also self-refer, i.e. walk-in, to San Francisco city and county behavioral health centers. When members are receiving behavioral health services, either by referral from the PCP or by self referral the mental health provider will coordinate care with the PCPs managing the physical health care needs of the member with the consent of the member. SFHP educates PCPs and medical groups about its procedures for referring members to mental health and substance abuse services. Community Behavioral Health Services annually distributes a copy of their directory to SFHP and providers offices. San Francisco Community Behavioral Health Services 1380 Howard Street San Francisco, CA 94103 (415) 255-3737 (888) 246-3333 (415) 205-8125 Psychiatric Emergency Services Pharmacy Prior Authorization SFHP has established a list of drugs that require prior authorization. When prescribing such drugs, the physician or the pharmacist completes a prior authorization (PA) request form and submits it to SFHP s contracted Pharmacy Benefits Manger (National Medical Health Care Systems) for review. PA requests will be processed in accordance with SFHP criteria. PA request forms may be found in the SFHP Formulary or on the SFHP website at http://www.sfhp.org/providers/provider_resources/download_forms.aspx For further information on the pharmacy prior authorization process, please consult the SFHP Formulary or contact the SFHP Clinical Pharmacist at 415-615-4253. For a complete list of San Francisco Health Plan Formulary, please visit the SFHP website at http://www.sfhp.org/providers/provider_resources/drug_formulary.aspx Certificate of School Entry and Sports Physicals If a child requires a school entry health assessment that must be presented to the school where the child is to enroll, the physician providing or supervising the assessment will give the child, the parent, or guardian a certificate documenting that the child has received the appropriate health screening procedures. This service will be provided with no cost to the child or parent. If a child requires a sports physical, the physician providing the assessment will give the child the parent, or guardian the documentation or certificate that the child has received the Revised October 2011 7-3

VII. Coordination of Care Services appropriate preventive services and examination. This service will be provided with no cost to the child or parent. CHDP PM-160 Reporting Each participating provider must report all well child visits on the Confidential Screening/Billing Report, Prepaid Project Code/Provider Number SFHP 307, PM 160- Information Only form. These reports must be sent to the Plan by the 15 th day of each month for the previous months encounters. The Plan will submit these forms to the State DHS and to the local CHDP program by the 30 th day of the month following the date of service. Termination of a Patient/Provider Relationship When there is a breakdown of the provider/sfhp member relationship, the provider must take two steps: Notify the member of the termination by certified mail, return receipt requested; and allow the member a reasonable amount of time (usually 30-45 days) to locate another SFHP provider effective the first of the given month. Services should be provided to the member during the reasonable period of time necessary for the member to locate a new provider. The reasonable period of time shall be determined by the availability of a new provider assignment and appointment that can be facilitated by the SFHP Customer Service Department and the member s IPA/Medical Group. The termination letter to a member must be sent to the SFHP Medical Director and Customer Service Department, as well as to the IPA/Medical Group in which the provider is enrolled. For further information, please refer to the San Francisco Health Plan Operation s Provider Manual Section II -- Enrollment and Customer Service. FACILITY SITE AND MEDICAL RECORD REVIEW SFHP follows DHS guidelines in administering Facility Site and Medical Record Reviews for network PCPs. Medical record reviews are conducted following 180 days of active status as a PCP and are repeated every three years. Ten (10) medical records are reviewed for each provider within 90 days of the date on which members are first assigned to the provider. An additional extension of 90 calendar days may be allowed only if the new provider does not have sufficient assigned Medi-Cal managed care plan members to complete a review of 10 medical records. Facility site reviews must be conducted prior to the PCP treating SFHP members and are repeated every three years. Facility site and medical record reviews are conducted by SFHP, Blue Cross, or State certified medical group personnel. Revised October 2011 7-4

VII. Coordination of Care Services Medical groups are expected to educate their providers on these requirements and facilitate SFHP reviewers access to the provider sites and medical records. Copies of the audit and review tools can be found on the SFHP web site www.sfhp.org/providers/resources or by calling the Provider Relations QI Nurse Manager. Facility Site Review The following criteria must be met for American with Disabilities Act (ADA) compliance and is assessed during the facility site review: Wheelchair access Water availability Elevator with floor selection within reach Pedestrian ramps with a level landing at the top and bottom of the ramp Designated parking Access in waiting rooms, exam rooms and bathroom; and Exam table access When SFHP providers are located at sites that do not meet the Americans with Disabilities Act requirements, the medical group must assist the provider and the member with special arrangements to allow access to their providers to meet their health care needs. Confidentiality and Storage of Medical Information SFHP establishes standards for its staff, providers and contractors for handling medical information in a manner that protects member rights and complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. These standards include: SFHP adult members are entitled to inspect their patient records upon written request to the health care provider, to prepare a specified addendum to their records, and to require the health care provider to attach that addendum to their record. SFHP, its providers and contractors disclose only the minimum amount of protected medical information needed to accomplish the intended purpose of the disclosure. SFHP, its providers and contractors prohibit the intentional sharing, sale or use of medical information for any purpose not necessary to provide health care services to the patient, except as specified by law. No disclosures are made to employers. SFHP, its providers and contractors obtain member consent for sharing medical information regarding sensitive services. Sensitive services include family planning services, services related to sexually transmitted diseases, HIV/AIDS services, and mental health and chemical dependency services. A minor s consent is required to disclose sensitive information to his/her parents. When a member consents to the disclosure of confidential medical information, the consent is for the release specified information to a specified person for specified purposes and for a specified timeframe, and may be revoked. Revised October 2011 7-5

VII. Coordination of Care Services SFHP, its providers and contractors educate their staff and the members of their quality improvement committees about their confidentiality policies, require signed confidentiality statements, and take strong actions when violations occur. For all other services, SFHP, its providers and contractors disclose individually identifiable medical information only for the reasons listed here or as allowed by law. Any other release of individually identifiable medical information requires specific member consent. Allowable disclosures without patient consent include: To provide clinical care. To allow for pharmacy benefit management. To determine the appropriate payment for covered services. To perform utilization management functions, including independent medical review. To perform quality improvement activities; confidential medical information that is reviewed as part of audits, HEDIS data collection, accreditation surveys, peer review or for credentialing must remain on site, and cannot be further disclosed. To comply with judicial, statutory and regulatory requirements, including a court order, for the purpose of a coroner s investigation under specified circumstances, or under compelling circumstances to protect the safety of an individual. Content of medical information The cumulative member medical record is required by SFHP to contain: Results of any screening services. Referral for diagnosis and treatment. Results of diagnosis and treatment services. Outreach and follow-up activities provided to ensure receipt of needed services. CHDP (PM-160 forms) on pediatric patients 0-18 years of age. Consent for surgical or invasive procedures. Durable Power of Attorney and Advanced Directives for any members 19 years of age or older. Storage of medical information All medical records must be kept for at least seven (7) years according to the California Code of Regulations Title 22, Section 70751(c). However, civil litigation lawyers want specific parts of the medical records to be kept for ten (10) years total (i.e. certain laboratory results, radiology reports, death documentation, etc.). For this reason, the San Francisco Health Plan suggests that you keep your patient charts at least seven (7) years following their last visit, but preferably for ten (10) years. Keep the records of adults and emancipated minors for 7-10 years following their last visit. Keep the records of children and non-emancipated minors until the individuals reach age 25-28 years of age or 7-10 years past age 18. Revised October 2011 7-6

VII. Coordination of Care Services MEDICAL GROUP CREDENTIALING All licensed independent practitioners who provide care to SFHP members, including physician and non-physician medical practitioners, must meet SFHP credentialing standards to be accepted into and to maintain good standing in the SFHP network. SFHP credentialing standards are based on federal and California requirements, and comply with SFHP s contract with the Department of Health Services. Re-credentialing must occur at least every three years. The physician re-credentialing process includes an assessment of quality indicators such as member complaints and medical record review scores. SFHP also requires that its medical groups have ongoing procedures to monitor and act to address issues of quality of care and service. SFHP requires that non-physician medical practitioners see SFHP patients only when their credentials and scope of practice comply with the relevant California codes governing their profession. This requirement applies to nurse practitioners, nurse midwives, clinical nurse specialists and physician assistants. SFHP requires that every contracted provider be subject to an initial assessment and re-assessed every three years. The assessment is structured to confirm that the organization is in good standing with regulatory bodies and meets the standards of an accreditation agency or has been audited against appropriate standards. This requirement applies to organizations like hospitals, home-health agencies, skilled nursing facilities and nursing homes, and freestanding surgical sites. Participating medical groups must keep complete and current provider files on file for each provider it contracts with or employs. When SFHP delegates the credentialing function to a medical group, SFHP is accountable to assure that the medical group performs the function or activity according to its standards. SFHP details specific credentialing requirements in a delegation agreement, and audits the medical group annually to assure that the medical group s credentialing program meets SFHP standards. The audit may review policies and procedures, examine credentialing files, and, when problems are identified, require corrective action. Medical groups may sub-delegate credentialing to a professional credentialing organization or its affiliated hospital. Sub-delegation occurs when a delegate of the Plan gives a third entity the authority to carry out a function. Either the Plan or the delegated entity conducts oversight of the sub-delegated function to ensure that the sub-delegate meets standards. The Plan is accountable for all activities performed by the delegate and sub-delegate on its behalf. To sub-delegate credentialing, the medical group must inform SFHP and provide a copy of the sub-delegation agreement for SFHP to review and approve. The sub-delegated hospital must hold JCAHO accreditation with no major deficiencies regarding the credentialing process and found in compliance with SFHP standards in pre-contractual and annual audits. The credentialing verification organization (CVO) must hold NCQA accreditation or be found in compliance with SFHP standards in pre-contractual and annual audits. Revised October 2011 7-7

VII. Coordination of Care Services When credentialing is delegated or sub-delegated, SFHP retains the authority to accept or reject the qualifications of all network providers, approve new practitioners and sites, terminate or sanction practitioners, and report serious quality deficiencies to appropriate authorities. NON-PHYSICIAN MEDICAL PRACTITIONERS Non-Physician Medical Practitioners (NPMP) with a valid, current license or certificate from the State of California may serve as the provider of primary care services for SFHP members under these conditions: The scope and requirements of practice for NPMP providing primary care services for SFHP are established by the Board of Registered nursing or the Division of Allied Health Professionals of the California Medical Board. They include supervision by a licensed physician, who has a contract with the medical group. Supervision may be direct or include the use of medical policies and protocols established by the physician. The supervising physician does not have to be physically present when the NPMP is seeing patients, but must be available either on-site or by telephone. The supervising physician will complete the provider information letter for each non-physician medical practitioner in accordance with CCR, Title 22, Section 51240(a)(1) through (7) and will report any changes to DHS within 30 days. The provider information letter is effective for a period of 12 months and reviewed by SFHP at the annual credentialing audit. A Non-Physician Practitioner Protocol establishes the scope and limitations of services to be provided by the NPMP, including the following: Standing orders that will be kept on file at the supervising physician office/clinic Guidelines as required by Title 16. Section 1470 for registered nurses, and Title 16. Section 1399.541 for Physician Assistants Physician assistants must have all progress notes co-signed as required by the state for the scope of practice for physicians assistants Supervisor Requirements The designated physician supervisor and a designated alternate physician supervisor must posses a valid Physician and Surgeon s license. In addition the supervising physician must also maintain: For Nurse midwives -- A current practice in obstetrics For Physician Assistants -- Approval of the Division of Allied Health Professionals of the California Medical Board Supervisory physicians may not supervise or oversee greater than the following full-time equivalent NPMPs: Four Nurse Practitioners Three Nurse Midwives Two Physician Assistants Revised October 2011 7-8

VII. Coordination of Care Services PROVIDER ORIENTATION AND TRAINING Medical groups are responsible for provider training and education. SFHP regularly updates the medical group staff with health plan information for dissemination to appropriate providers in their network. SFHP provides each medical group with a Medical Group Operations Manual. The manual provides the framework and detail of SFHP s program requirements. In addition, SFHP regularly communicates with and updates the medical groups with policy changes, new program implementations, provider/member survey results and other quality improvement outcome information through mechanisms such as special mailings, Provider Newsletters, Joint Administrative Meetings at the medical group sites, and/or Medical Group Meetings attended by representatives of each medical group. New provider training must be completed within ten days of the provider being added to the medical group, and a signed attestation of training must be submitted to SFHP in order for the provider to see SFHP members. An electronic version of the attestation is available on the SFHP web site. Training must cover the following topics: Medi-Cal Eligibility and Benefits; Member Rights as listed in SFHP Provider Manual Section 4; In and Out-of-Network Authorization Process and Second Opinion Referrals; Provider and Member Grievance and Appeal Process; After Hours Access/Appropriate Referrals to the Emergency Department; Direct Access to OB/GYNs; Case Management Services; Child Health and Disability Prevention (CHDP) and Comprehensive Perinatal Services Program (CPSP) Services; Coordination of care for: California Children s Services (CCS); Mental Health and Substance Abuse Services (SFMHP); Dental Benefits; Women, Infants, and Children s Program (WIC); Local Education Agencies (LEA); Golden Gate Regional Center (GGRC); Early Start; Health Education Services Independent Medical Review Initial Health Assessment (IHA) Staying Healthy Assessment (SHA) SFHP Drug Formulary Sterilization Services (PM-330 Forms) Sensitive Services Summary of SFHP Provider Operations Manual Revised October 2011 7-9

VII. Coordination of Care Services MEMBER RIGHTS AND RESPONSIBILITIES SFHP members have rights and responsibilities. Members are informed of their rights and responsibilities through SFHP member materials. Please consult the SFHP Evidence of Coverage or Member Handbook for detailed responsibilities and rights governing each line of business. San Francisco Health Plan members have the right to: Be treated respectfully regardless of my race, religion, age, gender, culture, language, appearance, sexual orientation, and disability and transportation ability. Get a clear explanation of how to obtain all health services available to me. Receive good and appropriate medical care including emergency services from any health care provider, preventive health services and health education. Receive enough information to help me make a knowledgeable decision before I receive treatment. Know and understand my medical condition, treatment plan, expected outcome, and the effects these have on my daily living. Know about any transfer to another hospital, including information as to why the transfer is necessary and any alternatives available. Have the meaning and limits of confidentiality explained to me. Receive interpreter services at no charge. Choose a personal doctor/nurse practitioner to provide or arrange for all the care I need. Obtain a referral from my personal doctor/nurse practitioner for a second opinion. Have confidential health records, except when disclosure is required by law or permitted in writing by me. With adequate notice, I have the right to review my medical records with my personal doctor/nurse practitioner. Be fully informed about SFHP s appeal and grievance procedures, understand how to use them, and how to present my appeal in personal without fear or interruption of health care. Make decisions regarding my care-including the decision to discontinue treatment. Have written instructions about my care prepared in advance, called Advance Directives. Request disenrollment from San Francisco Health Plan at any time without giving a reason. Participate in establishing public policy of the SFHP. Additionally, SFHP Medi-Cal members have the right to: Seek confidential and sensitive services for minors. Seek consultation and treatment of sexually transmitted diseases from a provider outside the SFHP network. Seek family planning services from any provider. Request a State Fair Hearing and to receive information on the circumstances under which an expedited fair hearing is possible. Receive written Member informing materials in alternative formats including Braille, large type print and audio format upon request. Revised October 2011 7-10

VII. Coordination of Care Services Be free from any form of restraint or seclusion used as a form of coercion, discipline, convenience or retaliation. Choose a personal doctor/nurse practitioner at an Indian Health Clinic or a Federally Qualified Health Center. San Francisco Health Plan member has the responsibility to: Read all San Francisco Health Plan materials immediately after enrolling to understand how to use the SFHP benefits. Follow the provisions of SFHP Membership as explained in the Evidence of Coverage. Maintain good health and prevent illness by making positive health choices and seeking appropriate care when it is needed. Follow the PCP s treatment plans and consider and accept the potential consequences if to refuse to comply with treatment plans or recommendations. Make and keep medical appointments; inform the medical office ahead of time when cancellation is needed. Communicate openly with personal doctor/nurse practitioner to develop strong partnership based on trust and cooperation. Treat all San Francisco Health Plan staff and health care providers respectfully and courteously. Present Member ID card at every medical appointment or hospitalization. Report lost or stolen Member ID cards to the SFHP Member Services Department. Pay premiums, co-payments and charges on time. Contact the San Francisco Health Plan Member Services Department at (415) 547-7800 (locally) or 1-800-288-5555 (toll free) for questions or problems regarding member rights and responsibilities. SECOND OPINIONS AND INDEPENDENT MEDICAL REVIEW Second Opinions SFHP members may request a second opinion from any qualified primary care provider within the same medical group, or from any qualified specialist within the same or any other medical group within SFHP s network. If the qualified specialist is not available in the SFHP network, SFHP will assist the medical group to identify an out-of-network specialist. SFHP provides a second opinion from a qualified health care professional when a member or a practitioner requests it for reasons that include, but are not limited to, the following: The member questions the reasonableness or necessity of recommended surgical procedures. The member questions a diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment, including but not limited to, a serious chronic condition. The clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating health professional is unable to Revised October 2011 7-11

VII. Coordination of Care Services diagnose the condition and requests consultation, or the member requests an additional diagnosis. The treatment plan in progress is not improving the medical condition of the member within an appropriate period of time given the diagnosis and plans of care, and the member requests a second opinion regarding the diagnosis or continuance of the treatment. The member has attempted to follow the practitioner s advice or consulted with the initial practitioner concerning serious concerns about the diagnosis or plan of care. SFHP educates its members and practitioners of the availability of second opinions in annual member publications. Policies regarding second opinions are available to the public upon request. Member rights include To be provided with the names of two physicians who are qualified to give a second opinion. To obtain a second opinion within 30 calendar days, or if the medical need is emergent or urgent, to obtain an opinion within a timeframe that is appropriate to the member s condition and that does not exceed 72 hours. To see the second opinion report. Independent Medical Review Members may ask for an independent medical review (IMR) from the Department of Managed Health Care (DMHC) if they or their provider believe that SFHP or their medical group has improperly denied, modified, or delayed health care services. A Member, or a provider on a Member s behalf, may apply for IMR within six months of any of the qualifying events.. The decision not to participate in the IMR process may cause the Member to forfeit any statutory right to pursue legal action against SFHP regarding the health care services at issue. The IMR process is in addition to any other procedures or remedies that are available, such as filing a grievance or an appeal of a grievance. The IMR process is without charge. Members have the right to provide any information to support the request for an IMR. SFHP provides Members with an IMR application form in all grievance disposition letters that deny, modify, or delay health care services. The member is informed that the IMR process is available after the Plan s grievance and appeal process is exhausted, or 30 calendar days after a grievance is filed, whichever is sooner. The member is also informed of the availability of an expedited review if the qualifying conditions are met. If the grievance process is expedited, the Plan notifies the California Department of Managed Health Care (DMHC), and the member may apply for IMR immediately. The SFHP Medical Director is responsible for implementing the IMR procedure. If a member applies for IMR through a provider or medical group, the practitioner or medical group contacts the SFHP Medical Director immediately. When DMHC notifies the Plan that a request for an IMR has been submitted, the SFHP Medical Director reviews the Request for Health Plan Information form and returns the form to DMHC within two calendar days for a standard request, or within 24 hours for an expedited request. Revised October 2011 7-12

VII. Coordination of Care Services When the DMHC notifies the Plan that a case qualifies for an IMR, SFHP will work with the medical group and its providers to forward all relevant medical records to DMHC. Relevant medical records must be submitted within three business days for a standard request, or within 24 hours for an expedited request. IMR submissions include: Medical records relevant to the patient s condition for which the proposed therapy has been recommended and any other pertinent documentation that is in the Plan or medical group s possession. Copies of any relevant document(s) used by the Plan or medical group to reach the conclusion that the proposed therapy should not be covered. A statement by the Plan explaining the rationale for the denial. Any member or provider statement in support of the request for coverage. When DMHC notifies SFHP of its IMR determination, the SFHP Medical Director informs the medical group, the member and the provider of the decision in writing within one business day. If the review was expedited, SFHP immediately contacts the member and provider by phone or fax, and sends written notification within one business day. The SFHP Medical Director works with the medical group to arrange and authorize any necessary services within five business days after the IMR decision or sooner if medically indicated. SFHP then notifies DMHC that the IMR determination has been implemented. If the service has already been rendered, any outstanding claims are reimbursed as directed. Action Expedited Standard DMHC notifies physician and SFHP if application is eligible SFHP returns the Health Plan Information Form to the DMHC SFHP submits medical records to IMR SFHP provides additional information to IMR IMR makes determination Within 48 hours after receipt of application Within 24 hours of DMHC notification Within 24 hours of DMHC notification Within one day of receipt Within three days of receipt of records, may take up to seven days for experimental care Within seven days after receipt of application Within two days of DMHC notification Within three days of DMHC notification Within one day of receipt Within 21 days of receipt of records DMHC issues written decision SFHP notifies medical group, member and practitioner SFHP or medical group authorizes or pays for approved treatment Within one day of receipt of IMR determination Immediately upon receipt of IMR determination Within 24 hours of receipt of IMR determination Within three days of receipt of IMR determination Within 24 hours of receipt of IMR determination Within five days of receipt of IMR determination Revised October 2011 7-13

VII. Coordination of Care Services CULTURAL AND LINGUISTIC SERVICES All non-english monolingual and limited English proficient members of SFHP must have linguistic services available to them for all member service inquiries and medically related visits. SFHP members have a right to: Interpreter services at no charge, including signers and telecommunication devices for the deaf Not use friends or family members as interpreters unless specifically requested by the member Request face-to-face or telephone interpretation services Receive fully translated informing documents in threshold and concentration languages such as Member Service guides, grievance and Notice of Action letters, welcome packets and marketing information Receive referrals to culturally and linguistically appropriate community services File grievances or complaints if linguistic needs are not met The medical group must inform providers that they must document primary language and need for language and/or interpretation services by a non-english proficient - or limited English proficient member in the medical record. Interpreters must also include sign language interpreters and telecommunication devices for the deaf (TDD). Providers must also document the member s refusal to accept the services of a qualified interpreter. The medical group must have a policy and procedure that includes, but is not limited to the following: Description of member s rights to interpreter services that is consistent with SFHP policies Description of the use of bilingual providers and office staff Description of how providers will access, arrange, and document the use of interpreters at key points of contact when bilingual providers and staff are not available Description of how individuals requesting interpreter services will be offered/matched with the same interpreter to ensure continuity of care to the extent possible Identification of multiple modes of interpreter services available to members on a 24- hour basis, including on-site and face-to-face and telephonic interpreter services Procedure for identifying language capability of providers and staff who provide linguistic services, including a method of assessment of interpreter skills, documentation of the number of years of employment as an interpreter or translator, documentation of completion of interpreter training or other reasonable documentation of interpreter capability The medical group must maintain a list of contracted interpreter service agencies and conduct cultural competency training for staff and providers. SFHP monitors the medical group s compliance with Cultural and Linguistic Services through review of medical group policies and procedures, Member Grievance logs, and the relevant sections of the DHS Medical Record Review/Facility Site Review. Revised October 2011 7-14

VII. Coordination of Care Services HEALTH EDUCATION SFHP members must be provided with health education services and may self refer to any health education service. Health education services include but are not limited to primary and obstetrical care, clinical preventive services, education and counseling, and patient education and clinical counseling. These services can be provided through: Individual classes; Group classes; Workshops; Support groups; Peer education programs; Disease management programs; Educational materials; Health education services may include: Educational interventions designed to help members to access appropriate care Educational interventions that cover behaviors such as: Tobacco use and cessation; Alcohol and drug use; Injury prevention; HIV/STD prevention; Family planning; Immunizations; Dental care; Nutrition; Weight control and physical activity; Parenting; Educational interventions designed to assist members to follow self-care regimens and treatment therapies for existing medical conditions, chronic disease, or health conditions including: Pregnancy; Asthma; Diabetes; Substance abuse; Tuberculosis; Hypertension; Medical groups may use their own services or may access SFHP s contracted network of health education vendors for health education programs that are not offered by the medical group. For information about SFHP s health education classes and additional resources, contact SFHP s Manager of Health Education, Cultural and Linguistic Services. Revised October 2011 7-15

VII. Coordination of Care Services COMMUNITY RESOURCES California Children s Services California Children s Services (CCS) provides special medical care for children less than 21 years of age who have physical disabilities and complex medical conditions. Services provided under the CCS program are reimbursed directly by CCS. SFHP is not financially responsible for the CCS services provided to its members. A SFHP member who is eligible for CCS services remains enrolled with SFHP, and the PCP coordinates and continues to provide care for all needs unrelated to the CCS condition. Physicians and medical group staffs are responsible for identification, referral, and case management of members with CCS eligible conditions. Until eligibility is established with the CCS program, the PCP and medical group continue to provide medically necessary covered services related to the CCS eligible condition. The member s PCP is responsible for all primary care and other services unrelated to the CCS-eligible condition and for coordinating care with CCS program staff and specialists. Eligible conditions include physical disabilities and complex medical conditions such as sickle cell anemia, cancer, diabetes, HIV, major complications of prematurity, etc. The member s clinical information and the CCS referral form are sent to: California Children s Services 30 Van Ness Avenue, Suite 200 San Francisco, CA 94102 Telephone: (415) 575-5700 Fax: (415) 575-5790 (Please refer to Appendix E for detail information of the CCS Program) Direct Observed Therapy (DOT) for the Treatment of Tuberculosis The Department of Public Health s TB Control Unit provides trained personnel to assist SFHP members who are eligible for direct observed therapy (DOT) services. TB DOT program staff will provide direct observation of the ingestion of prescribed anti-tuberculosis medications. Elderly and persons with language and/or cultural barriers can also be referred to DOT. In addition, members with memory or cognitive disorders or those too ill for self-management can be referred. Eligible conditions for DOT referral This program provides, delivers, and oversees the outpatient treatment of selected patients with active tuberculosis (TB) who meet one of the following criteria: Have demonstrated multiple drug resistance (INH and Rifampin) Whose treatment has failed or patient has relapsed post treatment Have significant functional impairment due to mental illness or substance abuse Children and adolescents with active TB Revised October 2011 7-16

VII. Coordination of Care Services HIV positive patients Admitted to a hospital for TB Homeless patients Patients who fail to keep appointments Referral to TB DOT Medical group staff and physicians forward medical records, consult reports, and appropriate laboratory findings for members who meet the above criteria to the local TB Control Program for evaluation and treatment for DOT services. San Francisco Health Plan is not financially responsible for the DOT services provided to its members. A SFHP member who is eligible for DOT services remains enrolled with SFHP. The medical group and PCP maintain responsibility for coordination of services and for continued medical care. Tuberculosis Control Program San Francisco General Hospital Ward 94 Telephone: (415) 206-8524 Fax: (415) 648-8369 Early Start Infants and children three years or under whom have developmental delays in cognitive, physical (motor, vision and hearing), communication, social/emotional and adaptive functions are eligible for Early Start Services. In addition children with a condition know to lead to developmental delay or whose early health history places them at risk for delay may also be eligible for Early Start. Early Start provides a wide range of services including speech and hearing evaluations and treatment. San Francisco Health Plan is not financially responsible for the Early Start services provided to its members. The medical group is responsible for covering the initial evaluation and treatment. A SFHP member who is eligible for Early Start services remains enrolled with SFHP, and the medical group and PCP maintain responsibility for coordination of services and for continued medical care. Medical group physicians can refer to Early Start by contacting: Golden Gate Regional Center 120 Howard Street, 3rd Floor San Francisco, CA 94105 (415) 546-9222 Golden Gate Regional Center Golden Gate Regional Center (GGRC) is a private, non-profit agency established to assist mentally disabled persons, individuals who are substantially handicapped by cerebral palsy, epilepsy or autism, and their families in locating services in their communities. Revised October 2011 7-17

VII. Coordination of Care Services To be eligible, a member must meet the following criteria: Disability is due to mental retardation, cerebral palsy, epilepsy, autism or a condition similar to mental retardation. Disability began prior to the age of 18. Disability is likely to continue indefinitely. Disability is substantially handicapping for the individual. GGRC provides services a member needs in order to function independently. Main areas of assistance include: Helping to find and secure efficient housing. School or adult day programs. Transportation. Providing respite services. Durable Medical Equipment. Speech or P.T./O.T. services. Social activities. San Francisco Health Plan is not financially responsible for the GGRC services provided to its members. A SFHP member who is eligible for GGRC services remains enrolled with SFHP, and the medical group and PCP maintain responsibility for coordination of services and for continued medical care. Medical group physicians can refer to GGRC by contacting: Golden Gate Regional Center 120 Howard Street, 3rd Floor San Francisco, CA 94105 (415) 546-9222 Local Education Agency The San Francisco Unified School District s Local Education Agency (LEA) provides services in San Francisco schools for low-income children (3-18 years of age) with one or more of the following conditions: Vision or Hearing Impairment Orthopedically Challenged Developmentally Delayed Children who have received the Early Start (ES) or Golden Gate Regional Center (GGRC) services are assessed between 2 3 years of age for referral to the San Francisco Unified School District Special Intake Unit for continued assistance. Medical group physicians and the ES or GGRC must obtain written consent from the parents prior to referral and to release any clinical information. Services provided under the LEA program are reimbursed by the San Francisco Unified School District. San Francisco Health Plan is not financially responsible for the LEA services provided to its members. A SFHP member who is eligible for LEA services remains enrolled Revised October 2011 7-18

VII. Coordination of Care Services with SFHP, and the medical group and PCP maintain responsibility for coordination of services and for continued medical care. Local Education Agency Special Education Telephone: (415) 242-2670 Fax: (415) 355-7740 Multipurpose Senior Service Program The Multipurpose Senior Service Program (MSSP) provides in-home care to members as an alternative to placing them in an institution. The County s Department of Aging administers the program. Services are available to physically disabled or aged members over 65 years of age who would otherwise require care at skilled nursing facility (SNF) or intermediate care facility (ICF) level. MSSP assists with a wide array of services that include: Personnel (nurses, home health aides, social workers, senior companions). Home Safety Modifications. Legal Assistance. Meal Delivery. Housing. Counseling and Crisis Intervention. Transportation. Assistance with Eviction or Elder Abuse. Respite Care. Medical group staff and physicians identify and refer potentially eligible members to the MSSP for evaluation who are: Aged 65 years or older Eligible for Medi-Cal Residents of San Francisco The medical group staff and physicians case manage and assist with the coordination and communication of services between the MSSP and Adult Day Health Care Center. Services provided under the MSSP program are reimbursed by the San Francisco County Department of Aging. San Francisco Health Plan is not financially responsible for the MSSP services provided to its members. A SFHP member who is eligible for MSSP services remains enrolled with SFHP, and the medical group and PCP maintain responsibility for coordination of services and for continued medical care. The PCP or specialist submits appropriate medical records and the MSSP referral to: Institute on Aging for Multipurpose Senior Service Program and Adult Day Health Care 3626 Geary Boulevard, Second Floor San Francisco, CA 94118 (415) 750-4141 Revised October 2011 7-19

VII. Coordination of Care Services Women, Infants and Children Women, Infants and Children (WIC) is a nutrition/food program that helps women who are pregnant, breastfeeding or have recently had a baby, and children under the age of five to eat well and stay healthy. WIC eligibility is determined by federal income guidelines. Medi-Cal, Healthy Families and many Healthy Kids & Young Adults members are eligible. Services include free food vouchers, nutrition education and breastfeeding support. Members may be WIC eligible are encouraged to contact their PCP for referral to WIC, who will determine clinical and financial eligibility. San Francisco Health Plan is not financially responsible for any of the WIC services provided to its members. A SFHP member who is eligible for WIC services remains enrolled with SFHP, and the medical group and PCP maintain responsibility for coordination of services and for continued medical care for members enrolled in WIC. Medical group physicians can refer to WIC in a number of ways: By calling 1-888-WIC-WORKS or 1-888-942-9675 for an appointment. By referring members to any WIC Center (See WIC Brochure for current location). Revised October 2011 7-20

NEMS-MSO Provider Manual VIII. Quality Improvement Program VIII. QUALITY IMPROVEMENT PROGRAM Purpose The Quality Improvement (QI) Program is designed to objectively and systematically monitor and evaluates the quality, appropriateness and outcome of care and services and the processes by which they are delivered to SFHP members, and to continuously pursue opportunities for improvement and problem resolution. The goal of the NMES-MSO QI Program is to continuously improve the quality of care and service delivered by the NEMS-MSO. This will include services provided to SFHP members, contracted providers and clinic staffs. The QI Program will work to develop, implement and coordinate all activities that are designed to improve the processes by which care and service are delivered. Review activities may include but not be limited to the areas of: Provider accessibility and availability Provider satisfaction Practice guidelines; clinical studies Trending of quality indicator data Under/over utilization Adverse outcomes and sentinel events Medical record keeping practices Member satisfaction, complaints/grievances Timeliness of handling claims High risk and high volume services Quality of Care Management Committee (QCMC) The NEMS QCMC monitors quality issues concerning the NEMS Clinic. The Family Health Center (FHC) QCMC monitors quality issues concerning the FHC. The NEMS-MSO QI Committee will review and handle common quality of care issues related to SFHP members. QUALITY IMPROVEMENT COMMITTEE & PROGRAM ACTIVITIES QI Committee Membership The Quality Improvement Committee is an interdisciplinary committee with membership that is appointed by the NEMS-MSO Executive Director and the NEMS-MSO Medical Director. It includes staff involved in the quality of care and services of patients, and providers that are representative of the Provider Panel. There should be representation from physicians, including sub-specialties. The NEMS-MSO QI Committee meetings will be scheduled on a regular basis at least once each quarter. Quality Improvement Program Activities The NEMS-MSO QI Committee works with member clinics and contracted PCPs in the medical group to develop a consistent one-year work plan. Common elements being identified to study: e.g., immunization, perinatal or PAP data. The QI Committee will work to establish Revised October 2011 8-1

NEMS-MSO Provider Manual VIII. Quality Improvement Program uniform standards of care that are consistent with the practices at each member clinic and contracted physician s practicing locations. QUALITY INDICATOR COLLECTION & CASE MANAGEMENT REVIEW Collection of Quality Indicator Data The following types of quality indicator data will be monitored: Data incorporating HEDIS 3.0 standards Monitoring access to services (with documentation) a) Primary care Physician examination (30 days) Routine appointments (14 days) Urgent appointments (same day) b) Specialty care Routine referrals available within 14 days Processes to discover and track missed appointments Adult preventive health services (SFHP Standards) a) Comprehensive History & Physical Examination within 120 days of enrollment: Blood pressure; height and weight; breast examination and mammography as indicated per USPSTF guidelines; Pap smear per USPSTF guidelines; counseling of selected items; TB skin test; STD screening; baseline cholesterol testing; stool examination for occult blood as indicated; immunizations b) Periodic re-examinations: Blood pressure; mammography; Pap smear; TB and STD screening; cholesterol and stool testing; counseling as needed. Sentinel events Mortality review Clinical studies as determined by the QI Committee (with quarterly report available) Complaints and Grievances Shared Information from the Members Services Department and the Providers Services Department Other quality indicators as determined by the QI Committee (with quarterly report available) Case Management Review Process Monthly summaries of Case Management activities are reviewed. Summaries are also submitted to the SFHP. Patient types monitored are as follows: AIDS patients High risk obstetrical patients Long term care services Adult day health care services California Children s Care (CCS) services Mental health services Alcohol and drug treatment services Revised October 2011 8-2

NEMS-MSO Provider Manual VIII. Quality Improvement Program Coordination of out-of-plan services EVALUATION QUALITY OF CARE ISSUES IDENTIFIED & PEER REVIEW Quality Improvement Method Data Generated and Analysis For clinical studies or access studies done for the clinic s general population, a representative number of SFHP patients should be included in the study. The Committee will identify common data elements between clinics to study: e.g., immunization, perinatal, or other data. The QI Committee will evaluate data from Quality Indicators and clinical studies. Statistical analysis will be made. Corrective Actions Recommended After evaluation and discussion of data, the QI Committee will issue recommendations for a Corrective Actions Plan (CAP) as necessary. The Medical Director at each clinic and the Office Manager at the contracted PCP s office will be responsible for the implementation of the CAP. Monitoring of Results The QI Committee will monitor the results of recommend procedure changes. Follow-up audits will be conducted at as specified by the QI Committee to verify implementation of corrective action and to monitor improvement. Utilization Management (UM) The Quality Improvement Committee will be the resource for utilization criteria for the Utilization Management Committee. The QI Committee will establish criteria for medical necessity and inappropriate utilization, and monitor decisions of the UM Department to deny services. Denials will be monitored and/or recorded to determine if there is an impact on the quality of care. Complaints and Grievances for Member Services The NEMS-MSO Member Services Department will be responsible for handling and resolving complaints and grievances related to SFHP members. The Member Services Department will follow a developed procedure for this process, and make quarterly reports available for the QI Committee. The QI Committee will review the reports of the Members Services Department during regular meetings, and recommend procedural changes as necessary. Peer Review The NEMS-MSO QI Committee will establish uniform peer review standards. Peer review discussions are held as part of the QI Meetings. As problems arise, reasonable efforts will be made to counsel providers regarding performance and needed improvement. Perceived problems not corrected will be forwarded to the Board of Directors for consideration. Providers who frequently experience utilization and/or billing Revised October 2011 8-3

NEMS-MSO Provider Manual VIII. Quality Improvement Program problems not corrected by these actions may be subject to more stringent monitoring or other restrictions, which the Board of Directors deems necessary to correct the problems. QUALITY IMPROVEMENT PLAN A Quality Improvement Plan is developed and implemented annually by the QI Committee and approved by the NEMS Board of Directors. The Plan describes planned projects and activities for the year including continued follow-up on previously identified quality issues and a mechanism for adding new activities to the plan as the need is identified. It delineates who is responsible and the time frame in which planned activities will be achieved. It provides a mechanism for annual review, evaluation and revision of the Plan with quality improvement reports on effectiveness and outcomes, including recommendations for approval, to the NEMS- MSO Executive Director and the NEMS Board of Directors. Clinical Indicator Studies Reports on the following indicators will be reported to the SFHP on a quarterly basis: Member immunization rates (pediatric) Member Pap smear screening rates (adult women) Member mammography screening rates (adult women) Member low-birth weight delivery rates (perinatal care) Member glycohemoglobin monitoring rates (diabetics) Additional clinical indicator studies are to be added as determined by the QI committee. Projects/Activities Added to Plan as Identified Throughout Year Activities are to be added during the year. This includes a plan to monitor quality of care issues, which are identified as QI Committee meetings are held. The QI Committee will delineate who is responsible and the time frame in which planned activities will be achieved. Reporting The Quality Improvement Committee will issue Quality Improvement progress reports to the NEMS Board of Directors quarterly, or more frequently if needed. The Quality Management Committee provides an annual summary and evaluation report on the activities and effectiveness of the Quality Improvement Program to the NEMS Board of Directors Body and NEMS-MSO Executive Director. The report includes progress made on achieving the goals of the Quality Improvement Plan including; summary and trending of monitoring and evaluation activities, special studies and reports, follow-up on previous studies and reports, actions taken, effectiveness of those actions and demonstrated improvement in the quality of care and service provided. The report makes recommendations on future Quality Improvement activities, Quality Improvement Plan revisions and changes to the overall Quality Improvement Program. The NEMS Board of Directors may approve the recommendations and report or may make independent recommendations for action as indicated. Revised October 2011 8-4

IX. Claims Processing and Payment Dispute IX. CLAIM PROCESSING AND PAYMENT DISPUTE CLAIMS PROCESSING AND ADJUDICATION Providers are encouraged to submit claims for payment as soon as practical to avoid denial for untimely submission. Professional providers are to bill for services rendered using a HCFA- 1500 claim form; Hospital and Institutional providers are to bill for services rendered using a UB-92 (CMC-04) claim form. All medical claim forms must be submitted with the rendering / attending physician s NPI number and full name listed. In the event that service was performed by a mid-level provider, such as a Physician Assistant, a Nurse Practitioner, or a Registered Nurse, the supervising MD s name and NPI number should be listed on the claim form for reimbursement. All medical claims should be submitted to the following address: Claims Processing Department NEMS Medical Group 1520 Stockton Street San Francisco, CA 94133 Timely Filing Limit In compliance with the Claims Settlement Practices and Provider Dispute Resolution Mechanism regulations, NEMS-MSO has imposed the following claims filing time limit: Panel providers/contracted specialists should submit claims for payment no later than 180 days from date of service; Emergency physicians/emergency Physician Groups must submit claims for payment no later than 365 days from date of service; In the event that NEMS Medical Group is not a primary payer under coordination of benefits, provider should submit the supplemental or coordination of benefit claim no later than 90 days from the date of payment, contest, or denial from the primary payer. Claims submitted outside the required filing time limit are subject to be denied for untimely filing. If the recipient has other health insurance coverage, NEMS-MSO policy requires that, with certain exceptions, providers must bill the recipient s other health insurance coverage prior to billing NEMS-MSO. If a received claim is under the financial responsibility of the member s Health Plan for adjudication, NEMS-MSO will forward the claim to the member s Health Plan within ten (10) business days from date of receipt. Claims submitted with incomplete information, such as missing CPT-4 / ICD-9 code, missing provider tax identification number, missing rendering physician s name or national provider identification number, etc, will be returned to the provider by mail with a NEMS-MSO covered letter indicating the information that is required for claims processing. When a provider is resubmitting a claim with the required information field(s) completed, the new receiving date will be used as the date of received of the clean claim for data processing. Revised October 2011 9-1

IX. Claims Processing and Payment Dispute Turn Around Time (TAT) The NEMS-MSO Claims Processing Department provides the following TAT: 90% of clean claim will be processed and adjudicated within thirty (30) calendar days; 95% of clean claim will be processed and adjudicated within forty-five (45) working days (63 calendar days). Claims Acknowledgement NEMS-MSO provides acknowledgement of receipt of claims through Customer Service personnel. The Customer Service phone and fax line for claim and payment inquires: Phone: 415-352-5041 (Wendy) 415-352-5049 (Winnie) 415-352-5043 (Patricia) Fax: 415-398-2895 For faster turn around, providers are encouraged to send requests to check claims status via fax. Claims Processing 1) Service Rendered without Authorization Covered services billed without prior authorization issued by the NEMS-MSO UM Department will be denied for payment. Provider can contact the UM Department to obtain retro authorization for eligible services. Please refer to the PCP Referral & Authorization section in this manual for more detail information regarding the NEMS- MSO UM criteria. 2) Auto Claims Payment Criteria The following services are exempted from the prior authorization requirement rule. Claims billed for these services without authorization will not be denied for payment. All Providers: Ambulance services; Anesthesia services for OB delivery and other surgeries; Emergency room services, in-area and out-of-area, both professional and facility charges; (high level ER pro-fee bill are subject to coding review); Immunizations provided by DPH clinics under urgent need condition; Pregnancy testing; HIV testing; Sensitive services for Medi-Cal members, include pregnancy testing, family planning services; Contracted Providers Only: Abortion Services; In-office procedures associated with prior authorized consultation; Mastectomy; Obstetrical services and related OB ultrasound; Revised October 2011 9-2

IX. Claims Processing and Payment Dispute CHDP/EPSDT preventive services per CHDP/EPSDT periodicity schedules an guidelines; Professional interpretation for Radiology & Pathology services; Sensitive services for Healthy Families & Healthy Kids members; Tuberculosis care include TB screening, testing, and treatment unless hospitalization is needed; Well woman care include preventive screening, pap smear, breast exam and mammography; 3) Possible Duplicate Services Same service code(s) billed by the same rendering physician for the same member on the same date of service, are consider duplicate service(s). If the service(s) was previously paid, the duplicated claim will be denied. If the service(s) was previously processed unpaid, and there s no indication of any additional information in the duplicate copy received, the claim will also be denied as previously processed. If a duplicate claim is submitted with additional information that was missing from the original claim, the new claim should be treated as a corrected claim, and will be process accordingly. There will be no interest accrued to process a corrected claim. In the event if a member receives two specialty consultations from two physicians from the same physician group, NEMS-MSO will reimburse both physicians claims only if the two physicians specialties are different and/or practice in different areas. For repeated procedure or bilateral procedure done by the same physician to the same member on the same date of service, provider is required to bill for the service with the appropriate modifier attached to the CPT-4 code. 4) Immunization Reimbursement NEMS-MSO will reimburse provider the contracted rate or the current Medi-Cal rate for immunizations given to the SFHP Healthy Families and Healthy Kids members. Please refer to Appendix C in this manual for a detail list of immunization code / description and billing rules. 5) Bundled Services/Procedures The following services are considered bundled with the primary procedure, and will not be separately reimbursed: General office supply (POS 11 only) CPT-4 code 99070; include bandage, glove, tray, sterile supplies, gauze materials, etc. Specimen handling (POS 11 only) -- CPT-4 code 99000 99002. Services provided outside regular hours CPT-4 code 99050 99053. Special reports CPT-4 code 99080 for insurance form, employment form, etc. Postoperative follow-up visit CPT-4 code 99024, this service is normally included in the surgical package. Note: Supplies billed by a hospital facility are NOT part of the bundled procedure. Physician who performed the procedure will not be reimbursed separately for any hospital supplies. Revised October 2011 9-3

IX. Claims Processing and Payment Dispute 6) Emergent Care / Urgent Care Claims Emergent and/or Urgent services are covered benefits. However, follow-up care received after emergency service or urgent care must be coordinated with the member s PCP to obtain authorization for such follow-up care (including admission to the hospital as an inpatient). NEMS-MSO is responsible to pay for all qualifying in and out of area emergency room services without requiring prior authorization. Providers billing for emergency room services are encouraged to submit the emergency room record along with the medical claim form for medical justification. NEMS-MSO covers Emergency Services outside of San Francisco (including outside of the United States). Member may submit reimbursement request for emergency services obtained out-of-area by providing complete medical documentation and proof of payment. All reimbursement requests will be reviewed by the NEMS-MSO Medical Director for medical necessity. Reimbursement will be made directly to the member as soon as the request is approved. Note: For supporting language relates to coverage for Out-of-Are emergency services, please refer to Page 7-2 in the Coordination of Care section in this manual. 7) Voluntary Sterilization and Consent Voluntary sterilization services are covered if the patient is at least 21 years old at the time consent is obtained. Provider is required to submit a copy of the completed and signed PM-330 consent form with the HCFA 1500 claim form in order to be paid for service provided. The written informed consent (PM-330) must be signed at least 30 days prior to the sterilization procedure, but not more than 180 days. Claims billed for sterilization services without submission of PM-330 consent form will be denied for reimbursement. Please refer to Section 6-2 in this manual for additional information related to elective sterilization and consent. Reimbursement Rate Covered specialty services with referral or prior authorization issued or primary care services provided by the member s PCP will be reimbursed based on the Medi-Cal or the contract fee schedule. If reimbursement rate is not available from Medi-Cal at time of service for a particular billed service code, NEMS-MSO will reimburse the provider according to the Medicare fee schedule with a 30% rate reduction. Usual, Customary, and Reasonable (UCR) Pricing Methodology NEMS-MSO reimburses all out-of-network / out-of-area providers using the Usual, Customary, and Reasonable (UCR) pricing methodology. The UCR reimbursement formula is determined by NEMS-MSO annually and falls within the common range of fees billed by a majority of providers for a procedure or service in a given geographic region, or is justified based on the complexity or the treatment severity for a specific case. Per California Code of Regulation, Title 28, Section 1300.61.3, the UCR value of each service rendered is deemed to be both an Allowable Expense and a benefit paid. It represents that reimbursement is provided in full for the charge for services. The SFHP enrollee has no obligation to pay any remaining balance other than the co-payment. Revised October 2011 9-4

IX. Claims Processing and Payment Dispute CLAIMS PAYMENT DISPUTE RESOLUTION MECHANISM A provider claim dispute is a written notice to the NEMS Medical Group appealing or requesting reconsideration of a claim that has been reimbursed, adjudicated or denied; or seeking resolution of a billing determination; or disputing a request for reimbursement of an overpayment of a claim. If a provider wants to dispute a claim payment or denial, the provider can submit a written dispute to the following address: North East Medical Services Attn: MSO Provider Claims Dispute 1520 Stockton Street San Francisco, CA 94133 415-352-5043 Providers must submit a Provider Dispute Request (PDR) form in writing along with any relevant and supporting documentation within 365 days of the last adjudication of the claim. The PDR Form (Appendix B) must include: 1) Provider s Name and Contact Information (Address and Phone Number); 2) Provider s NPI Number; 3) Patient s Name and DOB; 4) Claim Number from NEMS-MSO Explanation of Benefit; 5) Copy of original claim being disputed; 6) Identification of the disputed item(s); 7) Explanation of the basis that provider believes the payment amount, adjustment, denial, or request for reimbursement is incorrect; 8) Other pertinent documentation to support the appeal. NEMS-MSO will acknowledge the receipt of the PDR within fifteen (15) working days of receipt of the dispute. If the initial submission of the PDR is incomplete, NEMS-MSO will return it to the provider with identification of the missing information. Provider has fifteen (15) working days to resubmit an amended PDR with requested information. NEMS-MSO will issue a written determination, including a statement of the pertinent fact and reasons, to the provider within forty-five (45) working days after receipt of the provider claim dispute (or an amended PDR when applicable). Note: Claims that are denied due to provider s claim submission error or omission (e.g. missing modifier, incorrect CPT / ICD-9 or place of service code, etc) do not qualify for the Provider Claim Dispute Resolution Mechanism. These claims should be resubmitted within the time period for claim submission as corrected claim with a brief explanation of the error either noted on the claim or as an attachment. Please refer to Attachment B for the PDR form and complete instructions. Revised October 2011 9-5

X. Provider Complaints/Member Grievances X. PROVIDER COMPLAINTS AND MEMBER GRIEVANCES Provider Grievance Process Good provider relations are a key to the effective delivery of health care to members. Every effort will be made to give health care service providers the opportunity to have their concerns, complaints and grievances addressed whenever possible at the informal level by the Plan. If the proposed solution is unsatisfactory to the Provider, the Provider may make Formal Provider Grievance. The Provider Grievance Process addresses complaints or concerns related to any action taken by the Plan including, but not limited to: Scope of service determinations. Assignment or reassignment of members. Lack of or level of payment for an unauthorized or emergency claim. Delay of payment(s). Lack of cooperation by a member in following treatment plans. Lack of information or cooperation by the Plan staff. Disagreement by the provider with prior authorization decisions or utilization review decisions made by the Plan staff. Dispute with the Plan regarding Plan interpretations of provider actions which are reasons for contract termination as stated in the provider s contract. Dispute between a contracting hospital and the Plan arising from the interpretation and/or implementation of the terms and conditions of the Hospital contract. Concern about the quality of care being rendered by another provider or possible inappropriate billing by another provider. Other issues as determined by the provider. Whenever appropriate, grievances which should first be addressed on the IPA/Medical Group level will be referred to the IPA/Medical Group Medical Director. Provider complaints / grievances related to performance by the Plan or complaints regarding the decision making at the IPA/Medical Group level will be addressed by SFHP Provider Relations staff. Providers Filing a Grievance at SFHP - Level 1 Day 1 A provider may present a complaint to the Grievance Coordinator or Provider Relations staff by telephone, in person or in writing. Day 3 The Provider Relations Representative or Grievance Coordinator will acknowledge the receipt of the complaint in writing. The Provider Relations Representative will enter a summary of the complaint on the Provider Complaint Screen, and the MIS will automatically log the complaint and date on the Provider Complaint Summary Report. A copy of the complaint will be Revised October 2011 10-1

X. Provider Complaints/Member Grievances sent by the Provider Relations Representative to the appropriate Plan staff for investigation of the complaint and acquisition of the necessary documentation to propose a resolution of the complaint. The Provider Relations Representative will discuss the complaint with the appropriate Plan staff. The respective Plan staff will propose a resolution of the complaint. Day 10 The Provider Relations Representative (PRR) will discuss the proposed resolution with the provider. If a member is subject to an action as a result of a resolution to which he or she objects, no action will be taken until the member has been informed and has had the opportunity to exercise the member s grievance and fair hearing rights. When the PRR s efforts on behalf of the provider do not end in resolution of the issue, the PRR will complete the Complaint Form with a description of his or her activities, a statement of the problem as discovered during the process and a recommendation of the filing of a formal grievance. If the provider concurs in the filing of the formal grievance, the provider or the provider s representative will sign the Complaint Form. If no resolution is reached but the provider does not want to continue the complaint/grievance process, s/he will sign and date a written statement to that effect on the complaint form. If the provider decides not to file a formal grievance, but the PRR concludes that additional investigation/action on the issue is warranted, the PRR will refer the issue to the Grievance Coordinator and the Medical Director for appropriate action or referral. When the provider accepts the proposed resolution at the informal level, the Provider Relations Representative will complete the complaint documentation, log the resolution and file the complaint record in the provider s record. The PRR will then write a letter to the provider summarizing the resolution of the informal complaint, offer assistance with future problems and send the complaint resolution to the provider for signature indicating his or her acceptance of the resolution. Provider Formal Grievance Process - Level 2 When the provider does not accept the proposed solution, he or she may file a formal grievance with the Grievance Coordinator. The procedures to resolve a formal grievance will occur on the following listed schedule which is established by the in-date on the formal grievance screen, although every effort will be made to resolve problems in less time whenever possible. Note: Any outside date that lands on a weekend or on an SFHP holiday is extended to the next Plan business day. Day 1 The PRR will complete the grievance section of the Provider Complaint Form, print it, and submit it to the provider for signature in person or by mail and request additional information or data for submission with the formal grievance. Revised October 2011 10-2

X. Provider Complaints/Member Grievances Day 3 Day 7 Day 10 A certified letter acknowledging receipt of the grievance will be sent to the provider upon return of the signed, written complaint/grievance. The acknowledgment letter will include a written description of the grievance process, an explanation of the provider s grievance rights, a copy of the Provider Complaint/Grievance Form which has been filed, and a request to contact the Provider Relations Representative. When the signed grievance is returned to the Provider Relations Representative, the Coordinator will log the request for a formal grievance resolution and forward the Grievance Form, additional documentation from the provider and any additional documentation the Provider Relations Representative may have obtained from other staff in the Plan, members and others, to the Grievance Coordinator. The Provider Relations Representative will enter the grievance on the Grievance Summary Log. On behalf of the Chief Executive Officer, the Grievance Coordinator will contact the provider to discuss a proposed solution, or to suggest a further action toward resolution of the formal grievance within ten (10) days of filing the grievance. Under no circumstances will final resolution of any grievance involving a member occur without that member being notified and allowed to participate. If a member is subject to a direct action as a result of a resolution of a grievance, no action will be taken until the member s grievance and fair hearing rights are exhausted. When the proposed resolution to the formal grievance is unsatisfactory to the provider, the Grievance Coordinator will provide an explanation to the provider about the next level in the grievance procedure the Grievance and Accessibility Review Committee Hearing. Grievance and Accessibility Review Committee Hearing - Level 3 Day 1 The Grievance Coordinator will outline the following rights of the provider in the Grievance and Accessibility Review Committee Hearing Process: The right to legal counsel An opportunity to review the Plan s respective provider file Access to Plan policy manuals, protocols, and procedures Access to written position statements by the Plan staff five (5) days prior to the hearing An opportunity to present evidence and cross examine witnesses Access to evidence presented by the Plan s representative The right to a translator, and The right to propose a solution to the grievance. Revised October 2011 10-3

X. Provider Complaints/Member Grievances Day 7 Upon written confirmation of the grievant/provider s desire for a Grievance and Accessibility Review Committee hearing, the Grievance Coordinator will notify Committee members of the need for a hearing and establish a date for the meeting and provide the Committee members with a summary of the grievance, a list of the issues and supporting documentation prior to the hearing. The Grievance Coordinator will notify the grievant of the time, date, and place of the hearing. If the grievance in question concerns a specific member, that member will be informed that the provider has requested a Grievance Committee Review hearing. Day 15 The Grievance and Accessibility Review Committee procedures are as follows: Committee members will meet one half hour prior to the grievant appointed time o To select a Chairperson for the session, and o To review the background material and issues in preparation for meeting with the grievant. Committee members will then meet with the grievant in an informal setting which encourages an open exchange of ideas and information to consider the grievant s claims and the information available to them as a result of the Plan s investigation of the grievance. If the grievance in question involves a specific member, that member and his/her representative will be included in the meeting. The proceedings of the meeting will be recorded and the Plan will prepare minutes of the meeting which will be made available to the grievant. If the grievance in question involves a specific member, minutes of the meeting will also be made available to that member. The recording of the meeting will be made available to the grievant or to the member (if applicable) upon request. After hearing all evidence, the Committee will propose a resolution of the grievance. The Chairperson of the session will write up the proposed resolution. Day 20 The Grievance and Accessibility Review Committee will submit its decision and proposed resolution for the grievance in writing to the Grievance Coordinator. The Grievance Coordinator will log the Grievance and Accessibility Review Committee action on the grievance. Day 25 The Grievance Coordinator will send the grievant a letter which explains the decision of the Grievance and Accessibility Review Committee, the reasons for the decision, and informs the provider grievant of the right to appeal the decision will also be sent to any member directly affected by the resolution. The decision will not be implemented until said members have had the opportunity to appeal the decision or pursue their own grievance or fair hearing process. All decisions by the Grievance and Accessibility Revised October 2011 10-4

X. Provider Complaints/Member Grievances Review Committee are automatically approved by the Board of Directors unless they are modified due to Board review of a grievance review appeal. SFHP Board Appeal- Level 4 Day 1 Upon written confirmation of a provider s desire to appeal the decision of the Grievance and Accessibility Review Committee to the Board, the Chief Operating Officer shall immediately notify the Chairperson of the Board of Directors that an appeal for the Board to review a decision by the Grievance and Accessibility Review Committee has been filed. Where the appeal concerns or involves a specific member or members, these members will also be notified of the grievant s decision to appeal. Day 3 Day 7 An Ad Hoc Appeal Committee for hearing the appeal will be named by the Chairperson of the Board. The Ad Hoc Appeal Committee will include three Board members, representing the interests of consumers, physicians and other medical providers. The Chairperson will also appoint one of the Ad Hoc Appeal Committee members as Committee chairperson. At the request of the Chairperson of the Board, the Grievance Coordinator shall notify the members of the Committee of the appeal request. The notice shall include the date, time, and place of the meeting and copies of all of the documentation which has led to the appeal. The Grievance Coordinator shall also send written notice of the date, time and place to the provider who is appealing the decision of the Grievance and Accessibility Review Committee. Where the appeal concerns or involves a specific member or members, written notice will also be sent to this member(s). Day 15 The Committee shall meet with the appellant at the appointed time to consider the appellant s claims and any additional written information s/he has provided. The provider may also have the assistance of legal representatives, translators, and advocates, in presenting the appeal. While the rules of evidence in civil court will not apply here, every effort will be made to insure that all sides are heard and all appropriate evidence presented. Where the appeal concerns or involves a specific member or members, said member(s) will have the opportunity to participate in this hearing. The Committee Chairperson shall tell the provider that the Committee will make a decision on the appeal and prepare a resolution for action by the Board at its next regularly scheduled meeting. The provider is advised that the resolution shall include only the issues which were presented and that the confidentiality of all of the parties who were involved in the grievance will be assured. The grievant shall be notified of Revised October 2011 10-5

X. Provider Complaints/Member Grievances the date and time for the Board of Directors to act on the specific resolution dealing with the appeal. 12 Days Prior to Next Board Meeting The Appeal Committee Chairperson shall draft the resolution reflecting the decision of the Committee for action by the Board of Directors prior to the next scheduled Board meeting. The Appeal Committee members shall review and approve the resolution. The Appeal Committee Chairperson shall submit the resolution to the Executive Director of the Plan for inclusion on the agenda of the next scheduled meeting. Next Regular Meeting At their next scheduled meeting, the Board of Directors shall act on the resolution dealing with the appeal The action by the Board is the conclusion of the Plan grievance resolution process. 5 Days after the Board Meeting The Clerk of the Board of Directors shall prepare a letter to the provider who submitted the appeal. The letter shall include a copy of the resolution and a statement regarding the action of the Board of Director on the appeal. Where the original grievance concerns or involves a specific member or members, these members shall also be notified of the Board s action. MEMBER GRIEVANCES SFHP members may file a grievance by contacting the SFHP Member Services Department or by completing a SFHP Grievance Form (Appendix B). SFHP Member Services representatives are available to help and can provide interpreter services when needed. A grievance is any expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns and complaints, disputes, requests for reconsideration or appeal made by the member or the member s representative. SFHP works with the member, the provider, and the medical group to resolve member grievances within 30 calendar days of receipt, in accordance with all DMHC and DHS regulations. Through this process, the member is informed of their rights in the grievance process, including how they may appeal the resolution offered by the plan or request an independent hearing. Grievances can be submitted by mail, phone, fax, email, or in person to: Grievance Coordinator San Francisco Health Plan 201 Third Street, 7 th floor San Francisco, CA 94103 Phone: (800) 288-5555 Revised October 2011 10-6

X. Provider Complaints/Member Grievances Phone: (415) 547-7800 Fax: (415) 547-7825 Email: customerservice@sfhp.org SFHP provides PCPs and medical groups with copies of its Grievance Forms in threshold languages. Additional forms can be obtained by contacting SFHP or through the SFHP website at http://www.sfhp.org/providers/provider_resources/grievance_process.aspx. Providers must make these forms available to members who desire to express their dissatisfaction with any of the covered areas of service. ADDRESSING MEMBER COMPLAINTS/GRIEVANCES ABOUT PROVIDERS The purpose of this section is to establish a Plan process to resolve member complaints / grievances about Plan-contracted providers and to address with individual providers the essence and/or specifics of individual member complaints. This process is designed to be carried out in conjunction with the procedures for member complaints and for provider complaints; it does not replace those procedures. The member s complaint/grievance may or may not have been resolved and closed for the procedure described in this section to take place. The objectives of this protocol are as follows: To review and evaluate all complaints/grievances about providers for their impact on the provision of service to a specific member or members. To inform the provider of the complaint/grievance in a timely manner. To notify members of any notice the Plan may give the provider about the complaint/grievance. To keep the member who made the complaint/grievance informed as to the progress of the investigation and resolution of the complaint/grievance. To give the provider an opportunity to respond to the complaint/grievance. To provide, as appropriate, additional information to the Quality Improvement Committee regarding provider service. Reporting Complaint/Grievance The Grievance Coordinator will review the complaint/grievance, obtain any additional information and present the complaint to the Medical Director at the next regular or special meeting of the managers for review and discussion of the seriousness of the complaint. Depending on the urgency and seriousness of the issues addressed in the complaint/grievance, the Grievance Coordinator will discuss the complaint with the Medical Director prior to the next regular meeting of the Operations Managers. The Grievance Coordinator will determine whether the member chooses to pursue an informal or formal procedure for resolution of the complaint/grievance as described in Levels 3 and 4. The Grievance Coordinator shall assume responsibility for communicating with the member about the Plan actions. Revised October 2011 10-7

X. Provider Complaints/Member Grievances Notice of the Complaint/Grievance to the Provider Notice to the provider of the complaint/grievance may become part of the complaint/grievance resolution; or it may be delayed as appropriate to the complaint/grievance action. If the member ahs chosen to continue to pursue the informal complaint process, notification to the provider of the complaint will be at the discretion of the Grievance Coordinator who will prepare the standard complaint notice letter to the provider, summarizing the complaint as understood by the Plan. The complaint notice letter will be signed by the Medical Director and mailed in an envelope marked personal and confidential, and will ask the provider to respond to the letter within 30 days. If the member chooses at any point to file a formal grievance, the Grievance Coordinator will mail the standard complaint/grievance notice letter to the provider, summarizing the grievance as understood by the Plan, within 10 working days of the filing of the grievance. The letter will be signed by the Medical Director and mailed in an envelope marked personal and confidential, and will ask the provider to respond to the letter within thirty (30) days. Regardless of the resolution of the grievance, a copy of the complaint/grievance and the complaint/grievance letter will be filed in the provider s file in the Provider Relations Department. The original complaint and a copy of the notice to the provider will be filed by the Grievance Coordinator. Provider Response The provider will have thirty (30) days to respond to the complaint/grievance letter. When the provider does not respond to the complaint/grievance letter within 30 days: o The lack of response will be noted in a dated memo to the complaint file by the Medical Director or the Provider Relations Representative, with copies to the Grievance Coordinator, Chief Executive Officer, Medical Director, and member in question. o The Medical Director will review the complaint within 10 days for follow-up on quality of care issues. AT his/her discretion, the Medical Director may send another letter or call the provider for more information about the quality of care issues. At his/her discretion, the Medical Director may refer the quality of care issues to the Peer Review and/or Quality Improvement Committees. o Any further action by the Plan will be decided at a subsequent meeting of the Medical Director and Chief Executive Officer. At the time, the provider s action will be reviewed for compliance with the provider s contract, the California Code of Regulations, Plan protocols, etc. When a provider responds to a complaint/grievance letter: o The Medical Director or Provider Relations Representative will record the response, date it, and code it with the complaint/grievance control number from the member s file. The Medical Director or Provider Relations Representative will report on the provider s response at the next meeting of the Operations Managers. o Copies of the completed form will be filed in the provider s file and the Grievance Coordinator s file. The member and the member s advocate, if applicable, will be Revised October 2011 10-8

X. Provider Complaints/Member Grievances informed as to the response including any initiation of the provider complaint/ grievance process. The member will be invited to submit any comments on the provider s response. o The Provider Relations Representative will inform the provider of the grievance/complaint process as appropriate and send the respective procedure and enclosures to the provider. Provider Cross-Complaint When the provider states that s/he wishes to file a complaint/grievance about said member complaint his/her response and statement about filing a complaint initiates the implementation of the provider complaint protocol. In any provider complaint/grievance procedure proceeding from a member complaint, the member in question will be invited to participate in writing or in person, whether or not the provider complaint is a cross-complaint against the member. In the event that a cross-complaint is filed, the complaint and cross complaint may be formally reviewed together, at the discretion of the Grievance Coordinator and Provider Relations Representative. Referral of Complaints to Plan Committees for Review Individual and/or aggregate complaints/grievances about providers, whether written or verbal, and regardless of the provider s response to the complaint/grievance and the resolution of the complaint/grievance, may referred to the Quality Improvement Committee of the Plan for review and possible action according to the Quality Improvement Protocol delineated in the Quality Improvement Manual. Information from Additional Regulatory Groups Information received about a provider form other regulatory bodies (e.g., Department of Health Services, Board of Medical Quality Improvement, etc.) regarding such complaints will be included in the provider s file for review by Quality Improvement Committee. Reporting Complaints and Grievances to Plan Management The Grievances Coordinator will prepare quarterly summary reports of all complaint and grievance activities for the quarter. Copies of these reports will be provided to Plan Managers, Member Services and Provider Relations staff, Governing Board, Grievance and Accessibility Review Committee, Quality Improvement Committee and management, Beneficiary Committee, and others as appropriate for analysis and the development of recommendations. Please refer to Appendix B for a copy of the SFHP Member Grievance Form and complete instructions. Revised October 2011 10-9