BlueCare HMO FACILITY POLICY & PROCEDURE MANUAL TABLE OF CONTENTS

BlueCare HMO FACILITY POLICY & PROCEDURE MANUAL TABLE OF CONTENTS A. WELCOME B. TELEPHONE DIRECTORY & FAX NUMBERS C. INDEX D. GLOSSARY OF TERMS E. ADMISSION & DISCHARGE F. ANCILLARY SERVICES G. APPEALS H. BEHAVIORAL HEALTH CARE I. BILLING INFORMATION BLUECARD J. K. FORMS L. LEGISLATIVE M. MEDICAL MANAGEMENT REVIEW N. MEMBER OVERVIEW O. OTHER TYPES OF PRODUCTS P. POLICIES Q. QUALITY MANAGEMENT R. REGIONAL INFORMATION Date 1/2007 Page - 1

WELCOME First Priority Health, (FPH), an affiliate company of Blue Cross of Northeastern Pennsylvania (BCNEPA) and Highmark Inc., welcomes you as a participating provider. As the majority partner of FPH, BCNEPA welcomes and values the opportunity to partner with you in providing quality care to our Blue Care HMO members. FPH is committed to forging a strong, supportive partnership with network health care providers. Together, FPH, and its network of providers set the standards for progressive, high quality medical care that is also cost effective. First Priority Health s primary service area includes: - Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming Counties FPH also has providers located in surrounding contiguous counties. This manual does not contain subscriber benefits information. Please call the phone numbers listed in Section B, Telephone Directory or refer to the phone number listed on the back of the member s identification card. Please be advised that the monthly Provider Bulletin serves as an update to this Policy and Procedure manual. BLUECARE HMO PRODUCTS Blue Cross of Northeastern Pennsylvania (BCNEPA) and Highmark Blue Shield (Highmark) have restructured the relationship they have shared for many years. Highmark now shares a percentage of ownership with BCNEPA of the First Priority Health, (FPH) affiliate. FPH offers several managed care products, including a group, an accompanying conversion product and individual (non group) enrollment products. The new product names are as follows and all have the prefix of YZH: BlueCare HMO - group BlueCare Plus - group BlueChip - non group adultbasic - non group BlueCare HMO Individual Conversion - non group Please note that benefits co-payments and coinsurances may apply and may vary by group. For benefit information, contact Provider Customer Services at 1-800-822-8752. MISSION/VISION OUR MISSION: To provide innovative solutions that support more affordable health care, promote personal accountability for health and wellness, and to offer superior service and partnership to the constituents we serve. Introduction - A Date 1/2007 Page -1

OUR VISION: To be at the forefront of innovation and delivery of improved health management and financing services that promote healthier communities. ROLE OF THE PROVIDER RELATIONS DEPARTMENT The Provider Relations Department, which is part of the overall Health Delivery Division of BCNEPA, plays an integral role in network development and maintenance. Some of the responsibilities of personnel include, but are not limited to: serve as liaison between you and BlueCare HMO; educate participating network providers; and conduct provider training to ensure timely communication of key issues. For all your needs, Provider Relations is just an e-mail or phone call away at (570) 200-4700 or 1-800-451-4447, Monday through Friday, 8:00 a.m.- 5:00 p.m. For claims, benefits and eligibility information, contact Provider Customer Service at 1-800-822-8752, Monday through Friday, 8:00 a.m.- 5:30 p.m. BlueCare HMO members should be directed to call Customer Service at 1-800-822-8753, Monday through Friday, 8:00 a.m.- 5:00 p.m. with any questions regarding their coverage. Hearing and/or speechimpaired subscribers/dependents may call (TTY/TDD) 1-866-280-0486. Introduction - A Date 1/2007 Page -2

BlueCare HMO TELEPHONE DIRECTORY Business Hours are 8:00 a.m. to 5:00 p.m., unless otherwise stated. Behavioral Health Community Behavioral Healthcare Network of Northeastern Pennsylvania (Regional Referral Center) BlueCare HMO For all others, refer to the member s ID card. BlueCard Plan For benefits & eligibility: To locate a provider call: BlueCHIP Eligibility 8:00 a.m. to 5:00 p.m. (M-F) Case Management Department BlueCare HMO 8:00 a.m. to 4:15 p.m. (M-F) 1-800-599-2428 1-800-676-BLUE (2583) 1-800-810-BLUE (2583) 1-800-KIDS-199 Fax: (570) 200-6790 1-800-346-6149 Fax: (570) 200-6777 ChildLine (PA Child Abuse Hotline) 1-800-932-0313 Hearing and Speech Impaired Members 8:00 a.m. to 5:30 p.m. (M-F) (TTY/TDD) 1-800-413-1112 Fax: (570) 200-4459 Managed Pharmacy Program Express Scripts First Priority Health Pharmacy 1-877-603-8399 1-800-722-4062 Fax: (570) 200-6870 Medical Directors 1-800-462-0900 Member Customer Service 8:00 a.m. to 5:30 p.m. (M-F) NaviNet SM 1-800-822-8753 1-888-482-8057 Non-Par Provider Prior Authorization 1-800-962-5353 Fax: (570) 200-6799 Telephone Directory - B Date 1/2007 Page - 1

Pennant Laboratory Services (Lackawanna & Luzerne Counties) 1-800-459-7493 (570) 552-1538 Fax: (570) 552-1415 Courier Pickup Supplies (non-par provider prior authorization, par provider prior authorization): contact the laboratory provider in your area. Guthrie Clinic Physician Care (570) 888-5858 (570) 365-6300 Pre-certification Telephone Numbers 8:00 a.m. - 4:15 p.m. (M-F) BlueCare HMO, BlueCare POS/Self-Funded Accounts, BlueChip and adultbasic 1-800-962-5353 Provider Relations 8:00 a.m. to 5:00 p.m. (M-F) Provider Customer Service 8:00 a.m. to 5:30 p.m. (M-F) 1-800-451-4447 (570) 200-4700 Fax: (570) 200-6880 1-800-822-8752 Fax: (570) 200-6740 Telephone Directory - B Date 1/2007 Page - 2

BlueCare HMO FACILITY POLICY & PROCEDURE MANUAL INDEX ITEM Section Page Access to Medical Records - Policy P 1 Act 68 - Interest Payments I 4 Act 68 of 1998 - Quality Health Care Accountability & Protection Act L 1 Actively Working vs. Laid-Off or Retired Employees I 7 Adjustment Form I & K 5 & - Administrative Claims Process Appeals G 1 Administrative Termination Dispute Process G 2 Admission E 1 adultbasic Program O 1 Ambulance F 5 Ambulatory Surgical Services F 4 Ancillary Overview F 1 Ancillary Services F 1 Appeals G 1 Automobile Insurance I 9 Bariatric Surgery Precertification Worksheet K - Behavioral Health Care Program H 1 Behavioral Health Concurrent Review form K - Benefit/Eligibility Information E 1 Bill Types (Outpatient vs. Short Stay/SPU) I 2 Billing Information I 1 Billing Policies/Procedures I 1 BlueCard J 1 BlueCard Transfer of Medical Information Request form K - BlueCare HMO Products A 1 BlueCHIP Program O 1 Case Management Program E 1 CBHNP NEPA Re-authorization Assessment form K - CHAMPUS I 9 Chemical Recovery E & F 5 & 4 Claim Adjustments - Policy P 1 Confidentiality Policy P 1 Coordination of Benefits I 6 Co-payments E, I & N 3, 1 & 2 Concurrent Review E 1 Credentialing Q 8 Customer Service N 2 Delay/Cancellation Policy/Against Medical Advice (AMA) I 3 Delayed Claims List I 10 Dependent Children of Divorced/Separated Parents I 8 Dependent Children of Parents NOT Separated/Divorced Birthday Rule I 8 Detained Baby Claims I 2 Diagnostic/Screening Mammography I 2 Index - C Date 1/2007 Page - 1

ITEM Section Page Disability I 7 Discharge E 1 DRG/Per Case Payment Validation Procedure M 2 DRG Review Process M 1 DRG Validation (Post Payment Review) M 2 DRG Validation Review Unit M 1 Durable Medical Equipment (DME) F 4 Emergency Medical Transfers E 2 Emergency Room Admissions E 3 Emergency Room Visits E 3 Expedited Grievance (Act 68 Process) G 7 External Grievances (Act 68 Process) G 8 Forms K - Glossary of Terms D 1 Group vs. Non-Group Plans I 6 HBP (Hospital Based Physician) Provider Billing Information Form K - Hit & Run I 9 Home Health Care Services E & F 5 & 2 Home Health Initial Precertification Worksheet K - Home Health Extension Precertification Worksheet K - Home Infusion Services F 2 Hospice Services F 2 Identification Cards N 1 Informal Dispute Resolution Process (IDR) G 2 Injured on Private Property/Business (Other than Member s Employer) I 10 Itemization of Service I 2 Laid Off or Retired Employees vs. Actively Working I 7 Legislative L 1 Mandatory Claims Research Request Form NUCC 1500 I & K 5 & - Maternity Admission Fax Sheet K - Maternity Home Health Visit I 2 Maternity/Newborn E 4 Medicaid I 9 Medical Management Review M 1 Medicare I 8 Member Does Not Have Auto Insurance Or Doesn t Own A Motor Vehicle I 9 Member ID Card (Sample) N 1 Member Overview N 1 Mental Health E 5 Mission A 1 Mother/Baby Claims I 2 MRI E & F 5 & 4 MRA E 5 MRI/MRA Authorization Request form K - NaviNet SM I 4 Newborns E & I 4 & 8 Non-Coordination of Benefits Plans I 7 Non-Emergency Medical Transfers E 2 Index - C Date 1/2007 Page - 2

ITEM Section Page Observation Service E 5 Other Party Liability I 6 Other Types of Products O 1 Outpatient Laboratory Program (Lackawanna & Luzerne regions) R 1 & 2 Outpatient Radiological Program (Luzerne region) R 1 Outpatient Therapies E 5 PACE Process Appeals G 1 Payment Liabilities I 3 PET Scans E 5 PET Scan Authorization form K - Point of Service Account (POS) O 2 Policy Access to Medical Records P 1 Policy Claims Adjustments P 1 Policy Confidentiality P 1 Policy Retro Authorization P 2 Policy Terminations P 2 Policy Holder (Employee)/Dependent I 7 Postponement Policy I 3 Pre-admission Certification E & F 4 & 1 Pre-admission Testing (PATs) E & I 6 & 2 Primary Payor I 6 Prosthetics & Orthotics F 5 Provider Appeals G 1 Provider Initiated Member Appeals (Act 68) G 2 Quality Management Q 1 Re-admission I 3 Recredentialing Q 8 Regional Information (Lackawanna, Luzerne & Lycoming regions) R 1 Regional Referral Center Re-Authorization Assessment form K - Rehabilitation Initial Precertification Worksheet K - Rehabilitation Extension Precertification Worksheet K - Requesting Medical Criteria E 6 Remittance Advice (RA) I 10 Responsibility of Participating Hospital E 6 Retro Authorization Policy P 2 Retrospective Review M 1 Role of the Provider Relations Department A 2 Role of the Members N 1 Same Person, Subscriber on Two Plans I 7 School Insurance I 10 Secondary Payer I 6 Selected Surgical Procedures E 5 Self - Funded Account O 2 Short Procedure Unit (SPU) E 5 Skilled Nursing Facility (SNF) Services F 3 Skilled Nursing Facility (SNF) Initial Precertification Worksheet K - Skilled Nursing Facility (SNF) Extension Precertification Worksheet K - Index - C Date 1/2007 Page - 3

ITEM Section Page STAT Laboratory services (Lackawanna & Luzerne regions) R 1 & 2 Subrogation I 6 Telephone Directory B 1 Terminations - Policy P 2 Timely Filing I 1 UB92 (HCFA-1450) K - Units I 2 Utilization I 3 Vision A 2 Welcome A 1 Worker s Compensation I 10 Index - C Date 1/2007 Page - 4

BlueCare HMO GLOSSARY OF TERMS Acute Care: Admission Notification: Agreement: Allowable Charge: Ambulatory Care: Ancillary Care: Ancillary Facility: Applies to services that deal with needs of short-term duration (30 days or less), that are primarily oriented toward medical problems requiring intensive attention and treatment to restore a previous state of health or to prevent the worsening of a present state, that may at times, be emergent and may have related long-term effects. From a structural point of view, such care is most commonly found in organizations like hospitals, surgical centers and some clinics. The process by which the admissions department notifies the First Priority Health Utilization Review Department of a scheduled or emergency admission. A written document given to the member which outlines benefits, exclusions, etc. Applicable to the coverage(s) applied for by the member. Generic term referring to the maximum fee that a third party will use to reimburse a provider for a given service. All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients. Care provided by a nurse, X-ray, lab or emergency medical technicians, etc. An institution or entity other than a hospital which is licensed, where required, to provide covered services. Ancillary facilities include: - Ambulatory Surgical Facility - Behavioral Health Facility - Durable Medical Equipment Supplier - Freestanding Dialysis Facility - Home Health Care Agency - Home Infusion Therapy Agency - Hospice - Orthotics and Prosthetics Supplier - Skilled Nursing Facility Appeal: Assistant Surgeon: Procedure that reviews an adverse plan determination. A registered medical physician who aids a surgeon in performing an operation. Glossary of Terms - D Date 1/2007 Page - 1

BlueCard: Blue Cross Plan: Blue Cross and Blue Shield Association: Case Management: CBHNP: Chronic: Claim: Coinsurance: Complaint Concurrent Review: A program, which allows a member to receive covered services from participating providers located outside the geographic area serviced by First Priority Health and which are participating with their local Blue Cross and/or Blue Shield licensee. The local Blue Cross and/or Blue Shield licensee, which serves the geographic area where the covered service is provided, is referred to as the on-site Blue Cross and/or Blue Shield licensee. A corporation which administers a prepayment program for the purchase of hospital services in accordance with the membership standards of the Blue Cross and Blue Shield Association. Blue Cross of Northeastern Pennsylvania is the Blue Cross Plan that serves 13 counties of northeastern and north central Pennsylvania. The national trade association of Blue Cross and Blue Shield. A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual s health care needs through communication and available resources to promote quality, cost-effective outcomes. Community Behavioral Healthcare Network is an organization exclusively devoted to mental health/chemical recovery services. Of long duration. A request for payment for services provided by a health care provider. A provision in a member s coverage that limits the amount of coverage by the Plan to a certain percentage, commonly 80%. A dispute or objection by an enrollee regarding a participating health care provider, or the coverage (including contract exclusions and non-covered benefits), operations or management policies of a managed care plan, that has not been resolved by the managed care plan and has been filed with the plan or the Department or the Insurance Department. The term does not include a grievance. On-going review (of the treatment plan) during the patient s hospitalization, to ensure that it meets established medical criteria in a timely manner, certifies the necessity, and the appropriateness, and quality of services during a hospital episode. Glossary of Terms - D Date 1/2007 Page - 2

Control Plan: Coordination of Benefits (COB): Copayment: Cosmetic Procedures: Coverage: Covered Services: Credentialing: Criteria: Custodial Care: Deductible: Detoxification: A Plan administering a National Account and acting as an agent for the participating plans. Provisions and procedures used by insurers or thirdparty payers to avoid duplicate payment for losses covered under more than one policy or subscription agreement. The amount members must pay directly to providers in connection with the covered services set forth in the Member Copayment Schedule attached to their contract. Medical or surgical procedures which are intended to improve the appearance of any portion of the body and from which no improvement in physiologic function can be expected. The extent of benefits provided under a member s contract issued by the Plan. Those medically necessary health services that a member is entitled to receive and which are eligible for payment or reimbursement under the terms of the applicable Plan document. Internal certification process prior to acceptance into First Priority Health s network and re-certification process at a set period of time thereafter. Predetermined elements of health, the presence, absence and completeness of which indicate the quality of medical services. Services to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered. Custodial care essentially is personal care that does not require the continuing attention of skilled, trained medical or paramedical personnel. In determining whether a person is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision should not be based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential or place of service. That portion of covered hospital and medical charges that a member or insured person must pay before the Plan s liability begins. The process whereby an alcohol intoxicated or drugintoxicated or alcohol-dependent or drug-dependent person is assisted, in a facility licensed by the Pennsylvania Department of Health, to perform Glossary of Terms - D Date 1/2007 Page - 3

detoxification through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or other drugs, alcohol, drug or other drug dependency factors or alcohol in combination with drugs as determined by a licensed physician, while keeping the physiological risk to the patient at a minimum. Diagnosis: Diagnostic Related Group (DRG): Disenrollment: Drug Formulary: Durable Medical Equipment (DME): Elective Surgery: Emergency Medical Condition: The identity of a condition or cause of disease; e.g., admitting diagnosis, discharge diagnosis, final diagnosis, etc. Diagnostic related group refers to a hospital payment arrangement that provides a prospective rate based on the patient s diagnosis. With DRG, the provider assumes the financial risk of managing the care of an individual, regardless of the length of stay, for a fixed amount based on the patient s diagnosis. The process of termination of coverage. A continually updated list of prescription medications that represents the current clinical judgment of the members of First Priority Health's Pharmacy and Therapeutics Committee. This committee is comprised of physicians and pharmacists, many of whom are providers and experts in the diagnosis and treatment of disease. The drug formulary contains both brand name drugs and generic drugs, all of which have FDA approval. Equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in the absence of an illness or injury; and is appropriate for use in the home. Surgery not considered an emergency because reasonable delays will not affect the outcome unfavorably, even though such surgery is necessary and may be major. Any health care service provided to a member after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: Placing the health of the member, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part. Glossary of Terms - D Date 1/2007 Page - 4

Employee Retirement Income Security Act (ERISA): Explanation of Benefits (EOB): Fee For Service (FFS): First Priority Health (FPH): Gatekeeper: Generic Name: Grievance: Health Care Practitioner: Health Maintenance Organization (HMO): HEDIS : HIPAA: HMO Model Types: This act of 1974 provides protection for employees and their dependents covered by private pension and welfare plans. A statement to the member which explains action taken on each claim. A method of payment for health services in which a healthcare provider is reimbursed according to a current fee schedule. Managed care commercial product administered by Blue Cross of Northeastern Pennsylvania for the non- Medicare population. The Primary Care Physician who serves as the initial point of contact for patients of managed care. The established, official or nonproprietary name by which a drug is known as an isolated substance, irrespective of its manufacturer. A request by a member or a provider with his/her written consent, to have FPH or a utilization review entity review the denial of a health care service based on medical necessity and appropriateness. An individual who is authorized to practice some component of the healing arts by a license, permit, certificate or registration issued by a Commonwealth licensing agency or board. A managed care system that combines the delivery and financing of health care and provides basic health services to voluntarily enrolled subscribers for a fixed prepared fee. Emphasis is placed on preventive and primary care. The Health Plan Employer Data and Information Set is a standardized set of performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The federal Health Insurance Portability and Accountability Act of 1996. 1) Staff - a prepaid health care system in which most physicians are employed by the HMO entity. 2) Group - a prepaid health care system that contracts with one physician group to provide health care services. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Glossary of Terms - D Date 1/2007 Page - 5

3) Independent Practice Association (IPA) - a prepaid health care system that contracts with individual physicians to deliver services in return for a single capitation rate. 4) Network - a prepaid health care system that contracts with two or more physician groups. 5) Mixed - a prepaid health care system characterized by at least two of the model types and no one model being predominant. Homebound: Home Health Care Agency: A member will be considered homebound, if he/she has a condition due to and illness or injury which restricts his/her ability to leave his/her place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person, or if he/she has a condition which is such that leaving his/her home is medically contraindicated. The condition of these members should be such that there exists a normal inability to leave home and, consequently, leaving their homes would require a considerable and taxing effort. A facility/other provider that has been approved by the Joint Commission on the Accreditation of Health Care Organizations or First Priority Health that: A. provides skilled outpatient services on a visiting basis in the member s home; and B. is responsible for supervising the delivery of such services under a plan authorized by the Primary Care Physician. Home Infusion Therapy Agency: Hospice: Hospital: A facility/other provider that provides hi-tech services designed to coordinate the effective provision of physician-directed nursing, pharmacy and related services necessary to conduct a parenteral/enteral regime safely and effectively in the patient s home. A facility/other provider approved by First Priority Health that is primarily engaged in providing palliative care to terminally ill individuals. A provider that is a short-term, acute care or rehabilitation hospital approved by the Joint Commission on the Accreditation of Healthcare Organizations, the American Osteopathic Hospital Association or by First Priority Health and: A. is a duly licensed institution; B. is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of injured and sick persons by or under the supervision of physicians; Glossary of Terms - D Date 1/2007 Page - 6

C. has organized departments of medicine and/or major surgery; D. provides 24-hour nursing service by or under the supervision of registered nurses; and E. is not, other than incidentally, a: - skilled nursing facility - nursing home - custodial care home - health resort - spa or sanitarium - place for rest - place for the aged - place for the treatment of mental illness - place for the provision of hospice care, or - personal care home. Hospital Based Physician: Inpatient: Inpatient Mental Health Hospital: Inpatient Non-Hospital Residential Care: A physician who provides services in a hospital setting and has a contractual relationship with the hospital (e.g., is paid a salary by the hospital or receives compensation from or through the hospital). A member who is treated as a registered overnight bed patient in a hospital or facility/other provider. A short-term acute care hospital, which has been approved by the Joint Commission on the Accreditation of Healthcare Organizations, or the American Osteopathic Hospital Association, or a similar accrediting agency acceptable by the Plan and which provides services that are necessary for short-term evaluation, diagnosis, and treatment (or crisis intervention) of serious mental illness. The provision of acute medical, nursing, counseling, or therapeutic services to patients suffering from alcohol and/or drug abuse or dependency in a residential environment, according to individualized treatment plans. Inpatient Non-Hospital Residential Facility: A facility other provider licensed by the Pennsylvania Department of Health to render an alcohol and/or drug abuse treatment program designed to provide inpatient non-hospital residential care. (This is not a halfway house or group home). Long-Term Residential Care: The provision of long-term diagnostic or therapeutic services (i.e.: assistance or supervision in managing basic day to day activities and responsibilities) to patients suffering from alcohol and/or drug abuse or dependency. This care is provided in a long-term residential environment known as a Transitional Living Facility, on an individual, group, and/or family basis, with a program duration greater than sixty (60) days. Long-Term Residential Care is not inpatient nonhospital residential care. Glossary of Terms - D Date 1/2007 Page - 7

Managed Care Medicaid: Medical Criteria: Medical Necessity: A prepaid health plan or insurance program in which beneficiaries receive medical care in a coordinated manner to eliminate the duplication of services. This is accomplished through the use of quality assurance and utilization review to ensure the appropriate delivery of care. Managed care focuses on health care benefit management, and cost-containment strategies that facilitate the individual s return to an active, productive lifestyle. Grants to states for Medicaid assistance programs as set forth in Title XIX of the Social Security Act, amended from time to time. Predetermined elements of health, the presence, absence and completeness of which indicate the quality of medical services. (Medically Necessary or Medical Necessity): Services or supplies rendered by a provider that FPH determines are: (a) appropriate for the symptoms and diagnosis or treatment of the member's condition, illness, disease or injury; and (b) provided for the diagnosis, or the direct care and treatment of the member's condition, illness, disease or injury; and (c) in accordance with the current standards of medical practice; and (d) not primarily for the convenience of the member or the member's provider; and (e) the most appropriate source or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an Inpatient due to the nature of the services rendered or the member's condition, and the member cannot receive safe or adequate care as an outpatient. Medical Record Reviews: Process performed by FPH to monitor the appropriateness of care, consistency of charting and completeness of records. The content of the member s record is documentation of the quality of the care provided. Quality providers must consistently maintain both excellent medical care standards and follow up with comprehensive documentation. Medical record reviews can be conducted in a hospital and/or ambulatory care system. Glossary of Terms - D Date 1/2007 Page - 8

Medicare: Member: Member Handbook: MH/CR National Committee for Quality Assurance (NCQA): NaviNet SM : Network: Observation: Open Enrollment: Out-of-Area: Outpatient: Partial Hospitalization: A third-party reimbursement program administered by the Social Security Administration that underwrites the medical costs of qualified persons age 65 and over and some qualified persons under age 65. Part A covers hospital services and related care; Part B covers physician services and other health services, sometimes referred to as Title XVIII of the Social Security Act. Person who is properly enrolled with FPH and who otherwise is entitled to receive covered services under a Plan document. A member can be either the policy holder or a dependent. Written material provided to all members by First Priority Health, containing a summary of covered services, an explanation of how to access all benefits, Member Rights and Responsibilities and a copy of the group s specific contract. Mental Health/Chemical Recovery. A private, not-for-profit organization dedicated to improving the quality of health care by assessing and reporting on the quality of the nation's managed care plans to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed health care purchasing decisions. A web-based system that is designed to simplify administrative processes. The group of providers who are contracted with First Priority Health. A stay to determine or monitor a patient for possible admission. The time frame during which individuals may elect to enroll in a health insurance plan or prepaid group practice. Not in the approved Department of Health service area served by this Plan. A member who receives services or supplies while not an inpatient. The provision of medical, nursing, counseling or therapeutic services on a planned and regularly scheduled outpatient basis through a hospital or nonhospital facility licensed as a mental health or alcohol Glossary of Terms - D Date 1/2007 Page - 9

and/or drug abuse treatment program by the Pennsylvania Department of Health, designed for a patient or client who would benefit from more intensive services than are offered in outpatient treatment but who does not require inpatient care. Point of Service (POS): Practitioner of the Healing Arts: Pre-admission Testing: Pre-admission certification (PAC or Precertification): Primary Care Physician: Prior Authorization: Prosthetic Devices: A plan in which the member decides whether to consult a participating or a non-participating provider at the time medical care is needed. If the member consults a participating provider, health care delivery resembles that of a traditional HMO, with prepaid comprehensive coverage. If the member consults a non-participating provider, health care delivery resembles that of an indemnity insurance product, with less comprehensive coverage and deductibles and/or coinsurance. Any person who engages in the diagnosis or treatment of disease or any ailment of the human body. Routine tests and examinations performed in an outpatient facility or the outpatient department of a hospital prior to a scheduled admission. The process whereby Participating Providers are required to obtain certification from First Priority Health for Covered Services prior to the date of service. Precertification is usually conducted via telephone or telefax and the process results in the issuance of a precertification number by First Priority Health, without which the claim will not be paid. It is the responsibility of a Participating Provider to obtain pre-certification, when required, in accordance with First Priority Health s policies and procedures. First Priority Health, at its discretion, may add or delete services which require precertification, as it deems necessary. A physician who supervises, coordinates and provides initial care and medical services as a general or family care practitioner, an internist or a pediatrician, to members within the scope of practices approved by FPH; and maintains continuity of patient care. The process whereby members are given approval to receive covered services from a provider other than their Primary Care Physician. Prior authorization is precertification from First Priority Health, in accordance with First Priority Health s policies and procedures. Items (such as artificial limbs) used as substitutes for body parts. Glossary of Terms - D Date 1/2007 Page - 10

Provider: A hospital, physician, ancillary facility or professional, licensed where required, administering health care services within the scope of that license. A. Participating Provider - a provider that has an agreement with, has met all credentialing criteria and has been accepted as such by First Priority Health pertaining to payment for covered services rendered to a member. B. Non-participating Provider - a provider that does not meet the definition of a participating provider. Quality Management: Regional Referral Center: Rider: Secondary Carrier: Self-Funded: Self-Insured: The process of objectively and systematically monitoring and evaluating the quality, timeliness, and appropriateness of care, and administrative functions and of pursuing opportunities to improve processes and resolve identified problems. First Priority Health s dedicated unit that provides eligibility verification, triage, referral and utilization management for behavioral health care services, including referrals to psychiatrists. An additional benefit to a subscriber/group contract. The contract which pays the balance (or up to contract limits) when a member has two contracts and primary benefits are provided by the other contract. A health care program in which employers assume the risk for medical costs, funding benefit plans from their own resources without purchasing insurance. Selffunded plans may be self-administered or the employer may contract with an outside administrator for an administrative service only. An individual or group of individuals, employer, or organization that assumes complete financial responsibility for medical expenses. Short Procedure Unit (SPU): Surgical event which requires a stay of less than 24 hours. Skilled Nursing Facility (SNF): Specialist Physician: Subrogation: An institution or a distinct part of an institution, that provides skilled nursing care and rehabilitation services to patients who do not require full hospital care. A physician who provides medical care in any generally accepted medical specialty or subspecialty. The act of attempting to recover money the Blue Cross Plan has paid for services for which a third party, who Glossary of Terms - D Date 1/2007 Page - 11

URAC (Utilization Review Accreditation Company or Corporation): Utilization Management: Utilization: Utilization Review: Worker s (or Workmen s) Compensation: has caused injury to a subscriber, or the third party s insurance carrier, is liable. A nationally recognized external review organization. A quality component of managed health care with the comprehensive purpose of monitoring effective, efficient and timely use of covered services. Some of the activities utilized are pre-admission certification, admission review and concurrent review. The extent of usage of Plan benefits by subscribers or members. Evaluation of the necessity, appropriateness and efficiency of admission, services ordered and provided, length of stay and discharge practices, both on a concurrent and retrospective basis. A state law that assigns liability to the employer for injury or illness resulting from on-the-job accidents or conditions. Neither Blue Cross nor Blue Shield benefits are provided for this care. Glossary of Terms - D Date 1/2007 Page - 12

ADMISSION & DISCHARGE BENEFIT/ELIGIBILITY INFORMATION For information on benefits and eligibility, please contact the First Priority Health Provider Services Unit at 1-800-822-8752 or utilize NaviNet SM. See Section I, Billing Information - for further information regarding NaviNet SM. CASE MANAGEMENT PROGRAM The Case Management program is a voluntary program offered to BlueCare HMO members as part of their benefit package at no additional cost. Case Management s role is to coordinate necessary interventions and services with an individual s health care needs in a quality and cost effective manner. The program is proactive and may begin prior to the occurrence of any actual utilization, in anticipation of preventing the utilization from occurring. Intervention may occur at any point in the continuum of care, i.e., prior to hospitalization, during hospitalization, and post hospitalization. Potential cases can be referred to case management, internally or externally, by medical directors, utilization management staff or other internal departments, providers, social workers, discharge planners, physicians, vendors, subscribers, family, or other health care plans. Admission notification reports are generated and analyzed for possible case management involvement/intervention. Referrals are then triaged to determine the appropriateness of case management based on criteria. The Case Management Program is designed to augment, not replace the discharge planner. A case management assessment is available for members who: have chronic long term illness; are terminally ill; require frequent hospital admissions; may require high-tech or intensive home care; and/or have sustained traumatic injury. The Case Manager works collaboratively with the providers and members to coordinate available benefits and facilitate available alternatives. FPH/Case Management.1-800-346-6149 8:00 a.m. to 4:15 p.m. Fax # - 570-200-6777 CONCURRENT REVIEW The First Priority Health (FPH) Utilization Management Department performs utilization review functions for all BlueCare HMO members. Concurrent review nurses or clinicians utilize InterQual criteria and other criteria as appropriate when reviewing hospitalizations. Admission & Discharge - E Date 1/2007 Page - 1

1. The FPH nurse analyst verifies that all scheduled admissions and ambulatory surgery procedures requiring pre-certification have in fact taken place. 2. After a member is admitted, the nurse analyst will contact the admitting facility s Utilization Review/Quality Assurance Department to schedule a medical update. 3. Once an initial update has been received, the FPH nurse analyst will follow the clinical status of the member on an ongoing basis with the facility s Utilization Review/Quality Assurance Department, discharge planners, physicians, and social workers as needed in non-drg facilities. If the case is denied, a denial letter is mailed to the member, provider & facility stating the denial reason and that specific criteria for denial is available upon request. 4. The number of approved days will be assigned in non-drg facilities. The FPH nurse analyst will schedule another medical update as the member s condition warrants. Utilization Management must receive comprehensive medical updates within one (1) business day of the scheduled date. 5. Through medical updates, early coordination for home health services as well as referrals for case management intervention can be implemented. 6. Days will be administratively denied if delivery of required inpatient services are delayed. Examples of administrative denials are: a. Delays in scheduling of services b. Equipment failure c. Inadequate staffing d. Failure of the treating physician to order services in a timely manner (i.e. writing a discharge order on the last medically necessary day). 7. FPH Utilization Management Department requires all FPH participating home health agencies with NaviNet SM access to utilize NaviNet SM to precertify their home health admissions. If they do not have NaviNet SM access, they must fax in their initial reviews on the Home Health Worksheet. All concurrent reviews need to be faxed into the FPH Utilization Management Department using the worksheet. Please refer to Section I, Billing Information, for more information on NaviNet SM. FPH Fax # for Concurrent Review: (570) 200-6788 8. Inpatient psychiatric and substance abuse require continued stay reviews. Concurrent review is determined at the time of pre-certification. Contact the Regional Referral Center at 1-800-559-2428. Behavioral Healthcare services are only available to BlueCare HMO Group Product members. EMERGENCY MEDICAL TRANSFERS 1. Emergency medical transportation is provided for all BlueCare HMO members by the nearest available ambulance service. 2. Emergency medical transportation does not require pre-certification from FPH. Admission & Discharge - E Date 1/2007 Page - 2

NON-EMERGENCY MEDICAL TRANSFERS 1. A FPH participating ambulance provider must be utilized for ALL non-emergency transfers. 2. If a patient requires a medically necessary transport after business hours, please contact one of the participating ambulance providers or utilize your hospital ambulance service, if applicable. You may leave a telephone message on the FPH Utilization Management Department s answering machine or telephone FPH the next business day. 3. Non-emergency transfers to a non-participating facility requires a pre-certification from the FPH Utilization Management Department. 4. Only non-participating ambulance require pre-certification. EMERGENCY ROOM ADMISSIONS 1 The participating facility emergency room personnel should evaluate and stabilize the BlueCare HMO member. 2. If a BlueCare HMO member requires admission after stabilization in the emergency room, precertification is required and can be obtained by contacting the FPH Utilization Management Review Department Monday through Friday. Business Hours: 8:00 a.m. to 4:15 p.m. 1-800-962-5353 Non-Business Hours: 1-800-962-5353 (answering machine) FPH Fax #: 570-200-6788 3. If during business hours you do not receive a phone call from the FPH Utilization Management Department personnel, the BlueCare HMO member should be admitted, if the admission is medically necessary. The FPH Utilization Management Department will return your call within 24 hours and the admission would need to be reviewed for medical necessity. 4. During business hours, the FPH Utilization Management Department personnel will provide the caller with a pre-certification number. If the FPH Utilization Management Department is notified via answering machine during non-business hours, a representative from the FPH Utilization Management Department will return the call on the next business day. The pre-certification number can be viewed via NaviNet SM once obtained through the FPH Utilization Management Department 5. If the admission occurs after normal business hours, the admitting facility is responsible for notifying the FPH Utilization Management Department of the admission within 48 hours or the next business day if the admission occurs on the weekend. All inpatient admissions need to be reviewed for medical necessity and/or appropriateness of site. 6. If the BlueCare HMO member is admitted through the emergency room, the emergency room copayment does not apply. If the BlueCare HMO member is treated in the emergency room and is consequently placed in an observation bed or treatment in a SPU, the member will not be responsible for the emergency room copayment, as long as the observation bed or SPU, if required, was authorized by the FPH Utilization Management Department. Admission & Discharge - E Date 1/2007 Page - 3

EMERGENCY ROOM VISITS 1. First Priority Health encourages members to notify their Primary Care Physician (PCP) of an emergency room visit within 24 hours of the emergency. 2. The FPH member is responsible for an emergency room copayment. Do not collect the member s copayment at the time of service. After you receive your remittance advice, you will be able to determine the member s liability along with the FPH payment. 3. Emergency medical or accident follow-up services are payable, less applicable copayments, only with pre-certification from the member s PCP. 4. An emergency room prior authorization may be issued by the BlueCare HMO member s PCP if the member was directed to the emergency room by their PCP in advance of the service, and the service could have been provided by the BlueCare HMO member s PCP. The BlueCare HMO member would then be responsible for an office visit copay not the emergency room copay. MATERNITY/NEWBORN FPH Utilization Management Department will not be reviewing maternity admissions for medical necessity or appropriateness of care. However, the information documented on the Maternity Admission Fax Sheet is required for your claim to be processed. Please fax the completed fax sheet (refer to Section K, Forms ) to FPH Claims Department at 570-200-6790 within 24 hours after discharge. If you wish to confirm the pre-certification number, call our Provider Services Unit at 1-800-822-8752 or the pre-certification number may be obtained by utilizing NaviNet SM. Services covered by the maternity admission pre-certification include labor and delivery, newborn care and, if noted, post-delivery tubal ligation. If baby is detained after the mother is discharged, an additional pre-certification is required by contacting FPH Utilization Management Department. Please refer to Admission/Discharge, Section E, Preadmission Certification. For services rendered within 31 days of the baby s birth, submit all claims for the baby utilizing the mother s BlueCare HMO ID number or the father s BlueCare HMO ID number (if the mother is not covered). If after 31 days the newborn does not have a BlueCare HMO Member ID Card, please confirm benefits via NaviNet SM or the Provider Services Unit at 1-800-822-8752. For information on early discharge, postpartum skilled nursing visit, please refer to Act 85 of 1996 available through http://www.legis.state.pa.us/wu01/li/li/cl/act.htm PRE-ADMISSION CERTIFICATION 1. The Primary Care Physician or admitting Specialist is responsible for obtaining pre-certification for scheduled admissions. 2. The admitting physician and/or PCP obtains the pre-certification number either by utilizing NaviNet SM or by calling the FPH Utilization Management Department. It is the facility s responsibility to verify that the pre-certification has been completed. 3. If after stabilization in the emergency room the member is admitted for an inpatient stay, it is the facility s responsibility to obtain pre-certification. If the member is admitted through the emergency Admission & Discharge - E Date 1/2007 Page - 4

room for an SPU or observation, pre-certification may be required for select services. Refer to the most current FPH Focus Outpatient Procedure Pre-certification list in your provider bulletin or contact the Provider Services Unit at 1-800-822-8752. 4. Under certain circumstances such as, urgent/emergent or after hours/weekend services, precertification must be obtained the following business day by calling the FPH Utilization Management Department at 1-800-962-5353 or by utilizing NaviNet SM. 5. Comprehensive clinical information must be received by the First Priority Health Utilization Department within one (1) business day of admission. Comprehensive clinical information is defined as: All symptomatology related to the admission. Previous pertinent medical history. Treatment plan. Discharge plan. 6. All Inpatient admissions to an acute care, rehab, and skilled nursing facility, except maternity, require a pre-certification number before the services are rendered: 7. Other services requiring pre-certification are: Home Health Services Outpatient Therapies (certain groups may require pre-certification. Verify benefit information prior to service). PET Scans MRI/MRA refer to the most current list of select MRI/MRA s (contact Provider Services Unit at 1-800-822-8752 or the Provider Bulletin) Observation Service Mental Health/Chemical Recovery (Regional Referral Center at 1-800-599-2428). Selected Surgical Procedures (Refer to the most current FPH FOCUS Outpatient Procedure Pre-Certification list in the Provider Bulletin or contact Provider Services Unit at 1-800-822-8752). 8. BlueCare HMO members shall have access to outpatient services when medically necessary and appropriate. 9. Outpatient services may be provided in a physician office, outpatient facility or short procedure unit. Outpatient services when performed in a hospital are provided at a designated area of a hospital (treatment room, G.I. lab, radiology unit, etc.) or other health care facility where procedures are performed that do not require an operating room setting/sterile environment. To verify site appropriateness of procedures, please reference The Outpatient Billing Expert at the hospital. 10. If a member receives inpatient, SPU, mental health, chemical recovery, or other services that require pre-certification without the appropriate pre-certification, FPH will reject the claim. Members cannot be billed for these services. FPH requires that pre-certification is obtained prior to services being rendered, with the exception of urgent/emergent or after hours/weekend services where precertification should be obtained by the following business day. 11. Pre-certification must be obtained even if FPH is the member s secondary insurance. 12. Pre-certification is not a guarantee of payment. Admission & Discharge - E Date 1/2007 Page - 5

RESPONSIBILITY OF PARTICIPATING HOSPITAL 1. The participating hospital shall be responsible for furnishing to FPH Utilization Management department any required medical information relative to the pre-certification process. 2. In the event that one of the following situations occurs, an inpatient admission may be denied and the participating hospital may not charge either FPH or the member for services rendered with respect to such admission. a. a pre-certification was required, but not performed, and the participating hospital, nonetheless, admitted the member; b. a pre-certification was required and performed, but the admission was medically denied by FPH. The participating hospital admitted the member without adequate prior written notice to the member that the admission would not be paid by FPH, and without the member acknowledging this fact in writing, together with a request to be admitted and to assume financial responsibility; or c. a pre-certification was required and performed, but the admission was an inappropriate admission, and the diagnosis/procedure treated or performed differed from that certified and approved. PRE-ADMISSION TESTING Pre-admission testing will be covered even if the procedure is cancelled. Pre-admission testing can be performed at a different facility/entity than where the surgery is being performed. REQUESTING MEDICAL CRITERIA The First Priority Health Utilization Management Department bases its decision on specific criteria to determine medical necessity. This criteria is available to all FPH providers upon request. Criteria may be requested by either contacting or faxing the FPH Utilization Management Department with the following information: member s name, FPH identification number, date(s) of service, date(s) of denial and facility where services were rendered or by calling the Provider Services Unit at 1-800-822-8752. First Priority Health Medical Management Department 19 North Main Street Wilkes-Barre, PA 18711-0302 Phone: 1-800-962-5353 Fax #: (570) 200-6788 Admission & Discharge - E Date 1/2007 Page - 6

ANCILLARY SERVICES OVERVIEW First Priority Health s (FPH s) ancillary provider network is a comprehensive system of alternative health care services. The ancillary network provides a substitute to inpatient hospitalization and/or an alternative to more costly services when developing an individualized plan of care. FPH s ancillary network consists of the following provider types. home health; hospice; skilled nursing facility; ambulatory surgery; chemical recovery; ambulance; DME; home infusion; MRI; prosthetic/orthotic; independent lab; dialysis services. Contact Provider Customer Service at 1-800-822-8752 for verification of benefits. PRE-ADMISSION CERTIFICATION Pre-admission certification maybe required prior to ancillary services being rendered (check your Provider Bulletins for current information on pre-admission certification). Nurse analysts are available to answer questions, precertify and make all arrangements for the requested services. The FPH Utilization Management Department is available to receive calls at 1-800-962-5353 Monday through Friday, 8:00 a.m. to 4:15 p.m. Pre-admission certification maybe submitted electronically via NaviNet SM. During business hours, the First Priority Health (FPH) Utilization Management Department personnel will provide the caller with a pre-admission certification number. If the FPH Utilization Management Department is notified via answering machine during non-business hours, a representative from the FPH Utilization Management Department will return the call on the next business day. The pre-admission certification number can be viewed via NaviNet SM once obtained through the FPH Utilization Management Department. If during business hours you do not receive a phone call from the FPH Utilization Management Department, the BlueCare HMO member should be admitted, if the admission is medically necessary. FPH will return your call within 24 hours and the admission would need to be reviewed for medical necessity. If the admission occurs after normal business hours, the admitting facility is responsible for notifying the FPH Utilization Management Department of the admission within 48 hours or the next business day if the admission occurs on the weekend. Ancillary Services - F Date 1/2007 Page - 1

HOME HEALTH CARE SERVICES Benefits will be available if the member is homebound and the attending physician has: (1) ordered home health care, (2) received pre-admission certification approval from First Priority Health, and (3) furnished, in consultation with the participating home health agency s professional personnel prior to the first visit, a written plan of treatment stating that the services ordered are medically necessary. Continuing eligibility requires that the attending physician provide such a plan of treatment at thirty (30) day intervals. NOTE: As of January 1, 2006, providers who are NaviNet SM enabled MUST submit the initial precertification request for home health or inpatient rehabilitation services via NaviNet SM. BlueCare HMO Home Health providers offer the following services: registered nurse (excludes private duty nursing); medical social worker; physical therapy; occupational therapy; speech therapy; home phototherapy; and home health aide HOME INFUSION SERVICES Home infusion is designed to provide intravenous medication or solutions to members at home. BlueCare HMO home infusion therapy providers offer the following services: total parenteral nutrition (TPN)*; enteral nutrition*; intravenous therapy (e.g., medication, hydration, treatment, etc.); chemotherapy; anti-infective therapy (including Lyme Disease)*; pain management (continuous and epidural analgesics); and immune globulin therapy*. * Prior Authorization Required by First Priority Health Pharmacy Management Department Home infusion therapy benefits will be provided only if the member s physician prescribes the services. Certain home infusion benefits require prior authorization by the Pharmacy Management Department by calling 1-800-722-4062. The Pharmacy Management Department s fax number is 570-200-6870. Claim submission for home infusion charges must be on a HCFA 1500 form. Refer to Section I, for billing information. HOSPICE SERVICES Hospice care is a health care program, which provides an integrated set of services, primarily in the member s home, designed to provide palliative and supportive care to terminally ill members and their families. Services are coordinated through a hospice interdisciplinary team and the member s attending physician. The focus is on care, not cure. Ancillary Services - F Date 1/2007 Page - 2

BlueCare HMO shall provide coverage for hospice benefits when the member s attending physician certifies in writing to First Priority Health that the member has a terminal illness with a medical prognosis of six (6) months or less and when the member or responsible party elects in writing to receive care primarily in the home to relieve pain. Hospice services do not require pre-admission certification. BlueCare HMO will provide coverage for hospice services based on one (1) of three (3) levels of care. The hospice agency shall be responsible for administering the following benefits: routine; continuous - coverage for continuous care, during periods of crisis, consisting of nursing care for up to twenty-four (24) hours per day necessary to maintain the member at home; or respite - coverage for respite care on a short-term inpatient basis in a participating skilled nursing facility when necessary to relieve primary caregivers in the member s home. This is limited to ten (10) days per lifetime, and is subject to applicable deductible and/or coinsurance. The following services shall be eligible for coverage to an approved essentially homebound patient by an approved hospice agency responsible for the member s overall care: professional nursing services (excludes private duty nursing); home health aide services; laboratory services; therapy services (except for dialysis treatments); durable medical equipment and medical and surgical supplies; prescribed drugs; oxygen and its administration; medical social services provided by a social worker; palliation for pain control and symptom management; respite care in a participating skilled nursing facility (limited to ten (10) days per lifetime, and is subject to applicable deductible and/or coinsurance); family counseling related to the member s terminal condition; dietician services; hospice inpatient room, board and general nursing services for acute pain management (payable under the basic hospital benefit); and bereavement counseling (limited to two (2) visits). SKILLED NURSING FACILITY SERVICES BlueCare HMO shall provide coverage at a skilled nursing facility (SNF) when certified as medically necessary by a physician. Pre-admission certification is required at least forty-eight (48) hours prior to an admission to a skilled nursing facility. BlueCare HMO patient care in a SNF is covered if all of the following factors are met: Skilled nursing services or skilled rehabilitation services are performed by or under the supervision of a licensed/certified professional. The member requires the skilled services on a daily basis [at least five (5) days per week]. Skilled services are provided only on an inpatient basis in the SNF. Ancillary Services - F Date 1/2007 Page - 3

BlueCare HMO rehabilitation services in an SNF include the following: skilled physical therapy; speech pathology; and occupational therapy. AMBULATORY SURGICAL SERVICES Ambulatory surgical services can be safely performed in a less intensive, non-acute care environment and are generally surgical in nature but can include endoscopic/diagnostic procedures. For pre-admission certification requirements, refer to Section E, Admission & Discharge, pages 4 and 5. MAGNETIC RESONANCE IMAGING (MRI) Magnetic resonance imaging (MRI) is a noninvasive diagnostic imaging modality. This technique uses an interaction of a magnetic field and radiofrequency waves in order to generate, with computer assistance, an image of an area of the body. MRI scans must meet the criteria of medical necessity and reasonableness. It should be performed when the results are expected to impact the diagnosis and treatment of the member. Pre-admission certification may be required. Please refer to your provider bulletin for a current list of MRI services that need preadmission certification. Claim submission for MRI charges must be on a HCFA 1500 form. See Section I for billing information. CHEMICAL RECOVERY Inpatient detoxification is provided either in a participating hospital or on an inpatient basis in a participating non-hospital facility, which is licensed as an approved alcohol and/or drug addiction treatment program and is approved by the Pennsylvania Department of Health. Not all BlueCare HMO members will have this coverage. Contact Provider Customer Services at 1-800-822-8752 to verify member benefits/eligibility. Outpatient alcohol or other drug abuse services are provided in a participating facility appropriately licensed by the Pennsylvania Department of Health as an alcohol or drug addiction treatment program. Contact Regional Referral Center (RRC) (1-800-599-2428) to precertify all inpatient and outpatient treatment for BlueCare HMO members. In order to obtain pre-admission certification, the attending physician must provide evidence prior to ordering such treatment, in a format satisfactory to RRC, that alcohol or drug abuse treatment is medically necessary and appropriate. DURABLE MEDICAL EQUIPMENT Durable medical equipment (DME) is a device such as a wheelchair or walker, which can withstand repeated use, is primarily used to serve a medical purpose and would also be appropriate for use in the home. DME does not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement, and are subject to benefit limitations. Claim submission for DME must be on a HCFA 1500 form. See Section I for billing information. Ancillary Services - F Date 1/2007 Page - 4

PROSTHETICS AND ORTHOTICS Prosthesis is the replacement of a missing body part/organ by an artificial substitute, such as an artificial extremity. Orthotics is any device added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury, or assist with function. P&O does not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement, and are subject to benefit limitations. Claim submission for P&O charges must be on a HCFA 1500 form. See Section I for billing information. AMBULANCE Emergency and non-emergency medical transport services are provided for BlueCare HMO members based on benefits and eligibility. Ambulance services do not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement. Claim submission for ambulance charges must be on a HCFA 1500 form. See Section I for billing information. Ancillary Services - F Date 1/2007 Page - 5

APPEALS PROVIDER APPEALS First Priority Health (FPH) realizes that health care is rapidly changing and often challenging. As your partner in health care, FPH offers various internal avenues for providers to render an appeal, non medical or processing appeals, (section #1) and medical determination appeals (Informal Dispute Resolution or Provider Initiated Member appeals), (section #2). 1. There are (3) three types of appeals that do not involve determination of medical necessity. Claim Administrative Appeals, PACE Process Appeals and Appeals of Sanctions or Terminations. a. Administrative Claim Process Appeals These types of appeals include claim processing including denials for timely filing, questionable level of payment or failure to obtain necessary authorization for non-emergency services. Provider Relations shall provide oversight of all appeals. A record keeping and reporting system shall be in place for all appeals. There will be no further levels of appeals. The provider appeal(s) will be received in Provider Relations and forwarded to the designee. The designee will then gather any and all related information from the provider and any department within First Priority Health. All information shall immediately be presented to the appropriate Regional Manager. Written notification of the final decision shall be sent to the appealing entity within ninety (90) business days from date of the appeal letter Written Administrative Appeals can be sent to: First Priority Health Provider Relations Department 19 N. Main Street Wilkes-Barre, PA 18711-0302 b. PACE Process Appeals - First Priority Health has been processing claims on Facets, an integrated processing system since November 19, 2001. The Facets has PACE as its clinical editor. It was developed and maintained by PACE Healthcare Management. PACE contains both clinical criteria and claim editing criteria. Please refer to your Provider Bulletins for more information on PACE. As with all clinical editors, the Pace Clinical Editor database contains hundreds of thousands of edits relating to procedure coding practices. The clinical editor is based on the coding criteria and protocols in the CPT-4 manual, which is published by the American Medical Association. The database is updated annually in response to each year s release of the updated CPT coding manual. If your facility receives a PACE edit denial, the appropriate denial code will appear on your Remittance Advice (RA) Statement. If there is disagreement with the reason for the denial, an appeal can be made. To submit a PACE appeal, the following documentation is required to be submitted 90 days from the date of the RA: - a letter identifying the specific coding combination and supporting physician rationale for payment for the denied code(s); Appeals - G Date 1/2007 Page - 1

- a copy of the original claim form, or a new claim form which is identical to the original submission; - medical record documentation from the patient s chart; and - mandatory Claims Research Request Form with the appropriately checked box. Appeals must be submitted within ninety (90) days from the date of the RA and will be reviewed by a Clinical Coordinator and if necessary, an FPH Medical Director. Appeals submitted without all of the necessary documentation or after the 90-day limit has expired, are not eligible for consideration and will be returned to your office. The decision will be final. All appeals will be processed within thirty (30) days of receipt. First Priority Health Claims Research Department 19 North Main Street Wilkes-Barre, PA 18711-0302 c. Administrative -Termination Dispute Process - This is the third type of non medical determination appeal. There are several sources for your reference: a. Please refer to Section P, Policies, of this manual. b. Also refer to your executed FPH Agreement, Termination section and the appropriate attachments to your executed agreement: If you are unable to locate any of the above agreement references, please contact BCNEPA Provider Relations at 570-200-4700 or 1-800-451-4447. 2. For appeals related to medical decisions, a provider may choose one of two (2) avenues, Informal Dispute Resolution Process (IDR) OR Provider Initiated Member Appeals (Act 68). Providers may appeal Utilization Management decisions through the IDR process OR the Act 68 process to contest medical necessity decisions. Examples include a decision made regarding an admission, level of care or other health care service based upon the review of available information. The IDR process does not apply if the Member Appeal Process has been initiated. Providers must select either the Informal Dispute Resolution Process OR the Provider- Initiated Member Appeal Process. Providers cannot use both methods for the same member. a. Informal Dispute Resolution Process i. Informal Dispute Resolution Process (IDR) Expedited (Urgent) Appeal If a provider feels the decision in dispute is about urgent or potentially emergent care, the provider may request an Expedited or Urgent IDR Appeal by calling the FPH Medical Director at 1-800-462-0900 within one (1) business day of the initial decision. The provider discusses the appeal with the FPH Medical Director who made the initial decision, whenever possible. If the initial appeal decision is not satisfactory, the FPH Medical Director informs the provider of the right to initiate a standard appeal. ii. Informal Dispute Resolution Process (IDR) Standard Appeal If a provider wishes to contest a medical necessity decision and it does not involve urgent/emergent care, the provider may request a standard IDR appeal within sixty (60) days from the date of the initial decision. The provider may mail or fax their written appeal request to: First Priority Health Regulatory Compliance Department 19 N. Main Street Wilkes-Barre, PA 18711-0302 FAX: 570-200-6755 Appeals - G Date 1/2007 Page - 2

Please include the following information in the written request: member name and FPH ID#, provider name and FPH Provider ID#, provider s address, phone number, fax number, (if applicable), requested procedure or service, date of denial, diagnosis and medical justification for the procedure or service, copies of entire medical record/physician office notes, and a copy of the original denial. The FPH Medical Director reviews all information and renders a final decision. The review, decision and written notification to the requesting provider will occur within 30 (thirty) days of receipt of the written appeal request. There are no other provider appeal mechanisms after this final decision is rendered. b. Provider Initiated Member Appeals (Act 68) - Pennsylvania Act 68 gives providers the right, with the written permission of the member, to pursue an appeal in lieu of the member. A provider may ask for a member s written consent in advance of treatment but may not require a member to sign a document allowing the filing of a grievance as a condition of treatment. The regulatory requirements for providers apply to items that must be in the document giving the provider permission to pursue a grievance, and the time frames for member notification of provider intent to pursue or not pursue a grievance. These are important because under this scenario, the provider assumes the grievance and appeal rights of the member. However, the member may rescind the consent at any time. A PROVIDER WHO USES THIS PROCESS TO FILE AN APPEAL MAY NOT ALSO, FOR THE SAME MATTER, USE THE PROVIDER IDR PROCESS DESCRIBED ABOVE IN SECTION 2A. Provider Responsibilities under Provider-Initiated Member Appeals (Act 68 Process) If a health care provider assumes responsibility for filing a grievance, the health care provider may not bill the member for services that are the subject of the grievance until the external grievance review has been completed or the member rescinds consent for the health care provider to pursue the grievance. If the health care provider elects to appeal an adverse decision made by the plan or a certified review entity (CRE), the health care provider may not bill the member or member s legal representative for services provided that are the subject of the grievance until the health care provider chooses not to appeal an adverse decision to a court of competent jurisdiction. If the health care provider is prohibited from billing the member or chooses never to bill the member for the services that are the subject of the grievance, the health care provider may drop the grievance with notice to the member or the member s legal representative. Any member can ask another person to act as his/her representative in the appeals process ( member s representative ). If this representative is a health care provider, the provider must obtain the member s written consent to pursue a grievance. The member s or the member s legal representative s, if the member is a minor or is legally incompetent, consent to a health care provider to pursue a grievance must be in writing, and the consent is automatically rescinded upon the failure of the health care provider to file or pursue a grievance. Appeals - G Date 1/2007 Page - 3

The consent document giving the health care provider authority to pursue a grievance on behalf of a member must include each of the following elements: 1) The name and address of the member, the member s date of birth and the member s identification number. 2) If the member is a minor, or is legally incompetent, the name, address and relationship to the member of the person who signs the consent for the member. 3) The name, address and identification number of the health care provider to whom the member is providing the consent. 4) The name and address of the plan to which the grievance will be submitted. 5) An explanation of the specific service for which coverage was provided or denied to the member to which the consent will apply. The following statements must be in the consent document: 1) The member or the member s representative may not submit a grievance concerning the services listed in this consent form unless the member or the member s legal representative rescinds consent in writing. The member or the member s legal representative has the right to rescind consent at any time during the grievance process. 2) The consent of the member or the member s legal representative is automatically rescinded if the provider fails to file a grievance, or fails to continue to prosecute the grievance through the second level review process. 3) The member or the member s legal representative, if the member is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his/her satisfaction. The member, or the member s legal representative understands the information in the member s consent form. The consent document must also have the dated signature of the member, or the member s legal representative if the member is a minor or is legally incompetent, and the dated signature of a witness. The member may rescind consent at any time during the grievance process. If the member rescinds consent, the member may continue with the grievance at the point at which consent was rescinded. The member may not file a separate grievance. A member who has filed a grievance may, at any time during the grievance process, choose to provide consent to a health care provider to continue with the grievance instead of the member. The member s legal representative may exercise the rights conferred upon the member. Provider-Initiated Member Appeals (Act 68 Process) First Level The member, member s representative, or health care provider with written consent of the member, may file a written grievance with First Priority Health. A grievance is a request to First Priority Health to reconsider a decision solely concerning the medical necessity and appropriateness of a health care service. A grievance may be filed regarding a decision to: 1) deny, in whole or in part, payment for a service (if based on lack of medical necessity) 2) deny or issue a limited authorization of a requested service, including the type or level of service 3) reduce, suspend, or terminate a previously authorized service 4) deny the requested service but approve an alternate service. Appeals - G Date 1/2007 Page - 4

The member, member s representative, or health care provider with written consent of the member, must file a grievance within 180 days of the utilization management decision or from the date of receipt of notification about the utilization management decision. There is also an Expedited Grievance Process detailed at the end of this section. The provider, having obtained consent from the member or the member s legal representative to file a grievance, has 10 days from receipt of the standard written denial and any decision letter from a first level, second level, or external review to notify the member or the member s legal representative of its intention not to pursue a grievance. First Priority Health will send written confirmation of its receipt of the grievance to the member, the member s representative (if the member has designated one), and the health care provider, if the health care provider filed the grievance with member consent upon receipt of the grievance. The notification will include the following information: That First Priority Health considers the matter to be a grievance (rather than a complaint). The member, the member s representative, or health care provider, may question the classification of complaints and grievances by contacting the Pennsylvania Department of Health. That the member may appoint a representative to act on the member s behalf at any time during the internal grievance process. That the member, the member s representative, or the health care provider that filed the grievance with member s consent, may review information related to the grievance upon request and submit additional material to be considered by First Priority Health. That the member or the member s representative may request the aid of a First Priority Health employee who has not participated in the utilization management decision to assist in preparing the member s first level grievance. The first level grievance review shall be performed by an initial review committee. The members of the committee will not have been involved in any prior decision relating to the grievance. The committee will include a licensed physician or an approved licensed psychologist, practicing in the same or similar specialty that would typically consult on the health care services in question. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist s scope of practice if the psychologist s clinical experience provides sufficient expertise to review that specific behavioral health care service. An approved licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug. First Priority Health will provide the member, the member s representative, or a health care provider that filed a grievance with member consent, access to all information relating to the matter being grieved and will allow the provision of written data or other material in support of the grievance. The member, the member s representative, or the health care provider may specify the remedy or corrective action being sought. First Priority Health will provide, at no charge, at the request of the member or the member s representative, an employee who has not participated in previous denial Appeals - G Date 1/2007 Page - 5

decisions regarding the issue in dispute, to aid the member or the member s representative in preparing the member s grievance. First Priority Health will complete its review and investigation, and arrive at a decision within 30 days of receipt of the grievance. First Priority Health will notify the member, the member s representative, and the health care provider of the decision of the internal review committee in writing within 5 business days of the committee s decision. The notice to the member, the member s representative, and the health care provider, will include the basis for the decision and the procedures for the member or provider to file a request for a second level review of the decision of the initial review committee including: A statement of the issue reviewed by the first level review committee The specific reasons for the decision References to the specific First Priority Health provisions on which the decision is based and how to obtain these documents, if used An explanation of the scientific or clinical judgment for the decision An explanation of how to file a request for a second level review of the decision which must be filed within 180 days of the first level decision. Provider-Initiated Member Appeals (Act 68 Process) Second Level Review Upon receipt of a voluntary second level grievance, First Priority Health will send the member, the member s representative, and the health care provider, an explanation of the procedures to be followed during the second level review. This explanation will include the following information: How to request the aid of a First Priority Health employee who has not participated in any discussion of the issue in dispute in preparing the member s second level grievance. Notification that the member, the member s representative, and the health care provider have the right to appear before the second level review committee and that First Priority Health will provide the member, the member s representative, and the health care provider with 15 days advance written notice of the time scheduled for the review. The second level review committee shall be made up of three or more individuals who did not previously participate in the decision to deny coverage or payment for the issue in dispute. The committee will include a licensed physician or a licensed psychologist, practicing in the same or similar specialty who would typically consult on the health care services in question. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist s scope of practice if the psychologist s clinical experience provides sufficient expertise to review that specific behavioral health care service. An approved licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug. The second level review allows the following: The member, the member s representative, and the health care provider have the right to be present at the second level review, and to present a case. First Priority Health shall notify the member, the member s representative, and the health care provider at least 15 days in advance of the date scheduled for the second level review. Appeals - G Date 1/2007 Page - 6

First Priority Health will make reasonable accommodation to facilitate the participation of the member, the member s representative, and the health care provider by conference call or in person. First Priority Health will take into account the member s access to transportation and any disabilities or language barriers. If the member, the member s representative or filing health care provider cannot appear in person at the second level review, First Priority Health will provide the member, the member s representative or the provider, the opportunity to communicate with the review committee by telephone or other appropriate means. Attendance at the second level review is limited to: members of the review committee appropriate First Priority Health representatives the member, or the member s representatives, including any legal representative and/or attendant necessary for the member to participate in or understand the proceedings the health care provider who filed the grievance with the member s consent applicable witnesses. The committee may not discuss the case to be reviewed prior to the second level review meeting. A committee member who does not personally attend the review meeting may not vote on the case unless that person actively participates in the review meeting by telephone or videoconference and has the opportunity to review any additional information introduced at the review meeting prior to the vote. First Priority Health may provide an attorney to represent the interests of the committee but the attorney may not argue First Priority Health s position, or represent First Priority Health or First Priority Health staff. The committee may question the member, the member s representative, the health care provider, and First Priority Health staff. The committee will base its decision solely upon the materials and testimony presented at the review. The proceedings will be transcribed. The transcription will be maintained as a part of the grievance record to be forwarded upon a request for an external grievance review. First Priority Health will complete the voluntary second level grievance review and arrive at its decision with 45 days of receipt of the grievance. First Priority Health will notify the member, the member s representative, and the health care provider of the decision of the second level review committee in writing within 5 business days of the committee s decision. First Priority Health will include the basis for the decision and the procedures and time frames for the member. the member s representative, or the health care provider, to file a request for an external grievance review including the following: A statement of the issue reviewed by the second level review committee The specific reasons for the decision References to the specific First Priority Health provisions on which the decision is based and how to obtain these documents, if used An explanation of the scientific or clinical judgment for the decision, applying the terms of the plan to the member s medical circumstances. A statement that the member has 15 days from receipt of the second level grievance review to file a request for an external review with the plan. A statement that the member can request an external review by either calling or writing First Priority Health. The address and phone number are provided in the letter. Appeals - G Date 1/2007 Page - 7

Expedited Grievances (Act 68 Process) The member, member s representative, or health care provider with written consent of the member can file an Expedited Grievance with First Priority Health by calling First Priority Health. The member, member s representative, or health care provider with written consent of the member may request an expedited review at any stage of the plan s review process if the member s life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the review process. In order to obtain an expedited review, the member, the member s representative or the health care provider, with the written consent of the member, must provide First Priority Health with a written certification from the member s physician that the member s life, health, or ability to regain maximum function would be placed in jeopardy by delay. The certification must include the clinical rationale and facts to support the physician s opinion. The expedited grievance will be put into written form and be reviewed by the Medical Director. The Expedited Grievance Process will follow the process described above in Provider-Initiated Member Appeals (Act 68 Process) Second Level Review, with the following exceptions: Time frame is 48 hours for a decision. The hearing may be held telephonically if the member cannot be present in the short time frame (all information presented at the hearing is read into the record). If First Priority Health cannot provide a copy of the report of the same or similar specialist to the member prior to the expedited hearing, the plan may read the report into the record at the hearing, and shall provide the member with a copy of the report at that time. It is the responsibility of the member, the member s representative, or the health care provider to provide information to First Priority Health in an expedited manner to allow the plan to conform to the requirements of this section. An expedited internal second level review will be conducted within 48 hours of receipt of the request from the member, the member s representative, or health care provider, with written consent of the member, for an expedited review accompanied by a physician s certification. The notification to the member, member s representative, or health care provider will state the basis for the decision, including any clinical rationale, and the procedure for obtaining an expedited external review. The member, member s representative, or health care provider with written consent of the member, has 2 business days from the receipt of the expedited grievance decision to request an expedited external review. For Expedited External Review requests, First Priority Health will submit a request for an expedited external review to the Pennsylvania Department of Health by fax transmission and telephone within 24 hours of receipt of the member s, member s representative, or health care provider s, with written consent of the member, request. The Department of Health will assign a certified review entity (CRE) within 1 business day of receiving the request for an expedited review. The CRE will have 2 business days following the receipt of the case file to make a decision. Appeals - G Date 1/2007 Page - 8

External Grievances (Act 68 Process) Pennsylvania Act 68 allows for an external grievance process by which a First Priority Health member, member s representative, or a health care provider, with the written consent of the member, may request an external review of a denial of a second level grievance. The external grievance process shall adhere to the following standards: A member, the member s representative or the health care provider who filed the grievance, have 15 days from receipt of the second level grievance review decision to file with First Priority Health a request for an external review. If the request for an external grievance is being filed by a health care provider, the health care provider shall provide the name of the member involved and a copy of the member s written consent for the health care provider to file the external grievance. Within 5 business days of receiving the external grievance from the member or health care provider filing a grievance with member consent, First Priority Health will notify the Pennsylvania Department of Health, the member and the health care provider that a request for an external grievance review has been filed. First Priority Health s notification to Pennsylvania Department of Health by phone and fax shall include a request for assignment of a certified review entity (CRE). First Priority Health will notify the provider or the member of the name, address and phone number of the assigned CRE within 2 business days. First Priority Health will, within 15 days of request for an external review, forward the case file to the assigned CRE. First Priority Health will also send the provider or member a listing of all documents forwarded to the CRE. Once the CRE reaches its decision, First Priority Health will authorize a health care service and pay claim(s) determined to be medically necessary and appropriate by the CRE whether or not First Priority Health appeals the CRE s decision to a court of competent jurisdiction. The assigned CRE will review and issue a written decision within 60 days of the filing of the request for an external grievance review. The decision will be sent to the member and the member s representative, the health care provider, the plan, and the Pennsylvania Department of Health. Appeals - G Date 1/2007 Page - 9

BEHAVIORAL HEALTHCARE PROGRAM First Priority Health contracts directly with behavioral health care providers in order to offer members comprehensive behavioral healthcare services. Access to these services is through our agreement with Community Behavioral Healthcare Network of Pennsylvania (CBHNP). The responsibilities of CBHNP are to: Verify member eligibility and benefits Triage and refer member requests for services Authorize, review and approve treatment plans This centralized system for coordination of services ensures that members will be evaluated and referred to the most appropriate participating facility or professional in a timely manner. Throughout the course of treatment or hospitalization, CBHNP will review the member s progress within the established plan of treatment, and authorize the use of the member s benefits according to established criteria. Either the member, primary care physician, employee assistance representative, family member or a mental health provider must contact CBHNP for: Authorization for all outpatient and partial hospitalization services Pre-admission certification for inpatient psychiatric and chemical recovery services Inpatient detoxification/rehabilitation services *** The only prerequisite before an insured obtains non-hospital residential and outpatient coverage for alcohol and drug dependency treatment is a certification and referral from a licensed physician or licensed psychologist. The certification controls the nature and duration of the treatment. All other requests for Drug and Alcohol treatment by other than a licensed physician or licensed psychologist must be pre-certified by CBHNP before services are rendered and must meet medical necessity criteria. In all instances, services must be performed by a participating provider. CBHNP can be contacted: 24 Hours a Day 7 Days a Week 1-800-599-2428 Upon request, criteria for inpatient mental health services can be obtained by contacting CBHNP at 1-800-599-2428. For chemical recovery services, First Priority Health uses the American Society of Addiction Medicine criteria for any level of care. For information on how to obtain this criteria, also contact CBHNP. Behavioral Healthcare - H Date 4/2009 Page - 1

REQUESTING MEDICAL CRITERIA CBHNP base its Behavioral Healthcare decisions on specific criteria to determine medical necessity. These criteria are available to all FPH providers upon request. Criteria may be requested by either contacting or faxing CBHNP with the following information: member s name, FPH identification number, date(s) of service, date(s) of denial and facility where services were rendered or by calling the Provider Services Unit at 1-800-822-8752. CBHNP/Regional Referral Center 3 West Olive Street, Suite 107 Scranton, PA 18508 Phone - 1-800-599-2428 Fax - 1-888-548-8013 All Chemical Recovery treatment programs must be appropriately licensed by the Department of Health Bureau of Drug and Alcohol. Behavioral Healthcare - H Date 4/2009 Page - 2

BILLING INFORMATION BILLING POLICIES/PROCEDURES 1. Inpatient and outpatient services must be billed (electronically or via hard copy) to First Priority Health (FPH) using either the HCFA -1450 billing format or the NUCC-1500 form and the appropriate revenue, ICD-9 and HCPC/CPT-4 codes. The member is held harmless except for noncovered services, designated copayments, deductibles, co-insurances, etc., or when instructed in writing by FPH. 2. Synertech, an imaging service, is handling all hard copy claims that are submitted to FPH. All hard copy claims must be mailed to the following address: First Priority Health P.O. Box 69699 Harrisburg, PA 17106-9699 The following list will help to ensure that your claims are imaged properly: Use red NUCC 1500 forms. Use HCFA 1450/UB92 forms. Bar-coded forms are not required as stated in the past, but can still be used if you have a supply. If it is necessary to use a highlighter, use only yellow or circle important data with black or blue ink. Use solid line printing rather than dot matrix printing. Use only black or blue ink for preparing handwritten claim forms. When it is necessary to submit a copy of a claim for processing, ensure that the copied claim is legible and dark enough to read. Do no use red ink. Do not submit carbon copies or microcopies of a claim for imaging. 3. All providers are required to submit claims within the time frames established. Claims must be received by FPH within one year of the date of service and/or discharge date or as contractually stipulated, based on the received date of the claim. In absence of any contract provision, claims must be received by FPH within one (1) year of date of service. If a claim is received with dates of service beyond the timely filing limitation, the dates of service will be denied and the submitting party will be responsible for the charges. Please allow 45 days for processing before resubmission. 4. In the event that the hospital does not have a prior authorization, the bill should still be sent to FPH. The provider will be notified by FPH on a remittance advice of the rejection of payment if the authorization is not on record and whether or not the member is responsible for the charges. 5. FPH participates in Point-of-Service (POS) programs which gives members more flexibility in choosing services. In some cases, the member may be responsible for obtaining prior authorization when necessary. Billing Information - I Date 1/2007 Page - 1

6. Pre-admission Testing (PAT) - Luzerne County has an outpatient radiology program (excluding Berwick & Hazleton), however, the radiology portion of pre-admission testing (chest X-rays) is excluded. The X-rays are billed by the facility performing the tests using procedure codes 71010 or 71020 with the appropriate primary diagnosis codes of V72.81, V72.82, V72.83, or V72.84. Lackawanna and Luzerne Counties also have an outpatient lab program. All lab for pre-admission testing must be coordinated through the member s Primary Care Physician, located in Luzerne or Lackawanna, whenever possible. Members must go to their PCPs office for blood draws if their PCP office provides that service. If a member s PCP does not perform blood draws, the member must go to one of Pennant Lab s designated blood drawing stations. All other counties do not have an outpatient radiology or laboratory program, therefore, all preadmission testing can be provided at any FPH participating facility. Pre-admission testing is covered under the inpatient or SPU prior authorization regardless of date performed. Please note: Pre-admission testing is covered even if the procedure is cancelled. A script is required for all testing. Pre-admission testing does not have to be provided at the same facility as the surgery as long as it is a participating FPH facility. Outpatient surgery may require prior authorization; please refer to your Provider Bulletin for further details. 7. Mother/Baby Claims FPH requires both mother and baby charges be included on the same UB92 claim form. If your billing system cannot produce one claim for the mother/baby, two (2) separate claims may be submitted to FPH; however, these claims must be received together in order to ensure proper payment. (Exception is Point of Service Accounts). 8. Detained Baby Claims Pre-certification is required in all cases when the baby is detained after the mother is discharged. Therefore, charges incurred for these admissions are to be handled separately from the original mother/baby claim that was submitted for the delivery. The services billed will be for the detained stay only. 9. Maternity Home Health Visit When billing the mandated early discharge home health visit, use revenue code 551 and diagnosis code V24.2. A copayment does not apply to this service. 10. Bill Types (Outpatient vs. Short Stay/SPU) All outpatient claims are to be submitted using the correct bill type in Locator 4 of the UB-92 claim form that corresponds to the services being billed. 11. Diagnostic/Screening Mammography Submit claims for a diagnostic mammography with revenue code 401. Submit claims for a screening mammography with revenue code 403. The appropriate HCPC s code must be billed to identify the nature of the test. 12. Itemization of Service When billing for multiple dates of service on one claim (i.e. physical therapy, speech therapy, occupational therapy), please list each date of service in Locator 45 of the UB-92 claim form and the charge associated with the date in Locator 47. 13. Units The field or locator must contain a numerical value of one (1) or higher; zeros will not be accepted. For providers who bill electronically, an edit will be placed in the system to require a numerical value in the units field or locator, therefore, you will receive an error if this information is not entered up-front. Billing Information - I Date 1/2007 Page - 2

14. Re-admission Inpatient and outpatient claims will be examined for re-admissions and clinical correlation. Claims will be combined based on a leave of absence when a re-admission is expected following an initial discharge, indicating the need for further medical/surgical treatment. Examples include, but are not limited to: situations when surgery could not be scheduled immediately; a specific surgical team is unavailable; bilateral surgery was planned; or treatment cannot begin immediately. Placing the patient on a leave of absence will not generate two (2) payments. Only one bill and one payment will be made. Re-admissions within 30 days of a preceding discharge will be reviewed to determine medical appropriateness of the initial discharge. If the initial discharge is determined to be premature, payment will be adjusted to reflect one episode of care. 15. Utilization Claims will be reviewed to substantiate accuracy of billing and payment. Claims will be reviewed to verify accuracy and completeness of pre-admission certification information. If inaccuracies exist based on actual medical record documentation, payment may be adjusted. Cases in which a member is admitted and discharged the same day following a procedure will be reviewed for appropriateness of setting/accuracy of billing. Payment may be adjusted. Cases in which a member is transferred to and/or from their acute care or psychiatric areas in the same episode of care will be combined and reimbursed under one DRG payment. 16. Delay/Cancellation Policy/Against Medical Advice (AMA) If a BlueCare HMO member requests a delay or cancellation of an inpatient stay after the member has received some services, and the stay was considered medically necessary, the services which would have been covered on an outpatient basis, should be billed as an outpatient claim. Room and board charges are the member s responsibility. 17. Postponement Policy If the provider must postpone a procedure or test and the member must be re-admitted, one bill should be submitted that encompasses both admissions. 18. Payment Liabilities Any charge not covered under the member s First Priority Health agreement becomes the member s responsibility. Any charge rejected due to denial on the basis of medical necessity may become the member s responsibility. Billing Information - I Date 1/2007 Page - 3

Any charge rejected due to benefit eligibility becomes the member s responsibility. Such charges include, but are not limited to: a. durable medical equipment; b. private room differential; c. take-home drugs; d. educational training; e. deductibles; or f. co-insurance and co-payments. 19. Refer to the Blue Cross of Northeastern Pennsylvania & First Priority Health Billing Manual for additional billing information regarding the HCFA 1450 (UB92) and the NUCC 1500, NaviNet SM First Priority Health responded to the challenge to simplify and expedite administrative processes by offering providers in our network the web-based system NaviNet SM. This system allows providers to electronically link to FPH for a variety of purposes, including but not limited to: Member eligibility/copayments Service authorizations Claims submission/inquiry Electronic bulletin board (Blue Alert) BCNEPA Provider Center The E* Services Department offers the following options in regard to claims submission: E* Services has been working diligently with several clearinghouses to accept claims electronically. Depending upon what electronic clearinghouse your billing program/service uses, a single data entry may be all that is required. If you currently do not have a method for electronic claims submission, FPH offers online claims entry via NaviNet SM. For detailed information or connection to any of the above capabilities, call the Provider Services Unit at 1-800-822-8752. ACT 68 INTEREST PAYMENTS Under the terms of Act 68, Pennsylvania s managed care bill, insurers have 45 calendar days from receipt to pay a clean claim submitted for reimbursement. A clean claim is defined by the Act as a claim for payment for a health care service which has no defect of impropriety. A defect or impropriety shall include lack of required substantiating documentation or a particular circumstance requiring special treatment which prevents timely payment from being made on the claim. If the clean claim is not paid by the 45 th day, interest must be paid to the remitter of the claim. The interest is calculated beginning the day after the required payment date and ends on the date the claim is paid. FPH will mail the check and a detailed claim listing, which indicates the claims for which you are receiving interest. Billing Information - I Date 1/2007 Page - 4

ADJUSTMENT FORMS First Priority Health (FPH) allows providers to adjust previously submitted claims through the use of the FPH and Blue Cross of Northeastern Pennsylvania Adjustment form. Previously, two forms existed. The forms were combined to include both lines of business onto one form (Refer to Section K Forms ). Therefore, it is imperative when submitting the form that you indicate at the top whether or not it is a Blue Cross or FPH adjustment. The combined adjustment form must be utilized by participating providers when attempting to: Add or delete a charge to a revenue code previously billed. Add or delete a diagnosis code, procedure code, etc. Cancel a previously submitted claim. Notify FPH that a previously billed claim should have been submitted as secondary to another insurer. If you are submitting a late charge bill, please utilize the correct third (3 rd ) digit bill type frequency of 5 (i.e. 135 for outpatient). Late charges should only be submitted when adding a charge on a revenue code that has not previously been billed. Adjustment forms should be submitted to the following address or fax: First Priority Health First Priority Health Attention: Claims Department Supervisor, FPH Claims Research 19 North Main Street fax #: (570) 200-6840 Wilkes-Barre, PA 18711-0302 MANDATORY CLAIMS RESEARCH REQUEST FORM NUCC 1500 FPH requires all providers to utilize the Mandatory Claims Research Request Form when research is requested on your own claims. A copy of a NUCC 1500 or the remittance advice must be attached. Please be sure that all necessary information is completed to ensure timeliness in researching your request. Mail all requests to: First Priority Health Attention: Claims Research Department 19 North Main Street Wilkes-Barre, PA 18711-0302 Claim inquiries can also be made 30 days after the submission date by contacting the Provider Services Unit at 1-800-822-8752, Monday through Friday, 8:00 a.m. to 5:30 p.m. This form must be used or all documentation received will be returned. Please see Section K Forms for a copy of the Mandatory Claims Research Request Form. Billing Information - I Date 1/2007 Page - 5

OTHER PARTY LIABILITY (COORDINATION OF BENEFITS/SUBROGATION) The following information is intended to serve only as general information and to assist you in identifying various situations when you should contact all insurers involved to actually determine the rule in effect. Coordination of Benefits (COB) provisions were developed primarily to help eliminate duplication of medical payments. COB determines which insurer pays first when a member is covered under two or more health care plans. COB outlines what benefits available under the member s FPH plan will be coordinated with benefits available under any other insurance coverage such as a secondary health insurance, automobile insurance, Worker s Compensation, school insurance, or Medicare. Our member s Contract outlines that even when FPH is the secondary insurance, all services must be authorized by the PCP before they are rendered. Therefore, when your office is contacted for authorization, the appropriate pre-authorization should be given if the services are medically necessary and appropriate. FPH will perform a thorough review of the responsibilities on the part of the identified primary payer and pay claims as a secondary insurance ONLY when proper authorization exists. Primary Payer The primary plan, or the plan determined to pay first, must provide benefits up to the limitations of its contract as if no other insurance coverage existed. Secondary Payer If FPH is the secondary payer, FPH will pay for Member liability amounts for services rendered up to the limitations of the FPH contract. Our member s Contract outlines that even when FPH is the secondary insurance, all services must be authorized by the PCP before they are rendered. Therefore, when your office is contacted for authorization, the appropriate pre-authorization should be given if the services are medically necessary and appropriate. If FPH s internal COB files indicate that another insurance carrier is primary and FPH is the secondary carrier, FPH will require an Explanation of Benefit (EOB) form from the primary carrier before the claim will be considered for payment. If the EOB form from the primary insurance carrier is not submitted with the claim, the claim will be denied as FPH non-primary payer in need of an EOB from the primary insurance carrier. If you bill hard copy, please attach the primary carrier s EOB to the claim. If you bill electronically, you can fax the primary carrier s EOB to: FPH COB DEPT at (570)-200-6820 or mail the primary carrier s EOB to FPH COB Dept., 19 North Main Street, Wilkes-Barre, PA 18711. Group vs. Non-Group Plans First Priority Health coordinates with non-group policies. Billing Information - I Date 1/2007 Page - 6

Disability Using the same logic stated above, employees who are: disabled (not working); covered by Medicare; do not have COBRA; or listed as active by an employer group with more than 100 total employees, are now inactive for primary/secondary COB determinations. This change will shift a larger burden to Medicare as it is primary over group plans for inactive employees. Medicare has always been primary for inactive employees employed by groups with less than 100 total employees. Non-Coordination of Benefits Plans The health insurance plan that has no COB provision pays before a plan that has a COB provision. The non-cob plan shall be considered the primary payer. Same Person, Subscriber on Two Plans At times a person may be covered as an employee on two separate health plans, i.e. working two jobs. In that case, the plan covering the person longer pays benefits first, including any claims for covered dependents. Policy Holder(Employee)/Dependent The benefits of the plan that covers the individual as an employee or member (other than as a dependent) are determined before those of the plan that covers the individual as a dependent. Laid-Off or Retired Employees vs. Actively Working If a person has coverage under one plan as a laid-off or retired employee, and under another plan as an active employee, the benefits provided by the plan which covers the individual as an active employee are determined before those of the plan which covers the individual as a laid-off or retired employee. The same rule applies to dependents covered under both policies. For example: An individual is covered as a retiree under his former employer s plan and is also covered as an active employee by his current employer. The plan that covers the individual as an active employee pays first. The same individual has family medical coverage for his dependent children. The active plan would pay primary for the children and the retiree plan would be secondary. For determining the benefits for a retiree who is also covered as a dependent of an active employee, the plan that covers the person as a non-dependent (for example, as a retiree) pays before the plan that covers the person as a dependent. For example: Assume that an individual has retiree medical coverage from his former employer and is also covered under his wife s employer s plan as her spouse. In this instance, the retiree plan pays first. However, the above rules do not apply if the retiree is also a Medicare beneficiary. See the Medicare section below for further guidance. Billing Information - I Date 1/2007 Page - 7

Dependent Children of Parents NOT Separated/Divorced - Birthday Rule First Priority Health determines the order of benefit payment for a dependent child by use of the birthday rule developed under the guidance of the National Association of Insurance Commissioners (NAIC). The primary coverage for a dependent child is the coverage of the natural parent as an employee whose birthday (month and day, not year) falls earlier in the year. For example, the coverage for a parent born on June 6 would pay benefits for a child before the coverage of a parent born September 2. If both natural parents have the same birthday, the plan that has been covering the parent longer pays first. Since the birthday rule has not been mandated in all states, there may be some insurance carriers that still follow the male/female (gender) rule. If one coordinating plan uses the birthday rule and the other uses the male/female (gender) rule, both plans will follow the latter. Dependent Children of Divorced/Separated Parents When parents are separated/divorced, neither the male/female (gender) or birthday rule applies, except in the case of custody. For children of divorced/separated parents, the order of payers will be as follows: 1. The health care coverage of the natural parent with custody, as a policy holder, pays first; 2. The health care coverage of the spouse of the parent with custody, as a policyholder, (step-parent) pays second. 3. The health care coverage of the natural parent without custody, as a policyholder, pays last. If there is a court decree that states that one of the natural parents is responsible for the child s health care expenses, that plan pays first. The plan of the other natural parent shall be the secondary plan. First Priority Health requires copies of court decrees when applicable. Newborns Newborn children of a policyholder or covered dependent (male or female) are covered for the first 31 days immediately following birth. Coverage after 31 days is contingent upon the policyholder enrolling the newborn child as a dependent within the 31-day period. If both parents have health insurance, the birthday rule is followed to determine the primary and secondary payers. Medicare Status of Covered Member Employer with less than 20 employees Employer with more than 20 employees but less than 100 Employer with 100 employees or more Active employee & spouse age 65 or older Medicare Primary First Priority Health Primary First Priority Health Primary Disabled employee or dependent under age 65 & eligible for Medicare Medicare Primary Medicare Primary First Priority Health Primary Retired employee & spouse entitled to Medicare Medicare Primary Medicare Primary Medicare Primary Billing Information - I Date 1/2007 Page - 8

Medicaid Medicaid is always the secondary payer (except for members of the Children s Health Insurance Program), no matter who carries it. It is possible for someone to have FPH through an employer and also have Medicaid. Providers can bill Medicaid after payment is received from FPH, but Medicaid will only pay up to the amount it normally pays. In most instances, FPH will have paid more than Medicaid would pay, therefore, billing Medicaid for any balance will usually not result in any payment. Providers cannot bill a member for any balance after Medicaid pays its usual fee. He/she would have to accept any payment from Medicaid as payment in full. As far as a Specialist is concerned, the member is only responsible for the co-payment he/she has for Medicaid. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) CHAMPUS is health insurance given to active and retired service individuals. Not all service-related individuals have it. However, CHAMPUS is always the last payer (the only exception is that CHAMPUS remains primary payer to Medicaid). Automobile Insurance Automobile insurance, as required by the Pennsylvania Motor Vehicle Financial Responsibility Act, is primary over FPH coverage. Pennsylvania law does not require coverage for motorcycles, snowmobiles or ATVs. However, if a Member chooses to purchase an optional medical coverage policy for their motorcycle, snowmobile or ATV, FPH will consider that medical coverage policy primary over FPH coverage. If a FPH member is injured in a motor vehicle accident, or sustains injury due to maintenance or use of a motor vehicle, it is the member s automobile insurance that is the primary payer. FPH requires a letter of exhaustion from the applicable auto insurance carrier indicating that the Member has exhausted the First Party Benefits along with a copy of the payout sheet indicating the claims that were paid. What if a Member doesn t have auto insurance or doesn t own a motor vehicle? If a member doesn t have auto insurance, First Priority Health is not automatically primary for claims paid. Under Pennsylvania law, the following is the order or benefit determination that must be followed if the member does not own a currently registered vehicle or doesn t possess auto insurance: Resident Relative: any active automobile insurance of a relative residing within the Member s household. If the Member does not have auto insurance or does not have a resident relative with auto insurance, a notarized affidavit of NO AUTOMOBILE INSURANCE must state that the Member is/is not the owner of a currently registered vehicle and does not have active automobile insurance either through himself/herself or through resident relatives within his/her household on the date of the motor vehicle accident and must also provide FPH with a copy of the police report. Auto insurance of the vehicle the Member was driving, a passenger in, or hit by at the time of the accident. Auto insurance from any other motor vehicle involved in the accident. Hit and Run Automobile Accident If the Member was involved in a Hit and Run accident and does not possess auto insurance or does not have a resident relative with auto insurance, FPH requires the appropriate notarized affidavit of NO AUTOMOBILE INSURANCE and a copy of the police report indicating it was a Hit and Run accident. Billing Information - I Date 1/2007 Page - 9

If no automobile insurance carrier is applicable, FPH will coordinate benefits with other applicable health insurance carriers. NOTE: All notarized affidavits of NO AUTOMOBILE INSURANCE must be forwarded to FPH s Other Party Liability Department. Worker s Compensation Whenever an FPH member is injured, contracts a disease on the employer s property, or during any company-sponsored sports events or activities, medical claims incurred as a result of that accident are the responsibility of the employer s Worker s Compensation carrier. Worker s Compensation is always considered the primary carrier. FPH will review any claim previously denied as work-related upon receipt of a valid worker s compensation denial from the Worker s Compensation carrier. Injured on Private Property/Business (other than member s employer) FPH has the right to subrogate on claims paid on our members behalf if a member is pursuing a possible lawsuit or appealing a denial from another third party insurance. School Insurance: When a child attends school, he/she is frequently covered by a small health or accident policy through the school. This policy is for use in case of accidents occurring at school or in school-related activities. Most policies state in the contract that they are Supplemental Only or there is a No Coordination of Benefits clause, in which case they would be in the last payer position. DELAYED CLAIMS LIST According to the Unfair Insurance Practice Act, FPH is required to provide all providers a list of claims that have not completed processing within a specific time frame. The claim information is reported on the Patient List/Delayed Claims. Based on the date the claim was received by FPH, listings are made available on the following days: 12 days, 19 days, 30 days and every 45 days thereafter. REMITTANCE ADVICE (RA) All claims payments, denials and adjustments will be documented on a Remittance Advice (RA). You should retain this information for your records. RAs are now sorted alphabetically by the member s last name. Billing Information - I Date 1/2007 Page - 10

BlueCard First Priority Health as part of the BlueCard Program First Priority Health (FPH) is part of the national BlueCard Program. With BlueCard, members have a simple, direct way to receive out-of-area care through a large network of providers 85% of physicians and hospitals across the country contract with Blue Cross and Blue Shield Plans as well as some international providers. When traveling in another Plan s service area, FPH members receive the same benefits and pay the same copayments as they do with their First Priority Health coverage, and they have access to participating BlueCard providers through a single 800-phone number (1-800-810-BLUE) as well as a web site address (www.bcbs.com). The three-digit alpha code (YZH) and the suitcase graphic on the FPH membership identification card is used by out-of-area providers to identify First Priority Health as part of the BlueCard Program. The code and the suitcase let providers know that the patient is a BlueCard member and give providers the ability to process the member s out-of-area claims. Out-of-area BlueCard members will have a different three-digit alpha prefix on their identification cards. Urgent Care Urgent care is defined as care for an unexpected illness or injury that is not life-threatening, but cannot be reasonably postponed until the member returns home, (fever, flu, etc). When BlueCard members obtain services from your facility, they are responsible for the appropriate copayment as indicated on their identification card. Claims are submitted (electronically or via hard copy) to your local Blue Cross (BCNEPA). Remember to include the three-digit alpha prefix for out-of-area BlueCard members. Hard copy claims are to be submitted to: Referred Care BCNEPA Blue Cross Claims Department 19 North Main Street Wilkes-Barre, PA 18711-0302 Referred care is defined as follow-up medical care necessary to treat an illness or injury that originated at home (allergy shots, removal of stitches, etc.). Upon appointment, out-of-area members will present a Transfer of Medical Information Form (TMIF), which allows the transfer of necessary medical information. See Section K, Forms. Upon rendering services, complete the TMIF and mail or fax to the member s physician noted on the form. BlueCard members are responsible for the appropriate copayment as indicated on their identification card. Claims are to be submitted as noted above in the Urgent Care section. Emergency Care Emergency care does not change under the BlueCard Program. If a situation arises that the member requires emergency services, treatment is to be sought from the nearest facility. Copayments may be collected at the time of service. Claims are submitted as noted above. BlueCard - J Date 1/2007 Page - 1

FPH BlueCard Managed Care Point of Service Effective August 1, 2001, some of our POS accounts have transferred to BlueCard Managed Care/POS accounts. The BlueCard Managed Care/POS program is for members who reside outside their BCBS Plan s service area. However, unlike other BlueCard programs, First Priority Health BlueCard Managed Care/POS members are actually enrolled in the FPH network and Primary Care Physician panels. Therefore, you should treat these members as you treat any other FPH POS member, applying the same referral practices and network protocols. BlueCard - J Date 1/2007 Page - 2