TheraMatrix Network UAW-Ford Union Benefits Representative Overview Outpatient Carve Out Program
TheraMatrix. Inc. Overview Corporate Profile Incorporated in 1981, 27 years in business 13 clinics - designated as a Certified Rehabilitation Agency through the Centers for Medicare and Medicaid Services (CMS) - the highest certification available Nearly 200 certified network outpatient facilities throughout Michigan. Nearly 1,400 nationally. Innovative, pioneered on-site industrial rehab program - Original provider of on-site worker s compensation injury physical therapy clinics within UAW-Ford and the big three facilities since 1994 - Assessed by Johns Hopkins University Medical Center for provider performance and rated in the 97 th percentile for patient satisfaction and quality of care National on-site provider to UAW and major US corporations Selected by Ford Health Plan & the UAW and awarded exclusive outpatient physical therapy medical benefit carve-out program for Michigan, effective August 1, 2005. (Renewed for an additional 3 years through 2010) Tier 1 Minority Health Care Vendor Member Michigan Minority Business Development Council (MMBDC) Level 1 status Michigan s largest private practice outpatient physical therapy company National network established for physical therapy providers Membership in APTA, MPTA and NARA CLIENTS 2
TheraMatrix Network What is Outpatient? (OPPT) Physical therapy is a licensed profession Physical therapy is the use of physical, mechanical agents and specific activities or methods to treat a loss of neuro/musculoskeletal functions due to an illness, injury or following surgery OPPT services are defined as those rendered in a credentialed physical therapy facility TheraMatrix approved facilities must be certified as a provider of OPPT services by Medicare 3
TheraMatrix Network Provider Network Advantages Credentialed facilities with licensed Physical Therapists CMS Certified Rehabilitation Agency status highest regulatory certification available Professional, quality, appropriate and effective treatment Committed to convenient access Nearly 1400 network providers throughout the United States Appointments scheduled within 24-48 hours Network facilities near members home and work State of the art equipment Network accountability - ongoing network development, oversight and expansion Superior customer service with focus on quality improvement and member satisfaction Ease of transition for members currently receiving treatment Industry standard claims processing procedures for providers 4
TheraMatrix Network State and National Network Maps Nearly 200 certified and credentialed outpatient physical therapy locations in Michigan and nearly 1400 nationally. Conveniently located for members and family. *See Network Provider Directory for details on all locations 5
TheraMatrix Network UAW-Ford Outpatient Carve Out Program Who s Covered in the Program? All UAW-Ford active employees (Medicare and Non-Medicare) and their eligible dependents that are enrolled in the following plans:» National PPO Plan» Blue Preferred Plus PPO All UAW-Ford retirees or their surviving spouses (Medicare and Non-Medicare) and their eligible dependents that are enrolled in the following plans:» National PPO Plan» Blue Preferred Plus PPO 6
TheraMatrix Network UAW-Ford Outpatient Carve Out Program Who s not covered in the Program? The program is not applicable to employees, retirees, surviving spouses and their eligible dependents that are enrolled in plans other than the National PPO Plan and Blue Preferred Plus. All HMO and Blue Select PPO, TN plans are excluded from this program. UAW-Ford employees, retirees, surviving spouses and dependents that are not eligible for benefits. 7
TheraMatrix Network Outpatient (OPPT) Benefit Effective March 1, 2009 In-Network Covered at 100% No deductibles, co-pays, or co-insurance Current benefit: 60 visits per condition per calendar year maximum limit is combined for outpatient physical, speech, hearing and functional occupational therapy Out-Of-Network Not covered If there is no TheraMatrix network provider within 25 miles of a member s home, contact TheraMatrix at (888) NET-TPTN / (888) 638-8786 prior to services being rendered and we will make arrangements with an OPPT provider in the member s area. 8
TheraMatrix Network How to Obtain Program Services 1. Member must obtain a valid written prescription from their referring physician. 2. Contact TheraMatrix to identify a TheraMatrix network provider location that s convenient for the member. a. Contact TheraMatrix at (888) NET-TPTN / (888) 638-8786 b. Access our provider network online at www.theramatrix.com 3. Once prescription is obtained, services must begin within 30 days. 4. Providers must contact TheraMatrix to obtain prior authorization for services. 9
TheraMatrix Network Frequently Asked Questions (FAQs) For Members transitioning to the TheraMatrix Program March 1, 2009, what happens if the member is currently receiving outpatient physical therapy (OPPT) from a non-network provider? If the member is seeing a non-network provider when they become eligible for benefits, they may continue their course of treatment until expiration of the current prescription. If a member needs a prescription extended, TheraMatrix will work with the member, physician and current provider to transition them to an appropriate in-network provider based on diagnosis and treatment plan. Can the member choose any provider in the TheraMatrix network? Yes, the member has open access to any of our participating providers. How does the member select an in-network provider? Call TheraMatrix customer service at (888) NET-TPTN / (888) 638-8786. Visit our website at www.theramatrix.com. 10
TheraMatrix Network Frequently Asked Questions (FAQs) continued What if there is not a network provider within 25 miles of the member s home? The member can contact TheraMatrix at (888) NET-TPTN / (888) 638-8786 prior to services being rendered and we will establish arrangements with a physical therapy provider in their area. How convenient are your locations? Generally within 10 miles of the member s home or work. Nearly 1400 licensed and credentialed outpatient physical therapy sites throughout the United States. How are the network providers selected? Locations convenient to UAW-Ford eligible members and their family members. Strict credentialing and licensing requirements following the Center for Medicare and Medicaid Services (CMS) standards. 11
TheraMatrix Network Frequently Asked Questions (FAQs) continued Are the TheraMatrix network facilities credentialed? Yes, all the TheraMatrix network outpatient physical therapy sites are credentialed at the highest level based on CMS standards. Can I obtain outpatient physical therapy services from my physician? All outpatient physical therapy services must be obtained from one of our credentialed innetwork outpatient physical therapy facilities. Are Occupational and Speech Therapy included in this carve-out plan? The TheraMatrix plan covers outpatient physical therapy only. Reference the member s health care benefits plan for these services. 12
TheraMatrix Network Frequently Asked Questions (FAQs) continued What outpatient physical therapy services are covered under this plan? All non-work related and medically necessary covered services with a valid prescription written by a licensed physician. Benefit is subject to alternate primary payer coordination. What if a member requires care for a chronic or catastrophic condition? TheraMatrix will coordinate with a specialty provider to accommodate members with chronic and/or catastrophic care. What if a member requires additional services after they have exhausted their annual 60 visit limit? There continues to be a limit of 60 combined visits per calendar year. Once the annual 60 visit limit has been met for a condition the member is responsible for any additional outpatient physical therapy (OPPT) services that may be required for the duration of the benefit year. TheraMatrix will assist members in working with our network providers to continue required treatment and in making financial arrangements. 13
TheraMatrix Network Frequently Asked Questions (FAQs) continued How will COBRA members be accommodated? Members enrolled in health care plans included in the TheraMatrix carve out program who elect COBRA benefits will continue to be covered by TheraMatrix for outpatient physical therapy for the duration of their COBRA coverage period. Is there a separate ID card for this program? There is not a separate ID card for the TheraMatrix network program. Use your existing ID card or contact TheraMatrix at (888) NET-TPTN / (888) 638-8786 to verify eligibility. What if I have a question or concern about my outpatient physical therapy (OPPT) services? Please contact our member services department at (888) NET-TPTN / (888) 638-8786 for immediate, same day response. 14
TheraMatrix Network Frequently Asked Questions (FAQs) continued What do I do if I receive a bill from a TheraMatrix network provider? Please call (888) NET-TPTN / (888) 638-8786 and speak to one of our customer service representatives. How do I file an Appeal? Appeal requests can be filed by the member directly to TheraMatrix with any supporting documentation. The Appeal can be sent Attn: Complaints/Appeals, P.O. 321036, Detroit, MI 48342 15
TheraMatrix Network Frequently Asked Questions (FAQs) continued How will TheraMatrix network providers be monitored? TheraMatrix network providers have all been through an initial credentialing process and will be reviewed on a concurrent and retrospective basis to ensure that care is provided appropriately. TheraMatrix will perform ongoing oversight of our provider practice patterns and monitor outcomes of care. Best practices identified through evidence based care management will be shared with the TheraMatrix provider network as part of our continuous quality improvement programs. Non-compliance to the TheraMatrix Network guidelines could mean removal from the network. Provision of therapy is governed by the Guide to Physical Therapy Practice as established by the American Association. These were used as the cornerstone of our credentialing and selection process. Standard of care, operational protocols, documentation and treatment guidelines are included in this Guide. The TheraMatrix in-network providers are held to strict guidelines since a part of our credentialing process involves selecting CMS certified rehabilitation agencies, as per the Federal Government agency of Centers for Medicare and Medicaid. This means our documentation must meet their guidelines in order to receive reimbursement for services rendered. This ensures accurate billing and payment. 16
TheraMatrix Network Frequently Asked Questions (FAQs) continued Are all services provided by a Physical Therapist? In what instances are services rendered by a Assistant? Physical therapy services can be provided by Physical Therapists, which can be Master degreed and now Doctorate level professionals and must be licensed in the State in which they practice. The Physical Therapist conducts the initial evaluation and in conjunction with the referring physician, establishes a treatment plan that is very detailed regarding the type of services performed, the duration of treatment and preparation of complete documentation for each visit. Certain physical therapy services such as hot packs/cold packs, etc. can be provided by a varied number of therapy specialists. A physical therapy clinic, whether it is free-standing, in a hospital or in a physicians office can have treatment provided by any of the following therapy specialists:» Assistant (PTA)» Certified Athletic Trainer (ATC)» Technician (PTT) All therapy services must be prescribed by a physician and provided under the direct supervision of a licensed Physical Therapist. Each progress note or status report must be reviewed and signed by a licensed Physical Therapist and the care must strictly adhere to the treatment plan established by the PT and the referring physician. 17
TheraMatrix Network Frequently Asked Questions (FAQs) continued Will TheraMatrix coordinate benefits as the secondary payer with other carriers including Medicare? Yes, for in-network provider services, TheraMatrix will reimburse unpaid balances due on claims when the Ford Health Plan is secondary to an alternate carrier, including Medicare. In instances where the member has met their Medicare Cap, TheraMatrix will take over as the primary payer at that time as long as services continue to be medically necessary. Out of network provider services will not be payable unless one of the following scenarios apply: Transitional Care members with an active physical therapy prescription at the time they are eligible for benefits who are receiving care from a non-network provider will be covered for the duration of the current script only. If there is no in-network provider within 25 miles of the member s home, contact TheraMatrix at (888) NET-TPTN / (888) 638-8786 prior to services being rendered and we will establish arrangements with a physical therapy provider in the area. Based on these pre-approved arrangements, TheraMatrix will reimburse unpaid balances due on claims when the Ford Health Plan is secondary to an alternate carrier, including Medicare. 18
TheraMatrix Network Frequently Asked Questions (FAQs) continued How will physical therapy services be reimbursed that are related to an automobile accident? As a general rule, for no-fault auto states, auto related injuries are covered by the auto insurance carrier as the primary payer. TheraMatrix will reimburse no fault auto injury related claims under the following circumstances: As secondary payer for in-network provider services on claims for medically necessary services. What is the source of the eligibility information that TheraMatrix will utilize to identify covered members? Ford provides member eligibility information to TheraMatrix on a daily basis. 19
TheraMatrix Network TheraMatrix Contact Information Corporate Address and Toll-Free Phone TheraMatrix 900 Auburn Ave. Pontiac, MI 48342 Phone: (888) NET-TPTN (888) 638-8786 Fax: (248) 333-7957 Website: www.theramatrix.com Claim submission and appeals TheraMatrix P.O. Box 321036 Detroit, MI 48232-1036 Member Services, Provider Services, other inquiries (888) NET-TPTN (888) 638-8786 20