Provider Procedural Manual - The Health Plan

Volume2010 2014THE HEALTH PLANProvider RelationsProvider PractitionerProceduralManual Manual

T H E H E A L T H P L A NProvider Procedural ManualThis manual is intended for the sole use of the Physicians of The Health Plan. Any reproduction ordistribution of any part of this manual without the written consent of The Health Plan is prohibited.Approved by The Health Plan Executive Management Team on March 17, 2014.St. Clairsville Office52180 National Road EastSaint Clairsville • Ohio • 43950-9306Phone 800.624.6961 • Fax 740.699.6169Hearing Impaired 800.622.3925HomeTown Office100 Lillian Gish Boulevard • P.O. Box 4816Massillon • Ohio • 44648-4816Phone 877.236.2289 • Fax 330.837.6869Hearing Impaired 877.236.2291www.healthplan.org

Table of ContentsS E C T I O N 1INTRODUCTION..................................................... 1THE HEALTH PLAN MISSION STATEMENT .................. 3S E C T I O N 2PHYSICIAN AVAILABILITY ................................... 1STANDARDS FOR ACCESS TOCARE & SERVICES (PROVIDER)................................ 3PRIMARY CARE PHYSICIAN GUIDELINES.................... 6SECONDARY CARE PHYSICIAN GUIDELINES .............. 8SPECIALIST GUIDELINES ........................................ 10S E C T I O N 3MEMBER BENEFITS .............................................. 1PRODUCT MATRIX .................................................. 3MEMBER ID CARD SAMPLES .................................... 4Fully Insured HMO Plans .................................. 5Medicare Advantage (SecureCare) Fully InsuredMedicare Advantage Plan Introduction .............. 6SecureChoice(Medicare Advantage PPO Plan) ...................... 9Medicare Advantage PlanSpecial Needs Plan (D-SNP Program) ............ 12Notice of Medicare Non-Coverage .................. 16Coordination of BenefitsMedicare Advantage Secondary Payer ........... 16THP Medicare Select Plans............................. 17Adminstrative Services Only (ASO)Self Funded Employer Groups ....................... 18Mountain Health Trust WV Medicaid Program . 19Fully Insured Point of Service Plans (POS) .... 20Fully Insured PPO Plans ................................. 21PRESCRIPTION DRUG RIDERS ............................... 22VISION SERVICE PLAN .......................................... 24HP MEMBERS’RIGHTS & RESPONSIBILITIES STATEMENT .............. 28SECURECARE RIGHTS & RESPONSIBILITIES ........... 30MISSION STATEMENT ........................................... 36MANAGED WORKERS’ COMPENSATION PROGRAM .. 37Reporting Requirements ................................. 38Medical Management & Treatment ................. 3960 Day Presumptive Authorization Guidelines .... 39Standardized Prior Authorization Table ....... 41Treatment Guidelines .................................. 41Official Disability Guidelines...................... 41Ohio BWC / MCO StandardizedPrior Authorization table .............................. 42Request for Medical ServicesApproval Guidelines ..................................... 43Retroactive Medical Service Request .......... 44Billing & Reimbursement ............................. 45Miscellaneous .............................................. 45S E C T I O N 4HEATH PLAN ASO GROUPS ............................... 1

S E C T I O N 5MOUNTAIN HEALTH TRUST ................................ 1MEDICAID BENEFITS AT A GLANCE ........................... 2PRESCRIPTION BENEFIT .......................................... 3MOUNTAIN HEALTH TRUST (WV MEDICAID) ..... 4MOUNTAIN HEALTH TRUST ID CARDS & ELIGIBILITY...... 4MOUNTAIN HEALTH TRUST IDENTIFICATION CARDS ..... 5HEALTH CHECK (PREVIOUSLY EPSDT SERVICES) .... 7Periodicity Schedule & Coding Matrix ............... 8FAMILY PLANNING ................................................... 9LOCAL HEALTH DEPARTMENTS ................................ 9STAFFING............................................................. 10SURGICAL CONSENT FORMS ................................. 11PREGNANCY & NEWBORN ENROLLMENT ................. 11WV PRENATAL RISK SCREEN ................................ 12WOMEN’S ACCESS TO HEALTH CARE ..................... 14SMOKING CESSATION ........................................... 15DIABETES ............................................................ 15DENTAL ............................................................... 15IMMUNIZATION REGISTRY ...................................... 16MHT MEMBERS’ RIGHTS & RESPONSIBILITIES ........ 17APPEALS & GRIEVANCES ....................................... 20S E C T I O N 6OFFICE VISIT CO-PAYS, MEDICAL CO-PAYS,COINSURANCE, & DEDUCTIBLES ...................... 1QUICK REFERENCE GUIDE OFCPT CODES FOR OFFICE ENCOUNTERS ................... 4S E C T I O N 7MEDICAL MANAGEMENT PROGRAM ................. 1INTRODUCTION ....................................................... 2PRE-AUTHORIZATION /PRE-NOTIFICATION REQUIREMENTS ......................... 3PRE-AUTHORIZATION OPTIONS ................................ 4OUT-OF-PLAN (TERTIARY REFERRALS) .................... 5MEDICAL DEPARTMENT TELEPHONE DIRECTORY ...... 6ADMISSIONS / CONCURRENT REVIEW PROCESS ....... 7PRE-AUTHORIZATION / REFERRAL MANAGEMENT ..... 8REQUESTS FOR SECOND OPINION ......................... 10REVIEW EXEMPTION STATUS OF PROVIDERS .......... 10STANDING REFERRALS ......................................... 11SPECIALIST COORDINATION OFHEALTH CARE SERVICES ...................................... 11REVIEW CRITERIA ................................................ 12INTERQUAL® REVIEW ........................................... 12PODIATRIC SERVICES ........................................... 13CHIROPRACTIC CARE ........................................... 14APPEALS ............................................................. 15ADVANCE BENEFICIARY NOTICE (ABN) ................. 16CARE MANAGEMENT ............................................ 17CASE MANAGEMENT ............................................ 18SOCIAL WORK SERVICES ...................................... 20DISEASE MANAGEMENT &HEALTH PROMOTION PROGRAMS .......................... 21DIABETES PROGRAM ............................................ 23CHRONIC HEART FAILURE .................................... 25CHRONIC OBSTRUCTIVEPULMONARY DISEASE PROGRAM .......................... 27PRENATAL CARE PROGRAM .................................. 29MEDICAL DEPARTMENT STAFF &COMMITTEE OVERVIEW ........................................ 31Medical Director .............................................. 31Physician Advisory Committee ....................... 31The Focus Group Committee ......................... 32Medical Directors’ Oversight Committee......... 32Transplant & New Technology Committee ..... 33Pharmacy & Therapeutics Committee ............ 34ANNUAL PROGRAM EVALUATION ........................... 34PHYSICIAN VARIANCES ......................................... 35

S E C T I O N 7 C O N T I N U E DAPPENDIX AMEDICAL FORMS, TOOLS, & WORKSHEETS ............. 37Genetic Testing Referral Form ........................ 38HP Referral Worksheet ................................... 39Podiatry Precertification Form ......................... 40Chiropractic Treatment Plan Form .................. 41PET / CT Review Tool ..................................... 42S E C T I O N 8QUALITY MANAGEMENT PROGRAM .................. 1TABLE OF CONTENTS .............................................. 2INTRODUCTION ....................................................... 3QUALITY OF CLINICAL CARE INDICATORS .................. 5QI VARIANCE PROCESS .......................................... 9CUSTOMER SATISFACTION INDICATORS .................. 10QUALITY OF CARE & SERVICE INDICATORS ............. 11CLINICAL PRACTICE GUIDELINES &STANDARDS FOR CARE & SERVICE ........................ 13MEDICAL RECORD FOCUS ..................................... 15ADVANCE DIRECTIVES ........................................... 15WELLNESS & HEALTH PROMOTION EDUCATION ....... 18MEMBER EMPOWERMENT PROJECTS ..................... 20PROVIDER EDUCATION INITIATIVES ......................... 23QUALITY IMPROVEMENT FORMS &INFORMATIONAL MATERIALS SHEET ....................... 25Accessibility ..................................................... 26Availability / GeoAccess .................................. 26Continuity & Coordination of Care ................... 26Emergency Room Use .................................... 27Accreditation ................................................... 28Advance Directives Flow Chart ....................... 29Advance Directives .......................................... 30Appropriate Coding, Testing & Treatmentfor Children with Upper RespiratoryInfections (URI) & Pharyngitis ......................... 31Asthma ............................................................ 32Asthma Referral Form ..................................... 33Blood Lead Screening forMedicaid / MHT 2 Year Olds ........................... 34Body Mass Index (BMI) Coding Guide............ 35Body Mass Index (BMI) Charts ....................... 36Body Mass Index (BMI) Chart for Children ..... 38BMI Percentile Chart for Boys 2-20 Years ...... 39BMI Percentile Chart for Girls 2-20 Years ....... 40BMI: Pediatric Weight Assessment, NutritionCounseling, & Physical Activity Counseling .... 41Chart Stickers Available.................................. 42Diabetic Dilated Fundus Examination Form .... 43Diabetes MellitusPractice Recommendations & Flow Sheet ...... 44ECS / OPTUM Medical RecordReview for Medicare (CMS) ............................ 45Electronic Medical Records (EMR) ................. 46Envelope of Life(Emergency Medical Information) ................... 47Faxing and Mailing Documents ...................... 49Hedis® ............................................................ 50Immunization Registry .................................... 65Medical Record Audit Tool.............................. 66Medication List ................................................ 67Obesity Referral Form .................................... 68Onsite Office Reviews .................................... 69Pain Assessment Sheet ................................. 70Patient History Form ....................................... 71Physician Oversight ........................................ 73Prescription Agreement & Narcotic Use Contract ... 74Prescription Drug Abuse ................................. 75Prescription Drug Database ............................ 76Preventive Health Flow Sheet ........................ 77Problem List.................................................... 78Signature Log ................................................. 79Smoking Cessation Referral Form .................. 80Vaccine Administration Record .............................. 81VA Clinics & Health Fairs ......................................... 83Website .......................................................... 84

S E C T I O N 9BEHAVIORAL HEALTH ......................................... 1TABLE OF CONTENTS .............................................. 2BEHAVIORAL HEALTH UNIT (BHU) INTRODUCTION ..... 3PRE-AUTHORIZATION /PRE-NOTIFICATION REQUIREMENTS ......................... 4ADMISSION / CONCURRENT REVIEW PROCESS .......... 6CRISIS ENCOUNTERS .............................................. 6PRE-AUTHORIZATION / REFERRAL MANAGEMENT ...... 7REVIEW CRITERIA ................................................... 8INTERQUAL® REVIEW.............................................. 9CASE MANAGEMENT ............................................. 10CARE MANAGEMENT ............................................. 11SOCIAL WORK SERVICES ...................................... 12DISEASE MANAGEMENT &HEALTH PROMOTION PROGRAMS ........................... 13DEPRESSION DISEASE MANAGEMENT ..................... 15ANNUAL PROGRAM EVALUATION ............................ 17ACCESS TO CARE ................................................. 17CONTINUITY & COORDINATION OF CARE ................. 18BEHAVIORAL HEALTH UNIT FORMS ......................... 19Admission Review Information Form ............... 20BHU Medical Review Fax Cover Sheet ........... 23Concurrent Authorization forABA / Behavioral Services............................... 24Concurrent or DischargeReview Information Form ................................ 26Continuity of Care Consultation Sheet ............ 28Crisis Encounters Report Form ....................... 29Initial Authorization forABA / Behavioral Services............................... 30Psychological Testing Form ............................ 33Treatment Continuation Request Form ........... 35S E C T I O N 10HP PHARMACY CLINICAL MANAGEMENT(PHARMACY SERVICES) ..................................... 1S E C T I O N 1 1BILLING PROCEDURES ....................................... 1ELECTRONIC BILLING – DOCUMENTATION SUBMISSION .. 4MEDICAL REVIEW FAX COVER SHEET ...................... 5S E C T I O N 1 2ELECTRONIC DATA INTERCHANGE .................. 1S E C T I O N 1 3COORDINATION OF BENEFITS (COB) ............... 1ORDER OF BENEFIT DETERMINATION RULES ............ 2HP PROCEDURES REGARDING COB ....................... 3MEDICARE PRIMARY ............................................... 5COMMERCIAL CREDIT ADJUSTMENT EXAMPLE .......... 6PAYMENT EXAMPLES .............................................. 7HELPFUL HINTS ..................................................... 8COB DENIAL CODES .............................................. 9

S E C T I O N 1 4PAYMENT VOUCHER ............................................ 1PROVIDER REIMBURSEMENT VOUCHER EXAMPLE ...... 2CLAIM NUMBER DEFINITION ..................................... 3AGE OF CLAIM DETERMINATION ............................... 3DENIALS ................................................................ 4CLAIMS IN PROCESS ............................................... 4VOUCHER CREDIT EXAMPLE .................................... 5BENEFIT LIMITATION................................................ 6PROVIDER REIMBURSEMENT VOUCHER CLAIMSSUMMARY PAGE EXAMPLE FORM ............................. 7PROVIDER ADJUSTMENT CODES .............................. 8RESUBMISSION OF CLAIMS ...................................... 9RESUBMISSION OF CLAIMSDENIED FOR DOCUMENTATION ............................... 10CLAIM RESUBMISSION FORM ................................. 11JULIAN CALENDARS .............................................. 12S E C T I O N 1 5CREDENTIALING / RECREDENTIALING / RIGHTS .. 1STANDARDS FOR PARTICIPATION ............................. 3INITIAL CERTIFICATION ........................................... 5PRACTITIONER’S RIGHTS ........................................ 5SITE SURVEY OF STANDARDS (AUDIT) FORM............ 6Office Procedure Review ................................ 10SITE SURVEY OF STANDARDS (AUDIT)BEHAVIORAL HEALTH FORM .................................. 14Office Procedure Review ................................ 18OFFICE ORIENTATION FORM ................................. 22STANDARDS FOR PATIENT RECORDS ..................... 24MEDICAL RECORD AUDIT FORM ............................ 28MEDICAL RECORDS &CONFIDENTIALITY STATEMENT .............................. 29SIGNATURE LOG .................................................. 30TELEPHONE MESSAGE FORM ................................ 31S E C T I O N 1 6HEALTH PLAN TELEPHONE DIRECTORY ......... 1

PROVIDER PROCEDURAL MANUAL 2014Section 1 / Page 1

PROVIDER PROCEDURAL MANUAL 2014INTRODUCTIONRespect for our members, respect for our providers, and respect for our clients.At The Health Plan, our strong relationships with the communities we serve are driven byrespect for the people who reside in our service areas.Since, 1979, The Health Plan has been helping members stay healthier while helpingemployers provide high quality health coverage for their employees. Locally owned andoperated, we can effectively serve the needs or our communities throughout our marketarea. The acquisition of HomeTown Health Network in Massillon, Ohio enhances andexpands our local networks throughout Northeastern Ohio, nearly doubling our networksize, and providing wider network opportunities for our members.As a provider, there are TWO important concepts to understand about The Health Plan:The first concept is that of the personal physician. Members enrolled inour HMO and POS products are required to select a Primary Care Physician(PCP) who acts as the coordinator of care for the patient. Members mustcontact their PCP prior to making appointments with specialty providers.Upon assessment of the patient needs, the PCP may find it appropriate torefer the patient to other participating specialty providers.The second concept pertains to that of an established provider network.The Plan contracts with providers in order to obtain quality care at anaffordable price. This enables us to contain premium increases to ourmembership. All services that can be properly performed by Plan providersmust be referred in-plan. Services, which are not available through thisin-plan network, require preauthorization via an out-of-plan referral.In an effort to provide better access to services, The Health Plan has established contractswith out-of-plan providers. This is known as the Tertiary Network. Should a Health Planmember require specialty of care or services not available through the in-plan network ofproviders, then his/her physician will refer him/her to one of the participating tertiaryproviders. These are still considered out-of-plan referrals requiring preauthorization.These are discussed in greater detail in the pertinent sections of the manual.The purpose of this manual is to give you an overview of The Health Plan and itsstructure so that you can function more effectively as a provider.In addition to this manual and the training that accompanies it, The Health Plan CustomerService Representatives are always available to assist in any way possible by calling:The Health Plan Ohio Valley & Mountaineer Regions at (800) 624-6961 or (740) 695-7901HomeTown Region at (888) 830-4370 or (330) 830-4370Section 1 / Page 2

PROVIDER PROCEDURAL MANUAL 2014THE HEALTH PLAN MISSION STATEMENTThe Health Plan developed the following mission statement to reflect our view of the roleof our program.“In its mission to provide a comprehensive delivery of healthcare services, The Health Plan strives to protect the patient'sright to obtain services in a cost efficient and quality systemwhere patient dignity and satisfaction are enhanced by theservices of The Health Plan and its provider network.”In keeping with our mission, we have identified members’ rights along with theirresponsibilities, which are clearly indicated in the member’s handbook and in Section 3,5, and 8 of this manual.As a participating provider with The Health Plan, it is imperative that you be aware ofthese rights and responsibilities. You are expected to assist our members by makingthem aware of their rights and by supporting these within your practice. The followingCustomer Service Departments are available to assist with any member issues, whichmay arise:The Health Plan at (800) 624-6961 or (740) 695-7902HomeTown at (800) 426-9013 or (330) 837-6880Section 1 / Page 3


PROVIDER PROCEDURAL MANUAL 2014PHYSICIAN AVAILABILITYIn an effort to control the high cost of the Emergency Room Utilization and to reduce theunnecessary denial of Emergency Room claims, we would like to offer the following informationas a reminder of the physician's role as governed by his/her Physician Agreement.1. Physicians need to provide or arrange for service on a 24-hour basis / 7 days per week.The physician should list at least 2 participating Health Plan physicians as backups.The physician or designated backups are to be available by phone or answering service.Answering machines should contain an appropriate message.2. In cases of emergency (except for life endangering situations), The Health Plan membersare instructed to call their Primary Care Physician. If unable to reach their Primary CarePhysician, they are instructed to call The Health Plan 24-hour emergency number,1-740-695-3585, or 1-800-624-6961 for their physician's backups or for further assistance.3. Each Primary Care Physician is responsible for the total cost of care (direct or indirect) foreach member he/she represents as a Primary, including Emergency Room costs. Therefore,the Primary Care Physician should make every effort to provide services in the most costefficient manner.4. When a patient has been seen in the Emergency Room, the Primary Care Physician shouldreview the copy of the E.R. treatment sheet to decide the appropriateness of the visit.5. The physician may then advise The Health Plan of his/her recommendation for approval ordenial of the claim using one of the following options:a. Calling The Health Plan Customer Service Department at (800) 624-6961 ext. 7901 orOhio Valley and Mountaineer Region at (740) 695-7901 and for theHomeTown Region at (888) 830-4370 or (330) 830-4370, with your recommendationfor the claim.b. You may wish to send a copy of the E.R. treatment sheet with your writtenrecommendation. These must be received by The Health Plan within ten (10) days ofthe date of service and should be addressed to the Operations Department.This recommendation will remain confidential. Please review Access Standards on the next page.They are also contained in the Health Plan Practice Guidelines and Standards.Section 2 / Page 2

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PROVIDER PROCEDURAL MANUAL 2014PRIMARY CARE PHYSICIAN GUIDELINES1. You will be listed on The Health Plan Provider Directory under Primary Care Physicians(MEMBERS MUST SELECT A PRIMARY CARE PHYSICIAN).2. If you have a medical subspecialty, you may also be listed under a second category foryour specialty.3. If you wish to change to a different category on the Provider Lists, you must make a requestin writing to Provider Relations.4. If you wish to be listed as NOT ACCEPTING NEW PATIENTS on the Provider Lists,you must meet the required minimum and make a written request to Provider Relations.5. PATIENT ROSTER:a. Primary Care Physician Patient Roster can be obtained through our Provider SecureWebsite that enables your office to generate a member Roster at any time. The memberinformation is updated every 24 hours / 7 days per week. To access The Health Plan’sProvider Website, simply click on www.healthplan.org. Be sure to cross-reference themember I.D. number, date of birth, and name that appears on your Roster with theinformation in your member's chart to ensure that they are the same people.Please refer to Obtain a Member Roster, Electronic Communications Section of theProvider Web Site, for step-by-step instructions on how to obtain your member roster.b. You will only have access to see those patients who have you listed as their PrimaryCare Physician.c. Once you have obtained your Roster, it should be checked for patients who may belisted, but have never been seen and patients who are seen regularly but do not appearon the Roster.d. The Roster should also be checked before patient appointments.e. If you wish for the member to choose you as his/her Primary Care Physician,you may have the member call The Health Plan from your office. Members maychange their Primary Care Physician once per month by calling the following:The Health Plan Customer Service DepartmentOhio Valley and Mountaineer Region: (740) 695-7902 or (800) 624-6961HomeTown Region: (888) 830-4370 or (330) 830-4370Section 2 / Page 6

PROVIDER PROCEDURAL MANUAL 2014f. If you wish a patient to be removed from your Roster, you must submit a request toProvider Relations stating the reason for the request. You may make such a request inthe following situations:1. Non-compliance concerning the physician's orders.2. When a member has been seeing other Primary Care Physicians on a regularbasis.3. When a member has been referred by other Primary Care Physicians on aregular basis.4. When a distinct personality clash exists.You will receive a response from Provider Relations or the member will receive a letter fromThe Health Plan requesting that they choose another Primary Care Physician. In that case, youwill receive a copy of The Health Plan letter to the member.Section 2 / Page 7

PROVIDER PROCEDURAL MANUAL 2014SECONDARY CARE PHYSICIAN GUIDELINES1. You will be listed on The Health Plan Provider List with two (2) categories:a. Members may select a Secondary Care Physician.b. Specialist listed as Primary or Secondary Care Physician – may require a referral ifSpecialist is not the member's Primary or Secondary Care Physician.2. If you wish to change to a different category on the Provider List, you must make a requestin writing to Provider Relations.3. If you wish to be listed as NOT ACCEPTING NEW PATIENTS on the Provider List, youmust meet the minimum requirements and submit a written request to Provider Relations.4. PATIENT ROSTER:a. Secondary Care Patient Roster can be obtained through our Provider Secure Websitethat enables your office to generate a member Roster at any time. The memberinformation is updated every 24 hours. To access The Health Plan’s Provider Website,simply click on www.healthplan.org. Be sure to cross-reference the member I.D.number, date of birth, and name that appears on your Roster with the information inyour member's chart to ensure that they are the same people. Please refer to Obtain aMember Roster, Electronic Communications Section of the Provider Web Site, for stepby-stepinstructions on how to obtain your member roster.b. You will only have access to see those patients who have you listed as theirPrimary Care Physician.c. Once you have obtained your Roster, it should be checked for patients who may belisted, but have never been seen and patients who seen regularly but do not appear onthe Roster.d. The Roster should also be checked before patient appointments.e. If you wish for the member to choose you as his/her Secondary Care Physician, youmay have the member call The Health Plan from your office. Members may changetheir Primary Care Physician once per month by calling The Health Plan CustomerService Department at 1-740-695-7902 or 1-800-624-6961 for the Ohio Valley andMountaineer Region or 1-888-830-4370 or 1-330-830-4370.Section 2 / Page 8

PROVIDER PROCEDURAL MANUAL 2014f. If you wish a patient to be removed from your Roster, you must submit a request toProvider Relations stating the reason for the request. You may make such a request inthe following situations:1. Non-compliance concerning the physician's orders.2. When a distinct personality clash exists.You will receive a response from Provider Relations or the member will receive a letter fromThe Health Plan requesting that they choose another Secondary Care Physician. In that case, youwill receive a copy of The Health Plan letter to the member.Secondary Care Physicians may provide referrals only in cases where the referral is related tocare pertaining to his/her specialty. If you are not listed as the member’s Secondary CarePhysician, you are considered a specialist and a referral from the Primary Care Physicianis required.Section 2 / Page 9

PROVIDER PROCEDURAL MANUAL 2014SPECIALIST GUIDELINES1. You will be listed on The Health Plan Provider Directory under SPECIALISTS THATMAY REQUIRE REFERRALS. Although, The Health Plan has eliminated the call inreferral to The Health Plan Medical Department, the Primary Care Physician is still thecoordinator of all medical care for the member and still needs to coordinate referralsto specialists.2. If you wish to change to a different category on the Provider Directory, you must make arequest in writing to Provider Relations. Your request will be reviewed in accordance withPlan credentialing guidelines to assure you meet any qualifications required for aspecific category.3. Except in cases of emergency treatment, specialists shall only treat members upon referralfrom PCP or Secondary Care Physician.4. Except in cases requiring emergency treatment, specialists must submit a report to theappropriate Primary or Secondary Care Physician concerning the proposed plan ofspecialty treatment, including possible hospitalization or surgery as soon as possible afterexamination of a member.5. Specialists should contact the Primary Care Physician to arrange referrals to anotherphysician. Specialist-to-Specialist referrals are not generally permitted. In emergencysituations, a specialist to whom a patient has been referred may refer that patient to anotherspecialist only in cases where the referral is related to care pertaining to his/her specialty,i.e., specialized surgery and/or care requiring Tertiary services. The plan recommends;however, that the specialist communicate with the PCP regarding the need for the referral insuch instances. This may be done, after the fact, in instances where the emergency mayrequire immediate action.6. Specialists will send a copy of the member's treatment record to the appropriate Primary orSecondary Care Physician.Section 2 / Page 10


PROVIDER PROCEDURAL MANUAL 2014MEMBER BENEFITSThe Health Plan Member Handbook is the primary source of information regarding HealthPlan Member Benefits. The Health Plan Member Handbook is available upon request.OFFICE CO-PAYMENTSMembers with a $0.00, $5.00, $10.00, $15.00, $20.00 co-payment will have the samehandbook, with the exception of the office co-pay amounts. Office co-payments will belisted on the member’s identification card in order to assist in identifying the differentbenefit designs.PRESCRIPTION RIDERSThe Health Plan provides a separate card to identify Prescription Benefits Members.Those without prescription coverage will have “NO” or “N” on their cards. Refer toSection 15 of this manual for details of The Health Plan’s prescription drug benefits.VISION BENEFITSThe Health Plan offers Benefit Riders for vision benefits administered through VisionService Plan (VSP). Providers must be a participating provider with VSP to be eligibleto offer covered vision services. You will need to verify vision coverage throughVision Service Plan (VSP) at 1-800-225-5877.Please Note: Members are entitled to Vision Benefits only under this separateVision Service Program.Members may require Ophthalmologic Medical Services in conjunction with a medicalcondition. These medical services must be offered through The Health Pan contractedophthalmologist or optometrist. A referral from the Primary Care Physician is required inorder for the member to obtain medical services from an ophthalmologist or optometrist.PRODUCT MATRIXFollowing is a Product Matrix, which lists all of the products offered by The Health Plan.This Matrix identifies the basic plan design of each product and includes a sample ofeach ID Card.Section 3 / Page 2

HEALTH PLAN PRODUCT MATRIXSt. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365PH: 1.800.624.6961TTY PH: 1.800.622.3925FAX: 740.695.5297HomeTown Office100 Lillian Gish Boulevard • P.O. Box 4816Massillon, OH 44648-4816PH: 1.877.236.2289TTY PH: 1.877.236.2291FAX: 330.837.6869Color of ProviderDirectory andI.D. CardsMember selectsPrimary CarePhysician (PCP)Referralsrequired forSpecialty CareMember hasOB/GYNOpen AccessMember hasMental HealthOpen AccessMember hasOut-of-NetworkBenefitsHEALTHFully FundedHMOSecureCareMedicare HMOSecureCareSNPBLUEGREENBLUEYESYESYES*YES. PCPs mustcoordinate all specialtycare and documentall referrals in thepatient’s chart.Referrals must besubmitted to TheHealth Plan for anytertiary or out-ofnetworkcare.YES, through OB/GYNsecondary physicianwhen selectedYES, through OB/GYNsecondary physicianwhen selectedYES, through OB/GYNsecondary physicianwhen selectedYES, refer toDirectory forappropriate providersYES, refer toDirectory forappropriate providersYES, refer toDirectory forappropriate providersNONONOPLANMountain HealthTrustBLUEYESYESYESfor all in-networkOB/GYN servicesMental Health benefitsare administeredthrough the stateNOSelf-FundedHMO, EPO,PPO, POSCards and colorsmay vary byemployer group.HMO, EPO, POS: YESPPO: NOPPO: NOHMO, EPO, POS: YESServices requiringreferral/precert maydiffer by plan sponsor.ContactThe Health Plan toconfirm benefits.Determined byspecific employerbenefitsDetermined byspecific employerbenefitsDetermined byspecific employerbenefitsTFully InsuredPOSREDYESYES.*See above.YESfor all in-networkOB/GYN servicesYES, refer toDirectory forappropriate providersYESHPINSURANCECOFully InsuredPPOMedicareSelectPURPLEYELLOWNONONO.Member mayself-refer to anynetwork specialist toreceive “in-network”benefits.YESfor all in-networkOB/GYN servicesYESfor all in-networkOB/GYN servicesYES, refer toDirectory forappropriate providersYES, refer toDirectory forappropriate providersYESNOFor verification of eligibility or benefit information specific to a particular member, go to www.healthplan.org.If you require assistance with registering for access to this secure website, please call 1.800.624.6961, ext. 7649.Rev. 11/13SecureChoicePPOGREEN NO NO YESYES, refer toDirectory forappropriate providersYESwww.healthplan.org

Health Plan & THP Insurance Company Member I.D. Card SamplesHMO PlanID:123456789 EFF: 01/01/05 - 12/31/05 PLAN: Q1IC01 SMITH, JOHN A M 00/00/196002 SMITH, JANE A F 00/00/196203 SMITH, JILL A F 00/00/198604 SMITH, JACK A M 00/00/1988PCP: $10 SCP: $10 ER: $50 UC: $25 Ded: $0/0Health Plan ASOID:123456789 EFF: 01/01/05 - 12/31/05 PLAN: Q1IC01 SMITH, JOHN A M 00/00/196002 SMITH, JANE A F 00/00/196203 SMITH, JILL A F 00/00/198604 SMITH, JACK A M 00/00/1988PCP: $10 SCP: $10 ER: $50 UC: $25 Ded: $0/0SecureCare HMOID:123456789 EFF: 01/01/05 - 12/31/0501 SMITH, JOHN A M 00/00/1935ER: $65 PCP: $0INP: $175/$100 SCP: $35MENTAL HEALTH: CALL 1-800-XXX-XXXMEDICAL PLAN: Q4SEPOS PlanID:123456789 EFF: 01/01/05 - 12/31/05 PLAN: Q1IC01 SMITH, JOHN A M 00/00/196002 SMITH, JANE A F 00/00/196203 SMITH, JILL A F 00/00/198604 SMITH, JACK A M 00/00/1988PCP: $10 SCP: $10 ER: $50 UC: $25 Ded: $0/0SecureChoice PPOPPO PlanID:123456789 EFF: 01/01/05 - 12/31/0501 SMITH, JOHN A M 00/00/1935ER: $65 PCP: $0INP: $175/$100 SCP: $35MENTAL HEALTH: CALL 1-800-XXX-XXXMEDICAL PLAN: Q4SEID:123456789 EFF: 01/01/05 - 12/31/05 PLAN: Q1IC01 SMITH, JOHN A M 00/00/196002 SMITH, JANE A F 00/00/196203 SMITH, JILL A F 00/00/198604 SMITH, JACK A M 00/00/1988PCP: $10 SCP: $10 ER: $50 UC: $25 Ded: $0/0ID:H99001234 EFF: 01/01/2014EXIT: 12/31/201401 SMITH, JOHN AVIS NER: $65* PCP: $0*INP: $175* SCP: $35*MEDICAL PLAN: I4MBPREVENTIVE DENTALSecureCareSNPMedicare Select & Supplement PlansID:123456789 EFF: 01/01/05 - 12/31/05 PLAN: Q4MT01 SMITH, JOHN A M00/00/1935This plan pays SECONDARY to Medicare. Only servicesobtained from network providers or prior authorizedservices by non-network providers are covered with theexception of emergency services.Mountain Health TrustHP ID #: H99001234 01 EFF: 01/01/2014MHT ID #: 987654321REC NAME: SMITH, JOHNPCP NAME: YOUR PCP MDPCP PHONE #: (000) 123-4567Children’s Dental < 21 yr.PCP $0 SCP $0 ER $0 UC $0You must present this ID card and your WV Medicaid ID card each time you receive benefits.This card is for identification, not proof of eligibility, and is not transferable.Access this document as well as otherHealth Plan documents underProviders at www.healthplan.org.Rev. 11/13

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN(FULLY INSURED HMO PLANS)Fully Insured HMO Plans are plans that are fully insured by a Health Insuring Corporation (HIC).Employer groups with a minimum size of two (2) employees contract with The Health Plan toprovide a health insurance benefit plan and pay a monthly premium to cover eligible employees.The Plan assumes the responsibility for providing the benefit package, administering all aspects ofthe plan, and the risk for paying for all covered services. These plans require a member to choosea Primary Care Physician (PCP), and although The Health Plan has eliminated the need for thePCP to call in a referral for specialty physician services, the member must be referred by their PCPand to follow pre-certification guidelines for procedures, diagnostic testing, outpatient surgicalprocedures, and inpatient admissions. Members do not have out-of-network benefits unlessauthorized by the plan.HMO Benefit Plans generally have co-pays for:Primary and specialty care physician office visitsEmergency room servicesUrgent careOutpatient mental healthPhysical, occupational and speech therapyDurable medical equipmentBioTech drugsMembers may have a deductible associated with their benefit plan, as well as medical co-paymentsfor laboratory and x-rays depending on the plan. Click here to see Product Matrix for sample of Member ID Card.Section 3 / Page 5

PROVIDER PROCEDURAL MANUAL 2014MEDICARE ADVANTAGE(SECURE )(FULLY INSURED MEDICARE ADVANTAGE PLAN)INTRODUCTIONThe Health Plan has entered into a contract with the Centers for Medicare & Medicaid Services(CMS), the Federal Agency that administers the Medicare Program. Under this contract, CMSmakes a monthly payment to The Health Plan for each Medicare beneficiary who enrolls in ourPlan. This contract requires The Health Plan to provide comprehensive health services to personswho are entitled to Medicare benefits and who choose to enroll in The Health Plan. The HealthPlan receives a set rate for each member plus any enrollee premium.Medicare Advantage Benefit Plans generally have co-pays for:Primary and Specialty care physician office visitsInpatient AdmissionsSkilled Nursing Home ServicesEmergency Room ServicesUrgent CareOutpatient mental health visitsPhysical, Occupational and Speech TherapyBiological DrugsDurable Medical EquipmentIn keeping with our mission, we have identified members’ rights along with their responsibilitiesthat are clearly indicated in the member's handbook. Click here to see Product Matrix for sample of Member ID Card. Click here to review SecureCare / SecureChoiceRights and Responsibilities contained in this Section.Click here for The Health Plan Web SiteSection 3 / Page 6

PROVIDER PROCEDURAL MANUAL 2014It is imperative that you be aware of these rights and responsibilities as a participatingprovider with The Health Plan. You are expected to assist our members by making themaware of their rights and by supporting these within your practice. Please refer to thissection of this manual for important information regarding CMS quality standards you arerequired to meet when caring for SecureCare enrollees. The following Member ServicesDepartments are available to assist with any member issues, which may arise:The Health Plan at 1-740-695-7907 or 1-877-847-7907HomeTown at 1-330-834-2301 or 1-877-236-2296APPEALS OVERVIEWWhen an enrollee requests coverage for a particular service, the decision on whether to providesuch coverage is considered an “ORGANIZATION DETERMINATION”. Enrollees have aright within 60 days of a denial to request either a standard (30-day) or expedited (72 hours)reconsideration whenever a Medicare Advantage organization has denied an enrollee’s requestfor services (denied claim/referral). Where the Medicare Advantage organization affirms itsadvise “Organization Determination” in whole or in part, the Medicare Advantage organizationmust automatically forward the case file to CMS’s independent review entity so that it may makea final reconsidered determination. CMS contracts with MAXIMUS Federal Service, Inc.Appeals may be made by an enrollee, a provider or by a person authorized to act on behalfof an enrollee, including the Social Security Administration office and the RailroadRetirement Beneficiary.A provider may be appointed, as an enrollee’s representative either by signing a writtenstatement or by completing a standard form. When a provider acts as the representative of abeneficiary, both the beneficiary and the provider should sign a written appointment ofrepresentative statement. This form is provided in this section for your use. The detailedappeals policy is available upon request.Section 3 / Page 7

PROVIDER PROCEDURAL MANUAL 2014APPOINTMENT OF REPRESENTATIVE STATEMENTBeneficiary NameMedicare NumberProviderDates of ServiceHealth PlanI do hereby swear that I am the above mentioned beneficiary or an authorized representative of the abovementioned beneficiary. I do hereby appoint the following individualto act as my representative in requesting a re-consideration from the Health Plan and/or the Health CareFinancing Administration or its designee regarding the services for which the health plan has deniedpayment or authorization.SignatureDateSection 3 / Page 8

PROVIDER PROCEDURAL MANUAL 2014SECURE(MEDICARE ADVANTAGE PPO PLAN)SecureChoice is The Health Plan’s Medicare Advantage Preferred-Provider Organization (PPO)option. SecureChoice members are not required to select a Primary Care Physician (PCP) andreferrals to specialists are not required. All Health Plan preauthorization requirements apply.The SecureChoice plan provides benefits at an “In Network” level from The Health Plan’sextensive network of participating providers.The SecureChoice plan also provides benefits to SecureChoice members at an “Out-of-Network”level from any Medicare provider of choice at an additional out-of-pocket expense to the member.The benefits for SecureChoice members are identical to traditional Medicare benefits in additionto enhanced benefits that are offered by The Health Plan.Please click on the links below if you would like to review more details regarding this product: Click here to see Product Matrix for sample of Member ID Card.Click here for The Health Plan Web SiteIt is imperative that you be aware of these rights and responsibilities as a participatingprovider with The Health Plan. You are expected to assist our members by making themaware of their rights and by supporting these within your practice. Please refer to thissection of this manual for important information regarding CMS quality standards you arerequired to meet when caring for SecureCare enrollees. The following Member ServicesDepartments are available to assist with any member issues, which may arise:The Health Plan at 1-740-695-7907 or 1-877-847-7907HomeTown at 1-330-834-2301 or 1-877-236-2296Section 3 / Page 9

PROVIDER PROCEDURAL MANUAL 2014APPEALS OVERVIEWWhen an enrollee requests coverage for a particular service, the decision on whether to providesuch coverage is considered an “ORGANIZATION DETERMINATION”. Enrollees have aright within 60 day of a denial to request either a standard (30-day) or expedited (72 hours)reconsideration whenever a Medicare Advantage organization has denied an enrollee’s requestfor services (denied claim/referral). Where the Medicare Advantage organization affirms itsadvise “Organization Determination” in whole or in part, the Medicare Advantage organizationmust automatically forward the case file to CMS’s independent review entity so that it may makea final reconsidered determination. CMS contracts with MAXIMUS Federal Service, Inc.Appeals may be made by an enrollee, a provider or by a person authorized to act on behalfof an enrollee, including the Social Security Administration office and the RailroadRetirement Beneficiary.A provider may be appointed, as an enrollee’s representative either by signing a writtenstatement or by completing a standard form. When a provider acts as the representative of abeneficiary, both the beneficiary and the provider should sign a written appointment ofrepresentative statement. This form is provided in this section for your use. The detailedappeals policy is available upon request.Section 3 / Page 10


PROVIDER PROCEDURAL MANUAL 2014MEDICARE ADVANTAGE PLANSPECIAL NEEDS PLAN (D-SNP PROGRAM)Effective January 1, 2014 The Health Plan will administer a Medicare Special Needs Plan forthose members who have a chronic condition. The special needs population is recipients whoqualify for both Medicare and Medicaid. These “dual eligibles” are individuals who are entitledto Medicare and are also eligible for some level of assistance from their State Medicaid program.The Health Plan received approval as a contracted MA-Pd plan that is offering a new SNPprogram by completing a Model of Care (MOC) for CMS. This approval applied to the DualEligible Special Needs Program (D-SNP).The Health Plan has developed the Model of Care (MOC) to provide comprehensive caremanagement to members enrolled in the dual eligible SNP (D-SNP). The Health Plan’s MOC is awritten document that describes the measureable goals of the program, along with The HealthPlan staff structure and care management roles, the Interdisciplinary Care Team (ICT) and the useof clinical practice guidelines and protocols, training for personnel and our providers, a healthrisk assessment tool to collect information, the development of an individualize care plan,communication efforts, care management for the most vulnerable subpopulations andperformance and health outcome measures.MEASUREABLE GOALSImprove access to essential services including medical, behavioral health and socialservices by providing a comprehensive network. Every SNP member will be assigned acase manager with social services readily available.SNP members will select a primary care physician and a Health Plan case manager willbe assigned to the member.Streamline the process of transition of care across healthcare settings, providers andhealth services coordinated by the physician / provider and the care manager.Improve access to preventive careImprove member health outcomes through participating annual HEDIS data collection aswell as member surveys.The above measureable goals are just a brief description of some of our measureable goals.PROVIDER REIMBURSEMENT AND BILLINGThe Provider will bill Health Plan for medically appropriate covered services provided to the D-SNP member. The Health Plan will reimburse the provider for services rendered according tothe member’s benefit plan, less any copays coinsurance or deductible amounts. The providerwill then be eligible to submit any balance associated with the copays, coinsurance, anddeductible directly to West Virginia or Ohio Medicaid Program.Section 3 / Page 12

PROVIDER PROCEDURAL MANUAL 2014PROVIDER EDUCATIONProvider education will be conducted by several approaches: face to face, web based training,Seminars and Provider Focus Newsletter Articles. Additional information regarding the SNP’sprogram will be forth coming.To access our Model of Care (MOC) and The D-SNP Training Module, please click on thelinks below:http://www.healthplan.org/pdf/D-SNP%20MOC_2014.pdfhttp://www.healthplan.org/pdf/SNP_TrainingforProviders.pdfTo obtain referrals or eligibility information please call our Customer Service Department at(855) 577-7127 or (740) 699-6277.Section 3 / Page 13

PROVIDER PROCEDURAL MANUAL 2014APPEALS OVERVIEWWhen an enrollee requests coverage for a particular service, the decision on whether to providesuch coverage is considered an “ORGANIZATION DETERMINATION”. Enrollees have aright within 60 day of a denial to request either a standard (30-day) or expedited (72 hours)reconsideration whenever a Medicare Advantage organization has denied an enrollee’s requestfor services (denied claim/referral). Where the Medicare Advantage organization affirms itsadvise “Organization Determination” in whole or in part, the Medicare Advantage organizationmust automatically forward the case file to CMS’s independent review entity so that it may makea final reconsidered determination. CMS contracts with MAXIMUS Federal Service, Inc.Appeals may be made by an enrollee, a provider or by a person authorized to act on behalfof an enrollee, including the Social Security Administration office and the RailroadRetirement Beneficiary.A provider may be appointed, as an enrollee’s representative either by signing a writtenstatement or by completing a standard form. When a provider acts as the representative of abeneficiary, both the beneficiary and the provider should sign a written appointment ofrepresentative statement. This form is provided in this section for your use. The detailedappeals policy is available upon request.Section 3 / Page 14


PROVIDER PROCEDURAL MANUAL 2014NOTICE OF MEDICARE NON-COVERAGE(NOMNC)When The Health Plan has, for a Medicare Advantage member, authorized coverage of aninpatient admission or the admission was an emergency or urgently needed care, the memberremains entitled to inpatient hospital care until he/she receives a Notice of Discharge andMedical Appeal Rights (NOMNC), formerly known as the Notice of Non-Coverage.Physician’s concurrence with the notice is required.A member who wishes to appeal the determination made by The Health Plan that in-patient careis no longer medically necessary must request an immediate review by the Peer ReviewOrganization (PRO) of the determination. The member must request the immediate PRO reviewby noon of the first working day after receipt of the notice. The member will not be financiallyresponsible for the hospital care until the PRO makes its decision. If the admission was notauthorized by The Health Plan or the admission did not constitute emergency or urgently neededcare and the PRO upholds The Health Plan’s determination, the member is financiallyresponsible for the hospital costs.A member who fails to request immediate PRO review may request expedited reconsideration byThe Health Plan through the Appeal Process.COORDINATION OF BENEFITSMEDICARE ADVANTAGE SECONDARY PAYERMedicare Advantage is not always the primary payer for health insurance claims. The HealthPlan will comply with CMS’s requirement to provide information pertaining to claims in whichthe Medicare Advantage is secondary.Medicare Advantage is the secondary payer where the beneficiary is entitled to Veterans benefits,workers compensation, black lung benefits, or employer group coverage based on the MedicareSecondary Payer Guidelines. Click here to see Product Matrix for sample of Member ID Card.Section 3 / Page 16

PROVIDER PROCEDURAL MANUAL 2014THP INSURANCE COMPANYMEDICARE SELECT PLANSMedicare Select Plans are plans that are fully insured by a Health Insurance Company (HIC).Medicare Beneficiaries who have Medicare as their primary insurance pay a monthly premium tocover their Medicare Deductibles and coinsurance. The Plan provides benefit packages that aredesigned by Medicare and administers all aspect of the plan in accordance with MedicareGuidelines. These plans DO NOT require a member to choose a Primary Care Physician (PCP)or obtain a referral for specialty physician services. Members must use participating providers toreceive benefits on the THP Select Plan or must obtain authorization from the plan to access outof network providers. Click here to see Product Matrix for sample of Member ID Card.Section 3 / Page 17

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN ADMINISTRATIVE SERVICES ONLY (ASO)SELF FUNDED EMPLOYER GROUPSMany employers choose to pay claims as they are incurred rather than pay a prepaid monthlypremium for their employee’s medical benefits. The Health Plan offers Administrative ServicesOnly (ASO) to assist these employers with administering their benefit plan. The Plan offersthem a contracted network of providers, utilization management services and claims processing.These plans are most often designed by the employer group and administered by the plan’sAllied Service Division or HomeTown Administrative Management Services (AMS) These plansare most often designed by the employer group and benefits, co-pays, deductibles and ID cardsmay vary from the standard insured plans offered by the Health Plan.ID cards may vary from group to group. Click here to see Section 4 of this manual for more information.Section 3 / Page 18

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLANMOUNTAIN HEALTH TRUSTWEST VIRGINIA MEDICAID PROGRAMMountain Health Trust is a fully insured managed care plan offered to Medicaid Eligibleresidents of West Virginia. The plan requires a member to select a Primary Care Physician(PCP), obtain a referral for specialty physician services and to follow precertification guidelinesfor procedures, diagnostic testing, outpatient surgical procedures, and inpatient admissions.Members do not have out-of network benefits unless prior authorized by the Plan.Under the West Virginia Mountain Health Trust Program the State determines eligibility andenrollment is through Automated Health Systems, a broker hired by State of West Virginiafor enrollment services. Once the member selects Health Plan, the plan is notified electronicallyof enrollment. At that time, a packet of information is sent along with their Health Plan ID card.The Mountain Health Trust member will have (2) cards. The Health Plan ID card, as well as theWest Virginia Medicaid card, issued and sent monthly showing eligibility for the month.The Health Plan will not reissue their Health Plan ID card each month with the exception of areplacement ID card for a lost or misplaced ID card.The date appearing on the Health Plan ID Card is the actual date the card printed and not theeffective date of coverage. The effective date of coverage is always the first of the month exceptfor a newborn.You may contact The Health Plan Customer Service Department at (740) 695-7904or (888) 613-8385 to check eligibility or should you have any question regarding MountainHealth Trust Program.Eligibility, benefits and claims status is available through our Provider Secured Website. Click here to see Product Matrix for sample of Member ID Card. Click here to see Section 5 of this manual for more specific information related toThe Mountain Health Trust Plan.Section 3 / Page 19

PROVIDER PROCEDURAL MANUAL 2014THP INSURANCE COMPANYFULLY INSURED POINT OF SERVICE PLANS (POS)Fully Insured (POS) Plans are plans that are fully insured by a Health Insuring Corporation (HIC).Employer groups with a minimum size of two (2) employees contract with The Health Plan toprovide a health insurance benefit plan and pay a monthly premium to cover eligible employees.Fully insured (POS) Plans are designed to allow members the freedom to choose between havingtheir health care managed or arranged by their PCP as (In-Plan Option) or the member has theoption to manage and arrange their care as an (Out-of-Plan Option). The Plan provides thebenefit package giving the employer the option to choose from a variety of deductibles and copayplans. These plans require a member to choose a Primary Care Physician (PCP), obtain areferral for specialty physician services and to follow precertification guidelines for procedures,diagnostic testing, outpatient surgical procedures and inpatient admissions.Members have Out-of-Plan Option benefits and may choose to access services outside TheHealth Plan Network at an increase in their out of pocket expense for deductibles, co-pays andco-insurance amounts.POS Benefit Plans generally have co-pays for:Primary and Specialty Care Physician Office VisitsEmergency Room ServicesUrgent CareOutpatient Mental HealthPhysical, Occupational, and Speech TherapyDurable Medical EquipmentBiotech DrugsAdditionally, members are responsible for deductibles and coinsurance amounts associated withtheir plan benefit. Click here to see Product Matrix for sample of Member ID Card.Section 3 / Page 20

PROVIDER PROCEDURAL MANUAL 2014THP INSURANCE COMPANYFULLY INSURED PPO PLANSFully Insured PPO Plans are fully insured by a Health Insuring Corporation (HIC).Employers contract with Health Plan to provide a health insurance benefit plan and pre-pay amonthly premium to cover eligible employees. Members who are covered under the PPO Plangenerally are not required to select a Primary Care Physician (PCP) or obtain a referral forspecialty physician services. All pre-authorization guidelines for procedures, diagnostictesting, outpatient surgical procedures and in-patient admission apply. By utilizing The HealthPlan In-Plan or Tertiary network members receive a higher level of benefits. Members whoutilize out of network providers or fail to pre-authorize a service will have increased out ofpocket expenses for deductibles, co-pays and coinsurance amounts.PPO Benefit Plans generally have co-pays for:Primary and Specialty Care Physician Office VisitsEmergency Room ServicesUrgent CareOutpatient Mental Health BenefitsPhysical, Occupational, and Speech TherapyDurable Medical EquipmentBiotech DrugsAdditionally, members are responsible for deductibles and coinsurance amounts associated withtheir benefit plan. Click here to see Product Matrix for sample of Member ID Card.Section 3 / Page 21

PROVIDER PROCEDURAL MANUAL 2014PRESCRIPTION DRUG RIDERSHealth Plan member, may obtain their prescription drugs at any participating Health PlanPharmacy. A list of Health Plan Pharmacies is provided to the member at the time of theirenrollment or upon renewal of coverage.To fill prescriptions, Members need only to present their Health Plan Pharmacy ID card to thepharmacist showing prescription benefits. They will be required to pay a co-pay at the time ofservice based their prescription drug benefits. The members ID card will give the variation oftheir co-pay.A qualified generic prescription is an order for a drug that is available from multiple sources.A qualified brand prescription must be available only from a single source supplier of theparticular drug.Prescriptions must not be subject to any exclusions or limitations as outlined in the Exclusionsand Limitations Section below.What is coveredThe Health Plan covers "legend prescription drugs" and medications only if such drugs arepurchased at a participating Health Plan pharmacy and are prescribed by a participating HealthPlan physician. Each prescription may be dispensed up to a 31-day supply.“Legend prescription drugs" are those drugs which by Federal Law can be dispensed onlypursuant to a prescription and which are required to bear the legend "Caution: Federal Lawprohibits dispensing without a prescription.”Out-of-Area EmergenciesIn situations of emergency need for a prescription outside The Health Plan Service Area,please contact Pharmacy Benefits for the location of a participating pharmacy in that area at(Medco Health) (800) 988-2262. Present your Health Plan Identification Card with theemergency prescription and pay your co-pay. If no pharmacy in the area participates, you mustpurchase the emergency prescription then send your receipt to The Health Plan. You will bereimbursed in full, less your applicable co-pay, for the prescription provided the prescriptionmeets the guidelines specified in this document.Section 3 / Page 22

PROVIDER PROCEDURAL MANUAL 2014Exclusions and LimitationsThe following will not be covered or paid for by The Health Plan.1. The charge for any prescription refill other than the number set by the prescriber.No refills dispensed more than one year from the date of the original prescription.2. The charge for any prescription oral, topical or injectable that is prescribed forcosmetic purposes.3. The charge for any medications not FDA approved for use in the general population.Use of a FDA approved drug in the treatment of a non-FDA-approved indication.4. The charge for a drug not prescribed by a Health Plan participating provider except in trueemergency/urgent situations.5. The charge for any medication covered by any Workers' Compensation or occupationaldisease laws, any other group policy or government program that is not The HealthPlan's program.6. Vitamins, nutritional products or supplements. Prenatal vitamins are covered whenrelated to a pregnancy only.7. Dental related prescriptions such as, but not limited to, dental mouthwashes or devicesused in dental therapy. Oral fluorides will be covered provided they meet preventivemedication guidelines8. Prescriptions or some over the counter products related to smoking cessation are coveredproviding they meet preventive medication guidelines.9. Prescription for drugs or devices used to promote weight loss.10. Prescription used to treat sexual dysfunction (oral, topical or injectable) or devices usedfor impotence.11. Prescription drugs (oral, topical or injectable) for fertility, unless medically necessary.12. Appliances and therapeutic devices which require a prescription are not covered.These include, but are not limited to, garments, splints, bandages or braces regardless ofintended use.13. Over the counter aspirin, iron supplements and folic acid are covered providing they meetpreventive medication guidelines.Insurance Fraud Warning: “Any person who, with intent to defraud or knowing that he isfacilitating a fraud against an insurer, submits an application or files a claim containing a falseor deceptive statement is guilty of insurance fraud”.Section 3 / Page 23

PROVIDER PROCEDURAL MANUAL 2014THE HEALTH PLANVISION SERVICE BENEFITVision Examination - A complete analysis of the eyes and related structures to determine thepresence of vision problems.• Lenses - The VSP Panel Doctor will order the proper lenses. The program providesthe finest quality lenses fabricated to exacting standards. The doctor also verifies theaccuracy of the finished lenses.• Frames - The plan offers a wide selection of frames; however, if you select a framewhich costs more than the amount allowed by your plan (or a large frame thatrequires oversize lenses) there will be an additional charge.Necessary Contact lenses - Contact lenses and the necessary ophthalmic materials are coveredunder this Vision Service Plan when a VSP Panel Doctor receives prior approval for one of thefollowing conditions:a) Following cataract surgeryb) To correct extreme visual acuity problems not correctable with spectacle lensesc) To correct for significant anisometropiad) KeratoconusCosmetic (Elective) Contact Lenses - When contact lenses are chosen for reasons other than theabove, they are considered cosmetic in nature. An allowance of $100.00 will be made towardtheir cost in place of all other benefits (exam, lenses and frames) for the benefit period.I. How Often Are These Services Available?Examination - Once every 12 monthsLenses - Once every 24 monthsFrames - Once every 24 months... orContact Lenses - (In place of all other plan benefits for the benefit period).Necessary - Once every 24 monthsCosmetic - Once every 24 monthsII.How Much Do I Pay?When you obtain services from a VSP Panel Doctor, this plan covers the benefits describedherein (examination, professional services, lenses and frames).Any additional care, services and/or materials not covered by this plan may be arranged betweenyou and the doctor.Section 3 / Page 24

PROVIDER PROCEDURAL MANUAL 2014III.How Do I Use This Plan?In order to access vision care benefits, simply contact your VSP member doctor to makean appointment.When calling for your appointment, identify yourself as a VSP / Health Plan patient and giveyour Health Plan Identification Number. Your VSP doctor will obtain the necessaryauthorization and information about your eligibility and coverage.In order for services to be covered by this plan, services must be received from a panel doctor inthe Health Plan Service Area.IV.Who Is Eligible?Eligibility for and the termination of benefits under this Vision Service Plan will be determinedby the same rules that apply to your other health benefits.Questions regarding eligibility should be directed to your employer.V. What Vision Services And Materials Are Limited Or Not Covered Under This Plan?Extra Cost - This plan is designed to cover your visual needs rather than cosmetic materials.There will be extra cost involved if you select materials or services that are cosmetic in nature,for example:a) Blended or Progressive Lenses.b) Oversize Lenses.c) A frame that costs more than theplan allowance.d) Two pair of glasses in placeof bifocals.e) Cosmetic Contact Lenses(In excess of the plan allowance).f) Tinted or Coated Lenses(Other than solid pink #1 or #2).g) Any other materials or services notnecessary for the patient's visual welfare.Not Covered Items - There are no benefits for professional services or materials connected with:1) Orthoptics, vision training, ornon-prescription lenses.2) Lenses and frames furnished under thisprogram which are lost or broken.These will not be replaced unless you areeligible for frames or lenses at that time.3) Medical or surgical treatment of the eyes.4) Services or materials provided becauseof any Workers' Compensation Law orsimilar legislation.5) Any eye examination required by anemployer as a condition of employment; orany services or materials provided by anyother vision care plan, or group benefitplan containing benefits for vision care.Bi g for Medical Eye Exams with a Vision ScreeningVision Service Plan • Monday – Friday 8 a.m. to 11 p.m. • Saturday 9 a.m. to 8 p.m. • 800.877.7195For assistance with translation, hearing impaired callers may call 800.428.4833www.vsp.comSection 3 / Page 25

PROVIDER PROCEDURAL MANUAL 2014Bi g for Medical Eye Exams with a Vision ScreeningIn most situations a Vision Screening (CPT 92015 - Determination of Refractive State) isconsidered non-covered under a medical benefit plan, but is often covered by a Vision BenefitPlan. When there is the need to provide a Vision Screening as part of a Medical Exam thefollowing billing guidelines will assist you in obtaining appropriate reimbursement for the visionscreening if there is a benefit that is available through The Health Plan’s Vision Benefit Vendors,Vision Service Plan (Commercial and Medicare Advantage) and Block Vision (West VirginiaMedicaid) provided you are a participating provider with Vision Service Plan or Block Vision.Bi g ProceduresThe visit is billed to The Health Plan on the appropriate CMS 1500 form with the following codes:92002, 92004, 92012, or 92014 Eye Exam, New or Established Patient92015 VS Determination of Refractive StateAfter The Health Plan has made payment for the exam and denied the Refraction as non-covered,you can then submit the visit code and the 92015 -Determination of Refraction State to VSP orBlock Vision, as long as you are a contracted provider, for payment of the Refraction.You must include our payment voucher (with the page that shows the explanation of the denialcodes) when submitting to VSP or Block Vision for the remaining portion.VSP and Block Vision will coordinate benefits with The Health Plan and pay only the refractionwhich is still due when a benefit is available to cover the refraction. If the member has a visionbenefit through some other plan that is not associated with The Health Plan, you may also submita claim for the refraction to that plan in the same manner and they will adjudicate the claimaccording to their plan guidelines.The Health Plan encourages our diabetic members to see an In-Plan Ophthalmologist orOptometrist for an annual dilated retinal exam (Excludes Self-Funded ASO Participants).If a 92015 - Determination of Refractive State is also done during the visit, the followingbilling procedures apply (Please include Diabetic Dilated Fundus Examination Form found inSection 8 of Practitioner Procedural Manual): Without a referral and with a waiver of the associated office co-payment.Determination of Refraction State to VSP, as long as you are a VSP contracted provider,for payment of the Refraction. If the member is a Mountain Health Trust or Mountain HealthChoices member you submit the 92015 to Block Vision. You must include our paymentvoucher when submitting to VSP or Block Vision for the remaining portion. VSP willcoordinate benefits with The Health Plan and pay only the refraction which is still due.Section 3 / Page 26

PROVIDER PROCEDURAL MANUAL 2014PAGE: 1 Health Plan Upper Ohio Valley12/07/2011PROVIDER REIMBURSEMENT VOUCHEREYE CARE SPECIALIST NAME PROVIDER NO: QG00000 TAX ID: 000000000(000000)CLAIMS PAID *** COMMERCIAL *** CHECK NUMBER: 888888CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJDATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEEDSCNT CD201120112011 155555-55 H01010101 00 SUNSHINE, SALLY A Q111111 1111111111 JANE A. DOE OD11/04/2011 92004 1 165.00 147.69 17.31 15.00 .00 .00 .00 .00 132.69 .00 .00 L11/04/2011 92015 1 32.00 .00 .00 .00 .00 00 32.00 .00 .00 .00 .00 NV___________________________________________________________________________________________________________________________________TOTAL 1 197.02 179.69 17.33 15.00 .00 .00 32.00 .00 132.69 .00 .00***Could also be denied VS.*** (see below)PAGE: 6 Health Plan Upper Ohio Valley12/07/2011PROVIDER REIMBURSEMENT VOUCHEREYE CARE SPECIALIST NAME PROVIDER NO: QG00000 TAX ID: 000000000(000000)ADJUSTMENT CODE DESCRIPTIONL = BILLED AMOUNT EXCEEDS THE MAXIMUM ALLOWABLENV = VISUAL SERVICES ARE A NON-COVERED BENEFIT - PATIENT RESPONSIBLE[We deny NV when our member does NOT have vision coverage through The Health Plan; however, ifmember does have vision coverage through another carrier, please bill that carrier for this service.]RZ = THE PAYMENT OF THIS SERVICE IS INCLUDED IN ANOTHER SERVICE RECEIVED - MEMBER NOTRESPONSIBLEVS = VISUAL SERVICES - SUBMIT TO VSP[We us VS when our member DOES have vision coverage through The Health Plan. Please bill VSP forthis service.]ADJUSTMENT CODE DESCRIPTION# = CLAIM HAS CLEARED PROCESSING EDITS109 = Claim not covered by this payer/contractor. You must send the claim to thecorrect payer/contractor.204 = This service/equipment/drug is not covered under the patients current benefitplan97 = Payment is included in the allowance for another service/procedure.3 = Co-payment Amount45 = Charges exceed your contracted/ legislated fee arrangement.N418N538= Misrouted claim. See the payers claim submission instructions.= A facility is responsible for payment to outside providers who furnishthese services/supplies/drugs to its patients/residents.Section 3 / Page 27

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Members' Rights and Responsibilities StatementStatement of Members' RightsMembers have the rights to receive informationregarding the Plan. Information such as asummary of the Plan’s accreditation report and thePlan’s: services, policies, benefits, limitations,practitioners, and providers. Members have theright to information on member’s rights andresponsibilities and any charges they may beresponsible for. Members have the right to obtainevidence of medical credentials of a Plan Provider,(i.e. diplomas and board certifications). If amember needs assistance with any of the above,they may contact the Plan’s Customer ServiceDepartmentat1-888-847-7902 or (740) 695-7902.Members can expect to receive courteous andpersonal attention and to be treated with dignity.Plan employees, providers, and their staff willrespect members’ privacy.All information concerning a Health Plan member’smedical history and enrollment file is confidential.The member has a right to approve or refuse therelease of personal information by The HealthPlan except when the release is required by law.The Health Plan assures that all patientinformation is held in the strictest confidence. AllHealth Plan staff must adhere to the Health PlanConfidentiality Policy revised and adopted inNovember 1993. This statement acknowledgesthe confidential nature of the review work, includesan agreement to honor that confidentiality, anddocuments the consequences of failing to do so.The member’s personal choice of a primary carephysician enables the member to participate in themanagement of his/her total health care needs,including the right to refuse care from a specificpractitioner. Health Plan members are encouragedto establish a relationship with their chosen PCP sothat they can work together to maintain good health.A Health Plan member may change physicians onceper calendar month if so desired (depending uponthe availability of the chosen physician).Statement of Members' ResponsibilitiesA member must choose a Primary CarePhysician (“PCP”) for each person listed onthe Health Plan ID card. The member has aresponsibility to maintain a relationship with aPCP, as the PCP will act as the coordinatorfor all of his/her health care needs.A member must identify him/herself as aHealth Plan member to avoid unnecessaryerrors; always carry their ID cards; and neverpermit anyone else to use their ID card.A member is asked, through “Outreach”calls to new members, to read theirMember Handbook and understand thebenefits and procedures for receiving healthcare services. To assure maximumcoverage, the member has a responsibilityto follow the rules and to contact TheHealth Plan for assistance, if necessary.A member is required to notify The HealthPlan of any changes in the following:1. Name, Address, Telephone Number.2. Number of Dependents(Marriage, Divorce, Newborns, etc.)3. Loss of an Identification Card.4. Selection of a Primary Care Physician.Members are asked to be on time forappointments and to call the physician’soffice promptly if appointment can’t be kept.Members must provide necessaryinformation to the providers rendering care.Such information is necessary for theproper diagnosis and/or treatment ofpotential or existing conditions.Understand your health problems andparticipate in developing mutually agreedupon treatment goals, to the degreepossible, and follow those instructions andguidelines given by those providers whodeliver health care services.If members receive emergency careoutside The Health Plan’s service area,they are required to contact The HealthPlan as soon as possible with 48 hours.Section 3 / Page 28

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Members' Rights and Responsibilities StatementStatement of Members' RightsHealth Plan members have the right to expresstheir comments, opinions or complaints about TheHealth Plan or the care provided and to file agrievance for an administrative or medicalcomplaint and hearing procedures without reprisalfrom The Health Plan. Members also have theright to have coverage denials reviewed by theappropriate medical professionals consistent withThe Health Plan review procedures. Both informaland formal steps are available to Health Planmembers to resolve all complaints/grievances.Health Plan members may participate in decisionmakingabout their health care when possible andwithin the Plan guidelines. Members have a rightto discuss with providers, without limitations orrestrictions being placed upon the providers,appropriate or medically necessary treatmentoptions for their condition(s) regardless of cost orbenefit coverage. However, this does not expandcoverage by the Plan. Members also have theright to formulate Advance Directives.Health Plan members have the right to have ameaningful voice in the organization by expressingtheir suggestions & comments regarding theirHealth Plan coverage, policies, Members’ Rights &Responsibilities, and operations. Member’scomments and opinions are received by TheHealth Plan through yearly member satisfactionsurveys, telephone calls from our members, bye-mail to: information@healthplan.org, by InternetWeb Page: www.healthplan.org (under “MemberServices” – “Comments & Feedback”), and canalso be placed in our “Member’s Suggestion Box”located in The Health Plan lobby. Member’scomments/opinions are also received throughvarious Health Plan Departments.Members have the right to full disclosure, from theirhealth care provider, of any information relating totheir medical condition or treatment plan.Members have the right to examine and offercorrections to their own medical records, inaccordance with applicable federal and state laws.The Plan will not release personal healthinformation to an employer, or its designee, withouta signed Plan Authorization Form by the member.For information on obtaining medical records,contact The Health Plan Customer ServiceDepartment at (888) 847-7902 or (740) 695-7902.Statement of Members' ResponsibilitiesMembers must contact their Primary CarePhysician, Secondary Care Physician orOB/GYN before seeking any specialtyphysician/service.Members must provide The Health Planwith all relevant, correct information andpay The Health Plan any money owedaccording to coordination of benefits orsubrogation policies.Members must make required co-paymentsunder the “Schedule of Benefits”.Members are asked to be courteous andrespectful of Health Plan employees,providers, and their staff.Section 3 / Page 29

PROVIDER PROCEDURAL MANUAL 2014SecureCare / SecureChoiceRights and ResponsibilitiesIntroduction to your rights and protectionsSince you have Medicare, you have certain rights to help protect you. In this section, we explain yourMedicare rights and protections as a member of our Plan and we explain what you can do if you thinkyou are being treated unfairly or your rights are not being respected.Your right to be treated with dignity, respect, and fairnessYou have the right to be treated with dignity, respect, and fairness at all times. Our Plan must obeylaws that protect you from discrimination or unfair treatment. We don’t discriminate based on aperson’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or nationalorigin. If you need help with communication, such as help from a language interpreter, please callMember Services. Member Services can also help if you need to file a complaint about access (suchas wheel chair access). You may also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD1-800-537-7697, or your local Office for Civil Rights.Your right to the privacy of your medical records and personal health informationThere are federal and state laws that protect the privacy of your medical records and personal healthinformation. We protect your personal health information under these laws. Any personal informationthat you give us when you enroll in this plan is protected. We will make sure that unauthorized peopledon’t see or change your records. Generally, we must get written permission from you (or fromsomeone you have given legal power to make decisions for you) before we can give your healthinformation to anyone who isn’t providing your care or paying for your care. There are exceptionsallowed or required by law, such as release of health information to government agencies that arechecking on quality of care. The Plan will release your information, including your prescription drugevent data, to Medicare, which may release it for research and other purposes that follow allapplicable Federal statutes and regulations.The laws that protect your privacy give you rights related to getting information and controlling howyour health information is used. We are required to provide you with a notice that tells about theserights and explains how we protect the privacy of your health information. You have the right to look atmedical records held at the Plan, and to get a copy of your records (there may be a fee charged formaking copies). You also have the right to ask us to make additions or corrections to your medicalrecords (if you ask us to do this, we will review your request and figure out whether the changes areappropriate). You have the right to know how your health information has been given out and used fornon-routine purposes. If you have questions or concerns about privacy of your personal informationand medical records, please call Member Services.Section 3 / Page 30

PROVIDER PROCEDURAL MANUAL 2014SecureCare / SecureChoiceRights and ResponsibilitiesYour right to see network providers, get covered services, and get yourprescriptions filled within a reasonable period of timeAs explained in this booklet, you will get most or all of your care from network providers, that is, fromdoctors and other health providers who are part of our Plan. You have the right to choose a networkprovider (we will tell you which doctors are accepting new patients). You have the right to go to awomen’s health specialist (such as a gynecologist) without a referral. You have the right to timelyaccess to your providers and to see specialists when care from a specialist is needed. “Timely access”means that you can get appointments and services within a reasonable amount of time.You have the right to timely access to your prescriptions at any network pharmacyYour right to know your treatment options and participate in decisions aboutyour health careYou have the right to get full information from your providers when you go for medical care, and theright to participate fully in decisions about your health care. Your providers must explain things in away that you can understand. Your rights include knowing about all of the treatment options that arerecommended for your condition, no matter what they cost or whether they are covered by our Plan.This includes the right to know about the different Medication Therapy Management Programs weoffer and in which you may participate. You have the right to be told about any risks involved in yourcare. You must be told in advance if any proposed medical care or treatment is part of a researchexperiment, and be given the choice of refusing experimental treatments.You have the right to receive a detailed explanation from us if you believe that a provider has deniedcare that you believe you were entitled to receive or care you believe you should continue to receive.In these cases, you must request an initial decision called an organization determination or a coveragedetermination. Organization determinations and coverage determinations are discussed in Section 5.You have the right to refuse treatment. This includes the right to leave a hospital or other medicalfacility, even if your doctor advises you not to leave. This includes the right to stop taking yourmedication. If you refuse treatment, you accept responsibility for what happens as a result of yourrefusing treatment.Section 3 / Page 31

PROVIDER PROCEDURAL MANUAL 2014SecureCare / SecureChoiceRights and ResponsibilitiesYour right to use advance directives (such as a living will or a power of attorney)You have the right to ask someone such as a family member or friend to help you with decisions aboutyour health care. Sometimes, people become unable to make health care decisions for themselvesdue to accidents or serious illness. If you want to, you can use a special form to give someone thelegal authority to make decisions for you if you ever become unable to make decisions for yourself.You also have the right to give your doctors written instructions about how you want them to handleyour medical care if you become unable to make decisions for yourself.The legal documents that you can use to give your directions in advance in these situations are called“advance directives”. There are different types of advance directives and different names for them.Documents called “living will” and “power of attorney for health care” are examples of advance directives.If you want to have an advance directive, you can get a form from your lawyer, from a social worker, orfrom some office supply stores. You can sometimes get advance directive forms from organizationsthat give people information about Medicare. Regardless of where you get this form, keep in mind thatit is a legal document. You should consider having a lawyer help you prepare it. It is important to signthis form and keep a copy at home. You should give a copy of the form to your doctor and to theperson you name on the form as the one to make decisions for you if you can’t. You may want to givecopies to close friends or family members as well.If you know ahead of time that you are going to be hospitalized, and you have signed an advancedirective, take a copy with you to the hospital. If you are admitted to the hospital, they will ask youwhether you have signed an advance directive form and whether you have it with you. If you have notsigned an advance directive form, the hospital has forms available and will ask if you want to sign one.Remember, it is your choice whether you want to fill out an advance directive (including whether youwant to sign one if you are in the hospital). According to law, no one can deny you care ordiscriminate against you based on whether or not you have signed an advance directive. If you havesigned an advance directive, and you believe that a doctor or hospital hasn’t followed the instructionsin it, you may file a complaint with the Probate Court in the county in which you reside.Section 3 / Page 32

PROVIDER PROCEDURAL MANUAL 2014SecureCare / SecureChoiceRights and ResponsibilitiesYour right to get information about our PlanYou have the right to get information from us about our Plan. This includes information about ourfinancial condition, and how our Plan compares to other health plans. To get any of this information,call Member Services.Your right to get information in other formatsYou have the right to get your questions answered. Our plan must have individuals and translationservices available to answer questions from non-English speaking beneficiaries, and must provideinformation about our benefits that is accessible and appropriate for persons eligible for Medicarebecause of disability. If you have difficulty obtaining information from your plan based on language ora disability, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.Your right to get information about our network pharmacies and/or providersYou have the right to get information from us about our network pharmacies, providers and theirqualifications and how we pay our doctors. To get this information, call Member Services.Your right to get information about your prescription drugs, Part C medical careor services, and costsYou have the right to an explanation from us about any prescription drugs or Part C medical care orservice not covered by our Plan. We must tell you in writing why we will not pay for or approve aprescription drug or Part C medical care or service, and how you can file an appeal to ask us tochange this decision. See Section 5 for more information about filing an appeal. You also have theright to this explanation even if you obtain the prescription drug, or Part C medical care or service froma pharmacy and/or provider not affiliated with our organization. You also have the right to receive anexplanation from us about any utilization-management requirements, such as step therapy or priorauthorization, which may apply to your plan. Please review our formulary website or call MemberServices for more information.Section 3 / Page 33

PROVIDER PROCEDURAL MANUAL 2014SecureCare / SecureChoiceRights and ResponsibilitiesYour right to make complaintsYou have the right to make a complaint if you have concerns or problems related to your coverage orcare. See Section 4 and Section 5 for more information about complaints. If you make a complaint,we must treat you fairly (i.e., not discriminate against you) because you made a complaint. You havethe right to get a summary of information about the appeals and grievances that members have filedagainst The Health Plan in the past. To get this information, call Member Services.How to get more information about your rightsIf you have questions or concerns about your rights and protections, You can:1. Call Member Services at the number on the cover of this booklet.2. You can also get free help and information from your State Health InsuranceAssistance Program (SHIP). Contact information for your SHIP is in Section 8 of thisbooklet.3. Visit www.medicare.gov to view or download the publication“Your Medicare Rights and Protections”.4. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.What can you do if you think you have been treated unfairly or your rights are notbeing respected?If you think you have been treated unfairly or your rights have not been respected, you may callMember Services or:• If you think you have been treated unfairly due to your race, color, national origin,disability, age, or religion, you can call the Office for Civil Rights at 1 -800-368-1019 orTTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.• If you have any other kind of concern or problem related to your Medicare rights andprotections described in this section, you can also get help from your SHIP.Section 3 / Page 34

PROVIDER PROCEDURAL MANUAL 2014SecureCare / SecureChoiceRights and ResponsibilitiesYour responsibilities as a member of our Plan include:• Getting familiar with your coverage and the rules you must follow to get care as a member.You can use this booklet to learn about your coverage, what you have to pay, and the rulesyou need to follow. Call Member Services if you have questions.• Using all of your insurance coverage. If you have additional health insurance coverage orprescription drug coverage besides our Plan, it is important that you use your other coveragein combination with your coverage as a member of our Plan to pay your health care orprescription drug expenses. This is called “coordination of benefits” because it involvescoordinating all of the health or drug benefits that are available to you .• You are required to tell our Plan if you have additional health insurance or drugcoverage. Call Member Services.• Notifying providers when seeking care (unless it is an emergency) that you are enrolled in ourPlan and you must present your plan membership card to the provider.• Giving your doctor and other providers the information they need to care for you, andfollowing the treatment plans and instructions that you and your doctors agree upon. Be sureto ask your doctors and other providers if you have any questions and have them explain yourtreatment in a way you can understand.• Acting in a way that supports the care given to other patients and helps the smooth running ofyour doctor’s office, hospitals, and other offices.• Paying your plan premiums and coinsurance or co-payment for your covered services. Youmust pay for services that aren’t covered.• Notifying us if you move. If you move within our service area, we need to keep yourmembership record up-to-date. If you move outside of our plan service area, you cannotremain a member of our plan, but we can let you know if we have a plan in that area .• Letting us know if you have any questions, concerns, problems, or suggestions. If you do,please call Member Services.Section 3 / Page 35

PROVIDER PROCEDURAL MANUAL 2014MISSION STATEMENTThe Health Plan developed the following mission statement to reflect our view of the role ofour program.“In its mission to provide a comprehensive delivery of health careservices, The Health Plan strives to protect the patient's right to obtainservices in a cost efficient and quality system where patient dignity andsatisfaction are enhanced by the services of The Health Plan and itsprovider network.”Section 3 / Page 36

PROVIDER PROCEDURAL MANUAL 2014THE HEALTH PLANMANAGED WORKERS’COMPENSATION PROGRAMSection 3 / Page 37

PROVIDER PROCEDURAL MANUAL 2014THE HEALTH PLANMANAGED WORKERS' COMPENSATION PROGRAMIn 1993, the Ohio General Assembly passed House Bill 107. This reform legislationinitiated many changes in the Ohio Bureau of Worker’s Compensation (BWC) Programand mandated that the BWC develop a managed care system. The HealthPartnership Program (HPP) was developed, and HPP required that all state fundemployers utilize a Managed Care Organization (MCO) for the medical managementof their workers' compensation claims.The Health Plan Managed Workers’ Compensation Program an Ohio BWC CertifiedMCO and URAC Accredited care management organization medically managesworkers’ compensation claims for state funded employer groups and six (6) selfinsuredemployers. MCO’s ensure that the claimant receives appropriate and timelymedical treatment focusing on a safe return to work. We are responsible for assistingclaimants in obtaining quality medical care while assisting the employers in controllingworkers’ compensation costs.The Health Plan employs full time RN Case Managers who work in conjunction withsupport staff to provide quality medical management services to claimants, employersand provider offices.Compensability (allowance) determination rests solely with the Ohio BWC.Reporting RequirementsThe provider is responsible for reporting all injuries to the MCO utilizing the Ohio BWCFROI 1 accompanied by supporting medical documentation within 24 hours of treatment.Methods of reporting:Faxing: 1-877-847-6927Mailing:Online:Online:THE HEALTH PLAN MANAGED WORKERS COMPENSATION PROGRAMPO BOX 97SAINT CLAIRSVILLE OH 43950-0097www.ohiobwc.comwww.healthplanmwcp.comThe Ohio BWC will assign a claim number. The Ohio BWC will notify the provider of theclaim number. The Health Plan has distributed identification cards identifying TheHealth Plan as the MCO for the employer group.Section 3 / Page 38

PROVIDER PROCEDURAL MANUAL 2014Medical Management and Treatment60 Day Presumptive Authorization GuidelinesEffective January 1, 2001, BWC implemented a pilot program giving providerspresumptive authorization to provide specific medical services without waiting forprior authorization from the MCO. For dates of injury on or after November 1, 2002,presumptive approval to provide services were extended from 45 days from the date ofinjury to 60 days. The MCO shall adhere to the presumptive approval guidelines.For a period not to exceed 60 days following the date of injury, physicians havepresumptive approval to provide certain services when treating soft tissue andmusculoskeletal injuries that are allowed conditions in a claim. Following are theservices you can provide:Up to 10 physical medicine visits, including osteopathic, chiropractic,physical therapy and occupational therapy performed by a providerlicensed to provide such services.Diagnostic studies, including x-rays, CAT scans, MRI scans, andEMG/NCV.Up to three soft tissue or joint injections involving the joints of theextremities (shoulder including AC joint, elbow, wrist, finger, hip, knee,ankle and foot including toes) and up to 3 Trigger Point Injections.INJECTIONS OF THE PARASPINAL REGION INCLUDING ESI,FACET AND SI ARE NOT INCLUDED.E/M services and consultation services.You must complete the following before you initiate any or all of the aforementioned services:File the First Report of Injury (FROI) with the MCO.The MCO may use disclaimer language when the claim is not yet inallowed status.Complete and file the Physician’s Report / Treatment Plan for IndustrialInjury or Occupational Disease (C-9) with the MCO.Notify the MCO within 24 hours of treatment if the injured worker willbe off work for more than two calendar days.You will still report injuries and provide written medical treatment plans to the MCO formedical management. In addition, you agree to notify the MCO within 24 hours if theinjured worker will be off work for more than two calendar days. Except for emergencyservices, the services listed in the MCO Standardized Prior Authorization Table that do notfall within the Presumptive Approval parameters still require prior authorization. You mustsubmit a C9 to request formal authorization.Section 3 / Page 39

PROVIDER PROCEDURAL MANUAL 2014Medical Management and TreatmentWhy has BWC adopted the presumptive authorization policy?This change allows you to aggressively treat injured workers who suffer the mostcommon work-related injuries — soft tissue and musculoskeletal injuries. This newpolicy supports BWC’s Health Partnership Program’s goals of early and safe return towork with new emphasis on remain at work and transitional work initiatives.What are soft tissue and musculoskeletal injuries?They are injuries, such as sprains, strains, superficial injuries, and contusions, per theInternational Classification of Diseases (ICD-9-CM) book.Are there any limitations or non-covered procedures for diagnostic studies underpresumptive authorization?Medical necessity for the allowed conditions is always the driver for services. Surgicaldiagnostics, such as arthroscopic procedures, are not included, unless it is an emergency.What are the benefits of the presumptive authorization program?By eliminating wait time for authorizations, you can immediately schedule diagnostictesting and other procedures covered under the presumptive authorization policy at thetime of the office visit. Quicker treatment means faster recovery, lower disability costs,and injured workers returning to gainful employment.Will MCO case managers advise providers when they identify procedures that donot appear to be medically necessary?Yes, but as long as providers follow commonly accepted treatment guidelines whentreating the allowed conditions in a claim, the bill will be paid.Does presumptive authorization apply to treatments provided within the first 60days or requested within the first 60 days and provided later?The presumptive approval guidelines apply to services provided within 60 days from thedate of injury.Where can I get more information on presumptive authorization?For more information on presumptive authorization, call 1-800-OHIOBWC or the localcustomer service office.Section 3 / Page 40

PROVIDER PROCEDURAL MANUAL 2014Standardized Prior Authorization TableMedical Management and TreatmentThe MCO’s and Ohio BWC collaborated in the development and implementationof a Standardized Prior Authorization Table. The procedures included in theStandardized Prior Authorization Table require prior authorization that can be obtained bysubmitting a BWC Form C9, “Physician’s Request for Medical Service or Recommendationfor Additional Conditions for Industrial Injury or Occupational Disease” to the assignedMCO. Please refer to the attached Updated Standardized Prior Authorization Table.The claimant may only have one Physician of Record (POR). The POR must be OhioBWC certified if providing ongoing treatment to claimants with dates of injury 03-01-97and beyond. A non-BWC certified provider can provide initial treatment to anyclaimant; however, an Ohio BWC certified provider must provide subsequent treatment.If the claimant chooses to receive treatment from a non-certified provider, the OhioBWC will not reimburse for the services.Treatment GuidelinesThe Health Plan Managed Workers’ Compensation Program utilizes “Official DisabilityGuidelines 10 th edition” integrated with “ODG Treatment Guidelines in Workers’ Comp 3 rdedition” and “Guidelines for Chiropractic Quality Assurance and Practice Guidelines” todetermine medical appropriateness of services and/or testing and return to work guidelines.Official Disability GuidelinesEffective April 1, 2004, MCO staff began using the Official Disability Guidelines (ODG)in making their treatment authorization decisions. BWC staff will have access to ODG atthe same time but will not begin using them in the Alternative Dispute Resolution (ADR)process until this year when the guidelines have been added to our ADR rule.The ODG are evidence based treatment guidelines that BWC and the MCO’s will beusing extensively to assist in medical and claims case management. ODG is a webbasedtool available to BWC and MCO staff on their desktops. BWC and MCO staff willbe able to easily search and find pertinent information necessary to everyday issues inclaims and medical case management. Ohio providers can take advantage of the BWCnegotiated price if they order on the web www.worklossdata.comor call the toll free number 1-800-488-5548.Section 3 / Page 41

PROVIDER PROCEDURAL MANUAL 2014Ohio BWC / MCO Standardized Prior AuthorizationTREATMENT IS LIMITED TO THE ALLOWED CONDITIONS IN YOUR CLAIMServicePhysical Medicine Services,Including Chiropractic / Osteopathic ManipulativeTreatment and AcupunctureConsultations - Psychological/ChronicPain Program OnlyChronic Pain Program IncludingPre-Admission Evaluation and TreatmentDentalDiagnostic TestingDMEHome/Auto/Van ModificationsHome Health Agency ServicesHospital Inpatient Treatment, IncludingSurgery and Outpatient / ASC SurgeryInjections (Excludes IM)Non-Emergency Ambulance ServicesRequirementPrior Authorization (PA)PAPAPAPA (Except basic X-rays which do not require PA)PA if purchase price is > $250PA for all DME RentalPA from The Ohio BWCPAPA for Surgery from Date of Injury,IF NOT EMERGENCYOrthotic and Prosthetic Devices and/or Repair PA >$250Skilled Nursing Facility (SNF) /Extended Care Facility (ECF)TENS and NMEs UnitsTENS and NMEs Monthly SuppliesPAPAPAPA for Both Rentals and Purchases(Rental payment not to exceed purchase price)PA for a Maximum of Six Months Per AuthorizationVision and Hearing Services PA > $100Vocational RehabilitationAll Vocational Rehabilitation Services,Including Remain at Work,In or Out of PlanPANote: PA not required for transitional workon-site therapy services provided by an OT orPT that fall under the 60 day PresumptiveAuthorization Guidelines.Occupational Rehabilitation (Work Hardening)requires CARF accreditation.Section 3 / Page 42

PROVIDER PROCEDURAL MANUAL 2014Request for Medical Services Approval GuidelinesRequest for medial services must be submitted by the Physician of Record (POR) ortreating physician to the appropriate MCO prior to initiating any non-emergencytreatment. The preferred method of submission is the BWC Physician’s Request forMedical Service or Recommendation for Additional Conditions for Industrial Injury orOccupational Disease (C-9) form; however, any other physician generated documentmay be used, provided that the substitute document contains, at a minimum, the dataelements on the C-9 form. PORs should identify additional conditions to be allowed inthe claims on item six of the C-9 form and should spell out additional conditions withsupporting documentation.The MCO must respond to the physician within three business days with adecision regarding the proposed treatment request.The MCO must return fax of the authorized, denied or pended medical servicesrequest back to the physician within the required three business days. If faxing isnot feasible, the MCO is required to call the physician in order to communicatethe decision and follow-up in writing via mail.If the MCO is unable to make a decision within three business days due to theneed for additional information, the MCO will send a request for AdditionalMedical Documentation C-9 form (C-9-A) to the provider. The provider mustreturn the form C-9-A and any additional supporting documentation to the MCO.The MCO has ten (10) business days from the date additional information isreceived to make a subsequent decision. The MCO must render a decision toallow or deny the medical services request if the physician does not provide theMCO with any requested documentation within ten (10) business days asrequired by the Provider Agreement. The physician must be notified by fax orphone of the subsequent decision. If the MCO is unable to make a decisionwithin three business days due to the need for a medical review and thephysician is notified, the medical review must take place and a decision grantedwithin the five business day period. Again, the physician must be notified by faxor phone of the subsequent decision.The MCO must consider and communicate with POR possible alternativetreatments that may be eligible for reimbursement if requested by the provider,based on nationally accepted guidelines. Such alternative treatment proposals orsuggestions must be communicated in the denial letter to provider.Effective November 1, 2004, the Ohio BWC is responsible for treatment decisions oninactive claims. An inactive claim is defined as a claim with no claim or medical activityin greater than thirteen months.Section 3 / Page 43

PROVIDER PROCEDURAL MANUAL 2014Request for Medical Services Approval GuidelinesA medical service request will be considered approved and the provider may initiatetreatments when all of the following criteria are met:The MCO fails to communicate a decision to the physician within three businessdays of receipt of an original medical services request or five business days if therequest was pended;The physician has documented the medical services request completely andcorrectly on a C-9 or other acceptable document;The physician has proof of submission to the appropriate MCO;Medical services are for the allowed conditions;The claim is in a payable status.In instances when a C-9 is not responded to within three business days and theprovider initiates treatment, the MCO will provide concurrent and retrospective review ofthat treatment.If it is found before, after or during delivery, that any treatment, approved or notapproved within three business days, is not medically indicated or necessary, notproducing the desired outcomes, or patient is not responding, the MCO will notify theparties of decision to discontinue payment of said treatment. Only charges fortreatments already rendered will be paid. If the provider, IW or employer, wish todispute the decision, they may do so via the ADR process.The MCO’s may reject a C-9 when there is no evidence that the provider has seen andexamined the injured worker within the previous 30 days from the date of the C-9submission, unless there is proof that the injured worker requested a visit with theprovider. A C-9 rejected in this manner shall not be appeal able through the ADR process.Retroactive Medical Service RequestThe MCO shall authorize, deny, or pend a provider’s proposed retroactive medicalservice request (Submitted on a C-9 or other appropriate form) within thirty (30)calendar days from the MCO’s medical service request receipt date. A medical servicerequest will be considered approved if the MCO does not take action on the requestwithin the 30 calendar days. The MCO’s shall not automatically pend a retroactivemedical service request on day 30 after receipt and then take the additional five(5) days to make a decision on the pended medical service request. The MCO shallperform all the research necessary; obtain information, etc., within the 30-day periodfrom the MCO’s medical service request receipt date.Section 3 / Page 44

PROVIDER PROCEDURAL MANUAL 2014Billing and ReimbursementBills are to be submitted to The Health Plan. In accordance with the Ohio BWCguidelines, reimbursement will be the lower of the BWC scheduled fee, The Health Plan'scontractual rate or the billed charges.The provider will submit bills according to the Ohio BWC Billing and ReimbursementManual guidelines. These guidelines are updated quarterly by the Ohio BWC.The Health Plan will include the Ohio BWC explanation of benefits codes on thepayment voucher. The claims in process section of the payment voucher will includeadditional codes to inform you of the status of the bills and/or if additional information isneeded in order to process the bill.MiscellaneousAttached are the most current Ohio BWC forms. Please utilize these forms in the futurewhen corresponding with the MCO or the Ohio BWC. You may copy the attached formsor order additional forms from the Ohio BWC.If you have any questions regarding an injury or workers' compensation claim, pleasedirect your calls to 1-740-695-7678 or 1-888-847-7810.Additional references:Ohio BWC Provider Billing and Reimbursement ManualOhio BWC Website at www.ohiobwc.comSection 3 / Page 45


PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN ASO GROUPSSelf-Funded employer group benefits havebecome one key alternative for the employerand have become one of the fastest growingareas in the employee benefit industry. In theever-changing health care marketplace, theability to provide our managed care experiencein a self-funded environment has clearlyenhanced the marketability of The Health Planas a whole.March 1, 1992, The Allied Service Divisionofficially began administering health carebenefits under ASO arrangements.Our current employer funded plans are:American EnergyEffective: 02-01-2001Preferred Provider Option (PPO)Barnesville HospitalEffective: 01-01-1996Exclusive Provider Option (EPO)Exclusive Provider Option Plus (EPO plus)Corporate Aviation Services IncEffective: 08-01-2011Preferred Provider Option (PPO)Jefferson County GovernmentEffective: 02-01-2005Exclusive Provider Option (EPO)Ohio American EnergyEffective: 09-01-2005Preferred Provider Option (PPO)Ohio Valley Coal CompanyEffective: 01-01-1994Preferred Provider Option (PPO)Exclusive Provider Option (EPO)(Hourly Actives and Retirees Only)Coal Act (Medicare is primary, the plan will pay any deductiblesand co-pays applicable)Preferred Provider List (PPL)Ohio Valley Health Services & Education (OVHS)Effective: 01-01-1999Point of Service (POS)Reynolds Memorial HospitalEffective: 01-01-1996Point of Service (POS)Shadyside Local School DistrictEffective: 01-01-2005Village of BellaireEffective: 01-01-2010Preferred Provider Option (PPO)WesBancoEffective: 01-01-2004Exclusive Provider Option (EPO)WV Pipe Trades Local 83 & Local 565Effective: 07-01-2004 (1/1 Contract Year)Indemnity (Non-HMO coverage)WV Pipe Trades Local 625 (Charleston)Effective: 01-01-2013 (01/01-12/31 Contract Year)Indemnity (Non-HMO coverage)Bellaire Local SchoolsEffective: (10/1 Contract Year)Health Maintenance Organization (HMO)Riesbeck’sEffective: 01-01-1998Exclusive Provider Option (EPO)Section 4 / Page 2

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN ASO GROUPSIn the HomeTown Region, there are additional ASO Self Funded Employer Groups.These are administered under the name HomeTown Administrative ManagementServices (AMS). Some of these employer groups have selected the option of utilizing anetwork other than The Health Plan’s network as their preferred network.The preferred network is listed below each employer group. Your status as an in-networkprovider for each of these groups is based upon you having a direct contract with thereferenced network for each of these groups. Network and terms of reimbursement arebased upon the terms listed in your contract with that network.The ID card identifies self-funded members. This will reflect their self-funding entity.The employers providing flexibility in the design of their employee’s benefit packagescustomize self-funded member coverage.Current employer funded plans administered byHomeTown AMS are:Bekeart Corporation (Akron)Effective: (1/1 Contract Year)Health Maintenance Organization (HMO)Bekeart Corporation (Orrville)Preferred Provider Organization (PPO)Health Plan NetworkFreshmarkPreferred Provider Organization (PPO)Health Plan NetworkFirst Merit (Akron)Effective: (1/1 Contract Year)Health Maintenance Organization (HMO)THE HEALTH PLAN’S RECOMMENDATION FOR PROVIDER OFFICE STAFFPROVIDER WEBSITEReference Materials and Provider Support InformationAccess to Eligibility, Referrals, Pre-Authorization,& Claims Informationwww.healthplan.orgWebsiteST. CLAIRSVILLEMASSILLONMeteor Sealing SystemsPreferred Provider Organization (PPO)Health Plan NetworkCUSTOMER SERVICE DEPARTMENTBenefits for Self-Funded Plan Participants1-888-816-3096 or1-740-695-79101-800-426-9013 or1-330-837-6880Section 4 / Page 3


PROVIDER PROCEDURAL MANUAL 2014Medicaid Benefits at a GlanceBenefits TableChildren ( 0 up to 21 years ) Adults ( 21 years and older )Inpatient ServicesInpatient Hospital CareInpatient RehabilitationOutpatient ServicesDiagnostic x-ray, laboratory services,and testingPhysical TherapySpeech TherapyOccupational TherapyPhysician/NP/NMW/FQHC/RHC ServicesPrimary/Preventive Care VisitsPhysician Office VisitsSpecialty CarePodiatryCardiac and Pulmonary RehabilitationDentalOrthodonticsHome HealthDurable Medical EquipmentOrthotics & ProstheticsFamily Planning Services & SuppliesHospiceAmbulancePrescriptionsChiropractic ServicesTobacco CessationDiabetes ManagementSkilled NursingVisionHearingEPSDT (Well-child visits)Inpatient Psychiatric CareNursing Home ServicesNon-Emergency TransportationChemical Dependency/Mental Health ServicesBirth to Three ServicesSection 5 / Page 2Inpatient ServicesInpatient Hospital CareOutpatient ServicesDiagnostic x-ray, laboratory services,and testingPhysical TherapySpeech TherapyOccupational TherapyPhysician/NP/NMW/FQHC/RHC ServicesPrimary/Preventive Care VisitsPhysician Office VisitsSpecialty CarePodiatryCardiac and Pulmonary RehabilitationDental Services (Emergent Treatment)Home HealthDurable Medical EquipmentOrthotics & ProstheticsFamily Planning Services & SuppliesHospiceAmbulancePrescriptionsChiropractic ServicesTobacco CessationDiabetes ManagementThe services below are covered through Medicaid, but are not provided through your plan.For information on how to use these services, look at the sectionof the handbook that explains what Medicaid covers.Inpatient Psychiatric CareNursing Home ServicesNon-Emergency TransportationChemical Dependency/ Mental Health Services* There are additional services to those included on this list. If you have questions on whether a service iscovered, look at the services in the covered services section of the handbook or give us a call.

PROVIDER PROCEDURAL MANUAL 2014PRESCRIPTION BENEFITEffective April 1, 2013, the HMO began covering the prescription benefit for MHT members.The Health Plan contracts with ESI to administer the benefit. Pharmacy providers must contractwith ESI to serve our members. Please call (800) 922-1557 to contract. If you have anyprescription questions, please feel free to contact The Health Plan Pharmacy Department at(800) 624-6961, ext. 7914.Section 5 / Page 3

PROVIDER PROCEDURAL MANUAL 2014MOUNTAIN HEALTH TRUST(WV MEDICAID PROGRAM)The Health Plan began administering health care benefits to Mountain Health Trust (MHT)Members on September 1, 1996. Expansion continues to occur within the State. The mostrecent expansion for The Health Plan was April 2013, but we anticipate being in morecounties soon.Mountain Health Trust ID Cards &The MHT member will have two (2) ID cards: The Health Plan ID card and the WV medicalcard, which is sent monthly from the WV Department of Health & Human Resources (DHHR).The Health Plan no longer uses the member’s SSN as the ID number; instead, a random HIDnumber is used. The member should always present both ID cards since The Health Plan doesnot determine eligibility. The WV medical card has the name of the HMO printed on it for eachmember who belongs to an HMO. Each individual family member, who is eligible, will have aseparate Health Plan card with his/her own Health Plan ID number. The Health Plan ID card hasthe MHT logo and five (5) lines of information:Line 1Line 2Line 3Line 4Line 5Member’s Health Plan ID# including – 01 suffix(Important for billing correctly)Medicaid NumberMember’s NameMember’s PCP’s NamePCP’s Phone NumberThe Health Plan ID card is sent to the member once, unless they change PCP's, or lose the cardand request another one.All members, except newborns, become effective on the first of each month and could term onthe last day of the month. If you have any eligibility questions, please call the Customer ServiceDepartment at (888) 613-8385 or (740) 695-7904 to verify Health Plan coverage or visit theProvider Secure Web Site at www.healthplan.org. If you do not have access to this site,please contact:Provider Relations – EDI SupportPhone: (800) 624-6961 Ext. 7649 or (740) 695-7649E-Mail: hpecs@healthplan.orgFAX: (740) 699-6169Section 5 / Page 4

The Health Plan of the Upper Ohio Valley, Inc.www.healthplan.orgMedicaidWelcome to The Health Plan. The Health Plan is a Health Maintenance Organization (HMO). We arrange formedical care for our members by contracting with health care providers.both your Health Plan(over please)SMITH, JOE L100 MAIN ST.YOURTOWN US 99999MED: MHBC DRUG: WVMT VIS: 98 CHIRO: REGN: WV200_MHT.pdf RE-ENR CARDS/PACKET BOOK:N 01403025BC 26378Mountain Health TrustMountain Health TrustHP ID #: H99999999 01 EFF: 09/01/2013MHT ID #: 00000046434REC NAME: SMITH, JOE EPCP NAME: YOUR PCP MDPCP PHONE #: (555)-555-1234Children’s dental < 21 yr.PCP $0 SCP $0 ER $0 UC $0RxBIN: 610014RxPCN:Rx GROUP: THPWVMCID: H99999999NAME: 01 JOE E SMITHPREF: $0 NON-PREF: $0You must present this ID card and your WV Medicaid ID card each time you receiveTHPMHT - MEDICARDHP 2/97 FULL PACKETBMS approved MM/DD/YYYY

Please read coverage.an emergency situation.Members:To locate a participating pharmacy or for more information about your.Pharmacists: drug products where applicable in accordance with prevailing pharmacy laws and1.800.922.1557, 24 hours a day,Notice to Members: Please carry this card with you at all times. Present your Health Plan and WV MedicaidIn Case of Emergency:Please call Customer Service 1.800.624.6961 52160 National Road East, St. Clairsville, OH 43950 (740) 695.3585

PROVIDER PROCEDURAL MANUAL 2014HealthCheck(Previously EPSDT Services)Effective January 1, 2006, The Health Plan began to administer the HealthCheck (PreviouslyEarly and Periodic Screening, Diagnosis and Treatment (EPSDT) Services) Program. Thisshould be provided to all children and young adults up to age twenty-one (21). The providershould do the screening (Periodic, Comprehensive Child Health Assessments) to all eligibleenrollees.These should be regularly scheduled examinations and evaluations of the general physical andmental health, growth, development, and nutritional status of infants, children, and youth.At a minimum, these screenings must include, but are not limited to:a) A Comprehensive Medical and Developmental History, Including NutritionalAssessment, Developmental Assessment (Social, Personal, Language) andFine / Gross Motor Skills with Special Attention to Members Identified asChildren With Special Health Care Needs (CSHCN) and Asthmaticsb) An Unclothed Physical Yearly Examc) Laboratory Tests to Include Lead Screeningd) Hearing and Vision Assessmentse) Dental Screeningf) Pulmonary Function Testing for Asthmaticsg) Behavioral Health Screening (Does Not Include Behavioral Health Services)h) Immunization Status ReviewIt is important that the provider documents all of the above on the member’s chart as well as referrals.The provider should submit a 1500 claim form with the appropriate codes for services renderedto The Health Plan for reimbursement. HealthCheck claims are paid without any coordinationof benefits.The Health Plan sends a monthly notice to the PCP with the list of his/her patients(s) that areexpected to have a well child exam during that month. The PCP should mark the list that thepatient kept the well child appointment, missed the appointment, a new appointment date, and ifthe PCP referred the patient to a specialist. Please return this monthly list to the OutreachDepartment at the Health Plan’s St. Clairsville Office. Based on the PCP’s response, themember may be contacted for noncompliance issues. If the member is not a patient of that PCP,the sheet should be returned to The Health Plan and marked accordingly in order to correctthe records.REMEMBER, THESE DATES ARE FOR WELL CHILD EXAMS. If the provider does a wellchild exam at the same time as a sick visit, please use the appropriate codes.The Health Plan also sends a reminder notice to appropriate members each month that a wellchild exam is due.Section 5 / Page 7

ginia Officfice of Maternal, Child & Family HealthWest VirgiWell Child Check Up (1)Growth MeasurementsLength/Height and WeightHead CircumferenceBody Mass IndexBloodPressureTuberculosis RiskScreenLead Risk ScreenVisionScreenHearing ScreenDevelopmental/BehavioralDevelopmental SurveillanceDevelopmental ScreenPsychosocial/BehavioralScreen(2)Autism ScreenNewborn>>>SO>INFANCY3-5daysBy 1mo2 mo 4 mo 6 mo 9 mo 12mo> > > > > > >>>SS>>>SS> >>>SS>>SS> >>>>Begin@6 moSS>>>2010 HealthCheckProgramPeriodicity ScheduleFor more information contact the HealthCheck Program at 1-800-642-9704 or visit our website at www.wvdhhr.org/healthcheckPhysical Exam (3)Newborn MetabolicScreen (4)Immunizations (5)Hematocrit or HemoglobinBloodLead ScreenOral Health Screen (7)Health Education withAnticipatory GuidanceTuberculin TestDyslipidemia Screen (8) & (9)>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>(R)>>>(6)>>>>(6)>>>>>>> > >(6) > >>>(6)>>>>(6)>>>>(6)>>>>(6)>> > > > >>>>>(1) Well child check-ups incorporate all required components of the HealthCheck exam including: comprehensive history,history update, nutritional screening, applicable growth measurements plotted on a growth chart, blood pressure,Iron-Deficiency Anemia Screeningvision screening, subjective hearing screening, oral health screening, head-to-toe physical exam, lead risk screening,laboratory tests, and animmunization screen.Tuberculosis risk screening, health education, ordering appropriateRisk Factors:Additional screens may benecessary for high risk infants.(2) Alcohol and drug use screening is included in the psychosocial/behavioral screen.(3) All sexually active patients should be screened for sexually transmitted infections (STIs). Sexually activegirls shouldhave screening for cervicaldysplasia aspart of a pelvic exam beginning within 3 years of onset of sexual activityor age 21 (whichever comes first).(4) Newborn metabolic screening should bedone according to state law. Results should be reviewed at visits andappropriate retesting or referral done as needed.(5) Immunizationsshould be reviewed and updated untilcomplete at each visit. Immunizationsshould be administered inaccordance with ACIP, AAP, and AAFP recommendations.(6) As indicated by the lead risk screen.(7) Referral to dentist required at age 1. Earlier initial dental evaluation may be appropriate for some children.Low birthweight or preterm birthNon-iron-fortifiedformulaCow’smilk before age 12 monthsDiet low in iron, inadequate nutritionMeal skipping, frequent dietingHeavy/lengthy menstrual periods orrecentblood lossIntensive physical training orparticipation in endurance sportssPregnancy or recent pregnancy(8) Recommended: risk assessment shouldbe performed at 24 months, 4yrs, 6yrs, 8yrs, and 10-20 yrs.(9) In all adults aged 20 or older, a fasting lipoprotein profile should be obtained every 5 years.For CDC screeningrecommendationsfor iron-deficiency anemia by age seeS=Subjective Exam O=Objective Exam R=Required ReferralAppendix G of the HealthCheckProvider ManualRequired ScreenSelective Screen>>>> >SS>>SS>EARLYCHILDHOOD15mo18mo24mo30mo3 yr> > > > >>>>>> >> >SSSS> >>>>>>>>>> > >> > >SSSS> >>>>>Begin@3 yrOS>4 yr 5 yr> >.> >>>> >> >> >OOOO> >MIDDLECHILDHOOD6 yr 7 yr 8 yr 9 yr 10 yr11 yr 12 yr> > >>>>>> > >> > >>OO>SS>>OO> > >> >>>>>> >> >SSOO> >> >> >> >> >> > >Tuberculosis (TB) Risk Screen:Radiographic findings suggesting TBContacts with persons with confirmedor suspected TBImmigrant from high prevalence areas(eg, Asia, Middle East, Africa, LatinAmerica)Travel to high prevalence areas>>>>> > >> > >SSOS13 yr> > >> > >> > >> > >> > >For other riskfactors see Appendix Din the HealthCheck Provider ManualOnly childrenwith increased risk ofexposure to persons with tuberculosisshould be considered for tuberculinskin testing.>>SSADOLESCENCE14 yr 15 yr 16 yr 17 yr> >>>>>> >> >SSOS> >> >> >> >> >> > >>>>>> > >> > >SSSS18 yr> > >> > >> > >> > >> > >DyslipidemiaRisk ScreenPositive family history is defined as ahistory of premature ( 55 years of age)cardiovascular disease in a parent orgrandparentPositive family history, elevated bloodcholesterol greater than 240 mg/dlUnknown family history, adopteddCigarette smokingElevated blood pressureOverweight/Obesity(BMI > 85% %)*Diabetes mellitusPhysical inactivityPoor dietary habitsWhen one or more risk factors indicatethat thechild is high risk, then an initialfasting lipid profile should be obtained.>>OS19 yr 20 yr> >>>>>> >> >SSSS> >> >> >> >> >>WVDHHR/BPH/OMCFH/HealthCheck/March 22,20100

PROVIDER PROCEDURAL MANUAL 2014FAMILY PLANNINGFamily planning services may be obtained by a MHT member without a referral or priorauthorization through any Medicaid family planning provider, regardless if they are in TheHealth Plan network or not. Family Planning Services are defined as those services provided toindividuals of childbearing age to temporarily or permanently prevent or delay pregnancy.These services include:a) Health Education and Counseling necessary to make informed choices andunderstand contraceptive methodsb) History and Physical Examc) Pap Smear and Lab Tests if medically indicated as part of the decision makingprocess for choice of contraceptive methodsd) Diagnosis and Treatment of Sexually Transmitted Diseases (STD) ifmedically indicatede) Screening, Testing, and Counseling of At-Risk Individuals forHuman Immunodeficiency Virus (HIV) and referral for treatmentf) Follow-up and care for complications associated with contraceptive methodsissued by the Family Planning Providerg) Provisions for Contraceptive Pills / Devices / Supplies (Deprovera Injectionsare permissible; prescriptions are to be issued for contraceptive pills)h) Tubal Ligation and Vasectomies (Consent Forms Required)i) Pregnancy Testing and Counselingj) Family Planning provided at Postpartum Visitsand/or at discharge Post Delivery.(Postpartum Care should be provided within eight (8) weeks of delivery)LOCAL HEALTH DEPARTMENTSThe Health Plan contracts with local WV Health Departments to provide certain services for theMHT program without a referral. These services include:a) All Sexually Transmitted Disease Services Including Screening, Diagnosisand Treatmentb) HIV Services Including Screening and Diagnostic Studiesc) Tuberculosis services including screening, diagnosis, and treatmentd) Childhood Immunizationse) Family Planningf) Health CheckThe Health Department should forward all records to the member’s Primary Care Physicianand/or OB/GYN provider.Section 5 / Page 9

PROVIDER PROCEDURAL MANUAL 2014STAFFINGStaffing for the MHT program consists of a Member Advocate who is responsible forcoordinating programs between The Health Plan and WV Medicaid to assure compliance withthe program as well as ongoing education to MHT members.In addition to the Member Advocate, there are Outreach Representatives assigned to each countywho are under the direct supervision of the Member Advocate. The Outreach Representativesare responsible for ongoing education of MHT members.The Health Plan will ensure that follow-up and outreach contacts are initiated for missedappointments and failure to follow medical treatment plans.A provider should notify The Health Plan that a member is not keeping scheduled appointments,not following the medical treatment plan, the member’s behavior in the waiting room wasinappropriate, or any other reason in which the member could benefit from redirectionof behavior.The provider should document his/her chart accordingly. This documentation should beprovided to The Health Plan after a member misses a second appointment.Outreach Representatives will then contact the member to discuss the situation, suggestalternate methods, and otherwise educate, especially to follow the provider’s treatment plan.If transportation is the problem, members should be referred to their county caseworker fornon-emergency transportation assistance. The member needs to understand that the providercan ask for his/her removal from his/her roster if this noncompliance persists. Please call theGovernment Programs Department at (800) 624-6961, extension 7850 or call (740) 695-7850for an Outreach Representative to educate the member about these issues.MHT members are continually educated about appropriate use of the Emergency Room.If members present to the ER for non-emergency cases, they may be responsible for the costof the ER visit or a co-pay. The PCP should be contacted first for instructions, day, or night.The Health Plan should be contacted after going to the ER. If it is a life-threateningsituation, the member should go to the closest ER but still call the PCP and The Health Planwithin 48 hours. Follow-up care and treatment, including the removal of stitches, casts, anddressings must be given or arranged by the PCP.Section 5 / Page 10

PROVIDER PROCEDURAL MANUAL 2014SURGICAL CONSENT FORMSThe Health Plan, in accordance with the WV Medicaid guidelines, will continue to require thecompletion of the state surgical consent forms for the following procedures: Hysterectomy Voluntary Sterilizations (Male or Female) Pregnancy TerminationThe surgical consent form for voluntary sterilizations must be completed and signed by theMHT member thirty (30) days prior to the surgery. The consent form is valid for 180 days.Please note that none of the consent forms need to be submitted to The Health Plan but shouldremain with the member’s medical records.PREGNANCY AND NEWBORN ENROLLMENTIn accordance with the State of West Virginia requirements to effectively monitor and/or provideappropriate intervention during the member’s antepartum, delivery, and postpartum period,The Health Plan has elected to adopt the state’s guidelines. The Health Plan will continue torequire all providers rendering services for antepartum care to submit the appropriate code foreach encounter during the antepartum period that will be separately reimbursed. The Health Planwill also require separate billing for the delivery and postpartum services by submitting theappropriate CPT code(s).The Health Plan requires the completion of the Prenatal Risk Screening Instrument (PRSI) uponthe initial encounter for all MHT members receiving maternity services.Physicians are asked to complete the Prenatal Risk Screening Form and forward it to The HealthPlanor complete the Prenatal Risk Screen Form located on the ProviderWeb Site at www.healthplan.org.Non-WV ProvidersWV Providerswww.healthplan.org/Content.aspx/documents-formswww.healthplan.org/Default.aspx/prenatal-risk-screenwww.wvdhhr.org/mcfh/WV_PrentalRiskScreeningInstrument2012.pdfBased on this screening tool, members are contacted to begin tracking their pregnancy.An initial prenatal care visit must be scheduled within 14 days of the date on which a Medicaidwoman is found to be pregnant. Any member who has a high-risk pregnancy will be referred tothe Prenatal Care Coordinator who is a nurse with OB experience. If the member smokes, she isalso referred to the Smoking Cessation Program. Outreach Representatives monitor the low-riskpregnancies on a trimester basis. Members are encouraged to participate with the Women,Infant, and Children’s (WIC) program and the Right From The Start (RFTS) program.The Health Plan refers her to the appropriate Regional Care Coordinator (RCC) of RFTS.Based on the risk assessment, pregnant females may qualify to participate in the RFTS programfor enhanced services and/or care coordination. This care coordination is available for high-riskpregnancies. High-risk infants (up to age 1) may also qualify for RFTS services.Section 5 / Page 11

WEST VIRGINIAPRENATAL RISK SCREENING INSTRUMENTLast Name: First Name: MI: Date of Birth:Social Security #:/ // /Street: City:State: Zip Code: County of Residence: Telephone: Alternate #:Race:Ethnicity:White Black/African AmericanAsian American Indian/Alaska NativeNative Hawaiian/Pacific IslanderHispanic/Latino Not Hispanic/Latino(Check all that apply)Date of 1st Prenatal Visit: (MM/DD/YYYY)CurrentWeight (lbs) :Height(Ft-inches) :/ /Obstetrical History:Gravida ParaTermU.S. Citizen:YesNoPreMarried:YesInsurance Source:Health InsuranceNo InsuranceI am interested in further follow-up. I give my consent for necessary referrals to be made. I understand that my participation in any referral services is voluntary and that allinformation provided will be held strictly confidential.Patient Name: (print)Patient Signature:Date:NoLMP: (MM/DD/YYYY): / /EDC: (MM/DD/YYYY): / /Date of Last Delivery: / /Type of Delivery:1st Trimester Miscarriage AbortionMedicaid #Sensitive/Bleeding GumsYes/ /NoLoose/Broken/Decayed Teeth Yes NoDental visit within the last year Yes NoBloodPressure:Do you intend to breastfeed? Yes No2nd Trimester Miscarriage AbortionAre you currently breastfeeding? Yes NoPreterm Birth Term BirthPregnancy Risk Factors:Current Preg. Prior Preg.Current Preg. Prior Preg.Current Preg. Prior Preg.Y N Y NY N Y NY N Y NPrevious Cesarean Section na naFetal ReductionGroup B StrepLow Birth Weight (

WV PRENATAL RISK SCREENING INSTRUMENT INSTRUCTIONSThe Prenatal Risk Screening Instrument (PRSI) is intended to promote early and accurate identification of prenatal risk factors. Prenatal risk screening isconducted at the first prenatal visit. If the patient answers “Yes” to any pregnancy or medical risk factor, a Maternal Fetal Medicine consultation should beconsidered.General InstructionsPrint clearly. Complete the form accurately and completely. When asked to select “Yes” or “No”, choose only one option.Patient InformationName (List patient’s Last Name, First Name & Middle Initial)Date of Birth (List patient’s date of birth as MM/DD/YYYY)Social Security Number (List patient’s social security number; if patient is undocumented or a non-citizen use 000-00-0000)Address (Use current address where the patient resides)County of Residence (List the West Virginia County that patient’s address is located)Telephone Number (Use a current telephone number & alternate number, if applicable, where patient can be reached)Race/Ethnicity (Check all that apply)U.S. Citizen (Choose only one option)Married (Choose only one option)Insurance Source (Select type of insurance source that patient currently has; if Medicaid, list Medicaid number; private insurance, list insurance company name,ex: PEIA, BCBS)Entry into Prenatal CareDate of First Prenatal Visit (Enter the date of the patient’s initial medical examination during this pregnancy)Current Weight (List patient’s current weight in pounds)Height (List patient’s current height in feet/inches)Blood Pressure (List patient’s blood pressure reading at time of this visit)Obstetrical HistoryGravida (Enter # of pregnancies in the boxes; include current pregnancy in this number. If Gravida >1, the Para field must be completed.)Para (This is the # of: Term=Term Deliveries; Pre=Preterm Deliveries; SAB=Spontaneous Abortions; EAB=Elective Terminations; & L=Live Births)LMP (List date of last menstrual period)EDC (List estimated date of confinement)Date of Last Delivery (List patient’s last pregnancy delivery date, if applicable)Type of Delivery (Select type of delivery patient had from last pregnancy, if applicable)Oral HealthSelect “Yes” or “No”. If patient answers “Yes” to any of the questions, please consider a referral to a dentist or provide patient education.BreastfeedingSelect “Yes” or “No” to the questions regarding breastfeeding.Pregnancy Risk FactorsSelect “Yes” or “No” to indicate the presence of risk factors in the patient’s current and/or prior pregnancy(ies).Bleeding During Current PregnancyIf “Yes”, select the trimester(s) that bleeding occurred. Select “No” if bleeding did not occur.Family HistorySelect “Yes” or “No” to indicate the presence of risk factors in the patient’s current and/or prior pregnancy(ies) and/or whether there is a familyhistory for the selected risk factors.Medical ConditionsSelect “Yes” or “No” to indicate whether the patient currently has the listed medical risk factor and/or is taking medication for the condition.Psychosocial Risk FactorsSelect “Yes” or “No” for each risk factor listed.Environmental Risk FactorsIndicate by selecting “Yes” or “No” whether the patient has been exposed to listed items in their environment. A patient who lives in a house built before 1978 is atrisk for exposure to lead paint.Reasons for Late Entry into Prenatal CareComplete this section only when a patient enters prenatal care in the 2nd or 3rd trimester. Fill in “Yes” for all reasons that apply.Additional Screening QuestionsThese questions are used as a screening tool to begin discussion about use of drugs, alcohol, tobacco and/or abuse. Advise the patient that the responses sheprovides are confidential and may only be used for her evaluation and treatment. Any patient who answers “Yes” to one or more questions may warrant furtherassessment and follow-up.Provider InformationList name, title, individual NPI# and telephone number of provider completing the PRSI; list date the form was completed.ConsentPatient’s participation in any referral services is voluntary and her consent must be provided. If patient is interested in further followup/referrals, she must printname, sign and date the form. If patient is not interested in referral services, please leave this section blank.CompletionFax the form to (304) 957-0176. Do not include coversheets. Check to be sure the correct side of the form is transmitted. Fax only one form per patient; do not refaxa patient’s form. Duplicate faxes create problems with processing.

PROVIDER PROCEDURAL MANUAL 2014When a Health Plan Mountain Health Trust member gives birth, her newborn(s) is automaticallycovered from date of birth. The Outreach Representatives call new mothers in the hospital toenroll the newborn(s) into The Health Plan. The new mother is reminded to apply for a SSN forthe newborn and to select a PCP for the baby. The importance of well child visits andimmunizations are stressed. The new mother will receive a newborn packet from The HealthPlan along with the baby’s ID card.Members are encouraged to sign the baby up for the WIC program. A Health Plan ID card withthe PCP listed is sent to the newborn. The HMO is required to cover the newborn at birth. Thereis a process in place to get the newborn a Medicaid number within 30 days.If you need a newborn’s Health Plan ID number please call (855) 577-7124 or (740) 699-6274,but please allow 10 business days from the baby’s birth.The new mother is also reminded of the importance of her own postpartum checkup that shouldoccur within eight (8) weeks of delivery. The Outreach Representative makes a postnatalfollow-up call. She also does an initial newborn follow-up at that time. During the postnatalcontact, the Edinburgh Postnatal Depression Scale (EPDS) is reviewed for postpartumdepression. If the member has a high score, she is referred to The Health Plan Prenatal CareCoordinator who notifies the member’s OB provider.WOMEN’S ACCESS TO HEALTH CAREIn accordance with the Women's Health and Cancer Rights Act of 1998, The Health Plan coversreconstructive surgery after a mastectomy under the same terms and conditions as other regularinpatient services under the Plan, and will include:Coverage for reconstruction of the breast on which the mastectomy was performedSurgery and reconstruction of the other breast to produce a symmetrical appearanceCoverage for prostheses and physical complications of all stages of the mastectomy,including lymph edemaThis is all handled in a manner determined in consultation with the attending physician and thepatient and approved by The Health Plan as medically necessary and appropriate.The Health Plan allows women to have direct access to a range of women's health care providers,including obstetrician-gynecologists, advanced nurse practitioners, certified nurse midwives, andphysician assistants. This information is disclosed to members in the Member Handbook.An annual Pap test and physical breast exam is encouraged for each member and may be done bythe PCP and/or OB/GYN.Section 5 / Page 14

PROVIDER PROCEDURAL MANUAL 2014SMOKING CESSATIONMembers are encouraged to participate The Health Plan’s sponsored smoking cessation classesfree of charge. A friendly staff member will provide the member with one-on-one personalsupport that can help him/her quit.DIABETESInsulin pumps are covered in specific medical cases. Diet management and education arecovered as part of the Diabetic Disease Management program. Blood glucose monitors arecovered for diabetics when a participating provider writes the order.Diabetics should have an annual health assessment, dilated eye exam, and fasting lipid profile.Quarterly visits are encouraged for foot exam, HbA1c, and diabetic education. The Health Plansends diabetic members a yearly coupon as a reminder to have the dilated eye exam.Outreach Representatives do a diabetic assessment.ADULT DENTALThe benefit continues to be that only urgent/emergent dental extractions are covered for adultMHT members (ages 21 and over). Effective March 8, 2001, however, The Health Planchanged the referral process for adult MHT dental referrals. A referral from the PCP is nolonger necessary for the initial evaluation by the dental provider. The dental provider needspreauthorization only if more than two (2) teeth are extracted, if IV sedation is requested, orfor extraction of wisdom teeth. Panorex films will be requested for extraction of more thantwo (2) teeth.Examples of urgent/emergent dental services are:Dental caries with abscessI&D of abscessRepair of acute woundsTooth broken off to the gum lineDental caries with painNon-restorable toothThe extraction of impacted wisdom teeth is not a covered benefit, but wisdom teeth that areabscessed could meet the urgent/emergent guidelines. Neither IV sedation nor generalanesthesia is covered. TMJ is not a covered benefit for MHT adults.The claim must document that the services were urgent/emergent.CHILDREN’S DENTALEffective January 1, 2014, children's dental services (up to age 21) are covered by the HMO.Scion Dental is our administrator and providers must contract with them to provide services toour members. Providers should call (888) 983-4690.Section 5 / Page 15

PROVIDER PROCEDURAL MANUAL 2014IMMUNIZATION REGISTRYThere is now a West Virginia Statewide Immunization Information System (WVSIIS) for allchildren ages 0-6. This is a way to create an electronic childhood immunization record thatneither the public nor private sectors can do alone. Children often receive shots from severalproviders that can make the immunization record fragmented, causing missed doses or overimmunization. The benefits of this registry are access to a current immunization record, betterpatient care, and higher immunization rates and less disease.The data can be captured from the patient management system without any need for duplicationof data entries. There is web based or free on-site software to help manage the data.In order to participate, the site needs PC hardware, modem, and access to a phone line, vendorassistance, or access to the Internet plus browser software.The provider signs an enrollment packet, has training, and determines the access option best forhis/her practice. Based on this, the provider can begin using WVSIIS.For more information about this registry please contact:Tim Neely, Project Manager(304) 558-6439timneely@wvdhhr.orgWeb: https://wvsiis.wvdhhr.org/wvsiis/main.jspWVSIIS Help Desk(877) 408-8930Section 5 / Page 16

PROVIDER PROCEDURAL MANUAL 2014The Health Plan MHT Members' Rights and Responsibilities StatementStatement of Members' RightsYou have the right to express yourcomments, opinions, or complaints about TheHealth Plan, or the care provided, and topursue grievance and hearing procedureswithout reprisal from The Health Plan. Youalso have the right to obtain a promptresolution of issues raised, includingcomplaints or grievances and issues relatingto authorization, coverage, or payment ofservices.You have the right to choose a ParticipatingPrimary Care Physician (PCP) and OB/GYNand, with proper referrals, see a participatingspecialist. You also have the opportunityto refuse care from the designated Providerand select a different affiliated Provider. Youcan change your PCP at any time; however,the new PCP has to be available.You have the right to privacy andconfidentiality with regard to your personalinformation.All information concerning your medicalhistory and enrollment file is confidential. Youhave a right to approve or refuse the releaseof personal information by The Health Planexcept when the release is required by law,regulation, this Agreement, or to affectcoverage under the Agreement.You have the right to request and receiveyour medical records, and to request they beamended or corrected and receive promptaction in a timely manner of no later than30 days from receipt of the request forrecords and no later than 60 days from thereceipt of a request for amendments.You have the right to be informed of Planpolicies and any charges for which you maybe responsible. Also, to offer suggestions forchanges in policies and procedures.You have the ability to obtain evidence ofmedical credentials of a Plan provider suchas diplomas and board certifications.You have the right to have coveragedenials reviewed by appropriate medicalprofessionals consistent with The Health Planreview procedures.Statement of Members' ResponsibilitiesFor The Health Plan to provide appropriate andmedically necessary health care services and toallow you to get the most from your Health Planmembership, we want to work together with youand your family. Please share in responsibilitiesby doing the following:Choose a Primary Care Physician (PCP) foreach person listed on your Health Plan ID card.The member has a responsibility to maintain arelationship with a PCP. The PCP will act as thecoordinator for all of your health care needs.You may change physicians at any time if you sodesire (depending on availability of chosenphysician).Identify yourself as a Health Plan member toavoid unnecessary errors. Always carry your IDcard and never permit anyone to use it.Read and understand the benefits and proceduresfor receiving health care services. To assuremaximum coverage, the member has aresponsibility to follow the rules and to contact TheHealth Plan for assistance, if necessary.Be on time for appointments. Call the physician'soffice promptly if you cannot keep an appointment.Notify The Health Plan of any changes in thefollowing:‒ Name, Address, Telephone Number‒ Number of Dependents(marriage, divorce, newborn, etc)‒ Loss of an Identification Card‒ Selection of Primary Care PhysicianProvide necessary information to theproviders rendering care. Such informationis necessary for the proper diagnosis and/ortreatment of potential/existing conditions .Follow instructions and guidelines given by thoseproviders who deliver health care services.If you receive emergency care outside TheHealth Plan Service Area, contact The HealthPlan within 48 hours or as soon as possible.Section 5 / Page 17

PROVIDER PROCEDURAL MANUAL 2014The Health Plan MHT Members' Rights and Responsibilities StatementStatement of Members' RightsAlong with the rights to which you are entitled,you can expect to receive courteous, personalattention and be treated with respect, dignity,and privacy by Health Plan employees,providers and their staff.You have the right to participate in decisionmakingregarding your health care, includingright to refuse treatment, when possible andwithin the Plan guidelines as outlined in thisAgreement. Health care professionals, actingwithin the lawful scope of practice, are notprohibited or restricted from advising oradvocating on behalf of an enrollee who is his orher patient for the following: the enrollee’s healthstatus; medical care or treatment options(including any alternative treatment that may beself-administered); any information the enrolleeneeds for deciding among all relevant treatmentoptions; or the risks, benefits, and consequencesof treatment or no treatment. This information willbe presented in a manner appropriate to yourcondition and ability to understand, free-of-charge.You may discuss with providers appropriate ormedically necessary treatment options for yourcondition(s) regardless of cost or benefitcoverage; however, this does not expandcoverage by the Plan.You have the right to express your commentsand opinions to The Health Plan through theyearly member satisfaction survey, telephonecalls, or place them in our "Members SuggestionBox" located in The Health Plan lobby.You have the right to request a summary of ourAccreditation Report.You have the right to accessible services; tobe furnished health care services; and toreceive information regarding the Plan, itsservices, practitioners and providers, andmembers' rights and responsibilities annually.This information will be presented in a mannerappropriate to your condition and ability tounderstand, free-of-charge.Enrollees have the right to be free from any formof restraint or seclusion used as a means ofcoercion, discipline, convenience, or retaliation,as specified in other Federal regulations on theuse of restraints and seclusion.Statement of Members' ResponsibilitiesYou must contact your selected Primary CarePhysician (or Secondary Care Physician orOB/GYN if applicable) before seeking anyspecialty physician/service.You must provide The Health Plan with allrelevant, correct information and pay The HealthPlan any money owed according to Coordinationof Benefits or Subrogation policies.Make required co-payments under the"Benefits Schedule".Be courteous and respectful of Health Planemployees, providers, and their staff.Section 5 / Page 18

PROVIDER PROCEDURAL MANUAL 2014The Health Plan MHT Members' Rights and Responsibilities StatementStatement of Members' RightsStatement of Members' ResponsibilitiesAll services are accessible to all enrollees,including those with limited Englishproficiency or reading skills free-of-charge.You will not be discriminated against in thedelivery of Health Care Services consistentwith the benefits covered in your Policy,based on race, ethnicity, national origin,religion, sex, age, mental or physicaldisability, being homeless, sexual orientation,genetic information, or source of payment.Also, be assured that you have the right toaccess emergency health care services,consistent with your determination of the needfor such services as a prudent layperson,and post-stabilization services.We will permit the enrollee’s parent orrepresentative to facilitate care or treatmentdecisions when the enrollee is unable todo so. We will provide for the enrollee orrepresentative involvement in decisions towithhold resuscitative services, or to forgoor withdraw life-sustaining treatment, andcomply with requirements of Federal andState Law with respect to advance directives.Enrollee information provided by The HealthPlan is available, as needed, in alternativeformats (i.e. Braille, large print) for those whoare unable to see or read written materials orhave translation difficulties. We will make oralinterpretation services available in all non-English languages to all enrollees andpotential enrollees free of charge. The HealthPlan will provide audiotapes for the illiterateupon request. Written information is availablein prevalent languages. Please contactCustomer Services Department for anyassistance at 740-695-7904 or 1-888-613-8385,Monday through Friday 8:30 a.m. – 5:00 p.m.or our website athttp://www.healthplan.org/index.php/memberservices/wv-medicaid.Members have the right to receive informationregarding the Plan. Information such as asummary of the Plan’s accreditation reportand the Plan’s: services, cost sharing (if any),policies, benefits, limitations, practitioners andproviders in an easily understood formatand manner.Section 5 / Page 19

PROVIDER PROCEDURAL MANUAL 2014APPEALS AND GRIEVANCESIf you do not agree with the decision made by The Health Plan, or are not happy with anyservices received, you, your representative, or the legal representative of a deceased enrollee'sestate, or your doctor (with your written consent) can get in touch with The Health Plan’sCustomer Service Representative by calling (888) 613-8385 or (740) 695-7904 or writing itdown and send it to The Health Plan’s Customer Service Department at 52160 National RoadEast, St. Clairsville, OH 43950. The Health Plan’s Customer Service Representative can helpyou with your appeal and completing any required forms. We will provide this information uponenrollment, annually, and at least 30 days prior to any change.Receipt of an Appeal – The enrollee / provider has 90 days from the initial notification of TheHealth Plan’s denial to initiate an Appeal.You can call or write the Customer Service Representative about many different kinds ofappeals, such as the following:Claims regarding the scope of coverage for health care services,Denials, reductions, cancellations or non-renewals of enrollee coverage,The kinds of health care services you receive,Not being allowed to get certain health care services,Not being able to get services in a timely manner,The way your doctor or The Health Plan’s staff treat you, andNotice of your rights as a patient.The Health Plan has an appeal process to help make sure that your appeals are handled quickly.The Customer Service Representative can explain the appeal process to you and will let youknow what The Health Plan is doing to respond to your appeal. If you do request an appeal andif the appeal remains denied, you may have to pay for the services if care was already rendered.Appeal Process: (Started by the Member or their Doctor with Member’s signed consent).If you are not happy with our decision relating to a denial of a service, a reduction in service,termination of a previously authorized service, or failure to provide service timely, you, yourrepresentative or the legal representative of a deceased enrollee's estate, or your doctor(with your written consent) may file an appeal with The Health Plan’s Customer ServiceDepartment by phone or in writing. Your information will be recorded and reviewed.(Please note: No action will be taken against a provider who files an appeal on behalf of an enrollee).The Health Plan’s Grievance Committee will look at your appeal. If your appeal is aboutmedical service, a doctor will be involved in this review process. If you want, you can meetwith the Appeals Committee to review the situation.Section 5 / Page 20

PROVIDER PROCEDURAL MANUAL 2014Your appeal will be answered within the following time frames:You will receive a written response from the Grievance Committee within 15 calendar days(if the service has not been done yet), or 30 calendar days (if the service was already done).This timeframe may be extended up to 14 days if you ask for it to or if The Health Planshows that additional information is needed and the delay could help you in the appeal.If The Health Plan asks for the delay, we will notify you of this delay, in writing, and thereason for it. However, you will receive an answer from us within 45 days from receipt ofyour request.If a delay of our answer might seriously endanger your life or health, you or your doctor canrequest a quick review and we will call you and mail you a written notice of our decision within72 hours. If your request for a quick appeal is approved, any additional information you or yourdoctor want us to look at will need to be turned into The Health Plan shortly after your request sowe can complete the review within the 72 hours. If we don’t approve your request for a quickappeal, we will process your appeal within the 15 or 30-day timeframe listed above.Upon request, you may obtain a copy of the benefit provision, guidelines, protocol, or criteria onwhich the appeal decision was based. You are entitled to receive, upon request, reasonableaccess to or a copy of all the relevant documents ruled upon to make the appeal decision.You have a right to representation.For your information, we have provided the titles and qualifications of individuals participatingin your appeal decision review:Medical Director• Board Certified Physicians (Internal Medicine, Family Practice, Radiology,Behavioral Health Practitioner) with current state licensures.Referral Review Nurses• Registered nurses or licensed practical nurses with current state licensures.Case Managers• Registered nurses with current state licensures and case managementcertifications.Care Managers• Registered nurses or licensed practical nurses with current state licensures.If you are not happy with the decision of the Grievance Committee, you may request a StateFair Hearing.State Fair Hearings ProcessIf you are not happy with The Health Plan’s Appeal decision, you, your representative or thelegal representative of a deceased enrollee's estate, or your doctor (with your written consent)can request a State Fair Hearing if it is within 90 days of the notice of the Appeal decision fromThe Health Plan. You can only request a State Fair Hearing if it relates to a denial of a service, areduction in service, termination of a previously authorized service, or failure to provide servicetimely. Please contact your local Department of Health & Human Resources office to get theform you will need to fill out.Section 5 / Page 21

PROVIDER PROCEDURAL MANUAL 2014If a State Fair Hearing is requested, the State will hear your case and give you a decision inwriting within 90 days of the date you filed the appeal. If you are still not happy with thedecision, you can take your case to Circuit Court. If you want to proceed in taking your case tocircuit court, you must file within 120 days of your notice of the State Fair Hearing decision.Appeal After 90 DaysIf you did not request a State Fair Hearing within the 90 days, you may still be able to appealThe Health Plan’s original decision that you did not agree with. You can also use this processeven if the decision is not related to a denial of service, a reduction in service, termination of apreviously authorized service, or failure to provide service timely. You must have gone throughThe Health Plan’s internal appeal process and it must be within 1 year of the date of the originaldecision that you did not agree with.You can file an appeal to the Bureau for Medical Services (BMS). Send your request for anappeal to:Bureau for Medical ServicesOffice of Medicaid Managed Care350 Capitol Street, Room 251Charleston, WV 25301-3708BMS will only review appeals related to a denial of a service, a reduction in service, terminationof a previously authorized service, or failure to provide service timely. The BMS decision willbe sent to you in writing.If you are not happy with the Bureau for Medical Services decision, you can appeal to theInsurance Commissioner by sending your appeal to:The Office of the Insurance CommissionerP.O. Box 50540Charleston, WV 25305-0540If you are not satisfied with the decision of the Office of the Insurance Commissioner, you mayappeal to Circuit Court. Your appeal must be filed within 30 days after the InsuranceCommissioner’s order has been mailed. Please contact your local Department of Health &Human Resources office to get the form you will need to fill out.Note: If the Member chooses to continue their appeal through a State Fair Hearing,the member has the right to have the benefits continue while the hearing is pending.However, the member will be responsible for the cost of the services if the State FairHearing upholds Health Plan's decision.If the member wants their benefits to continue, or if there are any questions aboutcontinuing the service, even though they may be responsible for payment, please contactour Appeals Coordinator for assistance and/or to have the authorization for theseservices started.Section 5 / Page 22

PROVIDER PROCEDURAL MANUAL 2014OFFICE VISIT CO-PAYS, MEDICAL CO-PAYS,COINSURANCE, AND DEDUCTIBLESSection 6 / Page 1

PROVIDER PROCEDURAL MANUAL 2014OFFICE VISIT CO-PAYS, MEDICAL CO-PAYS,COINSURANCE, AND DEDUCTIBLESThe Health Plan offers a variety of benefit plans that require the member to be responsible for aportion of the cost of services. Member responsibility may take the form of co-pays for officevisits or other medical services, coinsurance amounts and deductibles. As groups re-enrollannually, the member co-payment may change, depending upon the plan selected by theemployer.Office Visit Co-Pay / Medical Co-PayGenerally, co-pays are a fixed amount, but may be a percentage of the allowed amount that isassociated with a specific services such as an office visit, therapy visit, or diagnostic service andwould be member responsibility. Members are expected to pay this amount at the time ofservice.It is imperative that the offices ask for the member’s ID card at every visit toassure coverage and obtain correct co-pay information. Samples of The HealthPlan ID cards are shown on the Product Matrix contained in section 3 of thismanual.Co-Pay may not be waived as this is in direct violation of the Providers Contract.The co-pay should be collected at the time of service, unless other arrangementshave been made. The co-pay amount should be listed as “co-pay” on the claimform.Co-Pays DO NOT apply to hospital inpatient physician visit and/or services, prenatal office visit(after the initial visit), physician nursing home visits or patient home visits when determined tobe medically necessary by the plan. Members of specific employer groups may have Co-Pay forspecific outpatient procedures.CoinsuranceGenerally, coinsurance is an amount based upon the member being responsible for a percentageof the allowed amount for a covered service. A provider may request payment at the time ofservice. However, the provider must take care to determine the member’s specific benefit andapply any contract reimbursement terms to determine the amount of the coinsurance. At no timeshould a provider collect more than the amount that is contractually obligated to pay. The mostaccurate method to assure that the provider is collecting the correct amount may be to wait forthe Explanation of Benefits (EOB) from the Health Plan showing the amount that is memberresponsibility. A copy of the EOB is also sent to the member letting them know the amount thatis their responsibility.Section 6 / Page 2

PROVIDER PROCEDURAL MANUAL 2014DeductiblesDeductibles are an annual amount, defined by the member’s benefit plan, that members mustsatisfy before the plan pays for any services. A provider may expect payment from the memberat the time of service, if the member has not satisfied their annual deductible. However, unless,the member knows that they have not met their deductible, it is generally difficult, due to claimslag, to determine if a member has met their deductible at any given point in time. At no timeshould a provider collect more than the amount that is the member’s responsibility.Collecting Co-Pays When Another Insurance Is PrimaryIf the primary insurance pays equal to, or more, than the office co-pay amount, do not collectThe Health Plan office co-pay.Example: Member has a $10.00 co-pay and his primary insurancecarrier pays $11.00, do not collect the $10.00 co-pay.If you have questions regarding whether or not to collect office co-pay, please contactThe Health Plan Coordination of Benefits/Funds Recovery Department.Determining a member’s responsibilityMember co-pays for physician office visits and certain other services may be found on themember’s Health Plan Identification Card, The Health Plan’s secure Provide Website(www.healthplan.org) or by calling The Health Plan Customer Services.Section 6 / Page 3

PROVIDER PROCEDURAL MANUAL 2014QUICK REFERENCE GUIDE OFCPT CODES FOR OFFICE ENCOUNTERSOffice co-pays are usually applied to all services representing a face-to-face encounter with thephysician or physician extender, except for surgical care.The following list of CPT codes represents the codes most frequently used to describe theseservices. This list represents most frequently used but is not all-inclusive.OFFICE MEDICAL SERVICES99201 99368 9939499202 99381 9939599203 99382 9939699204 99383 9939799205 99384 9940199211 99385 9940299212 99386 9940399213 99387 9940499214 99391 9941199215 99392 9941299366 99393 9942099367AUDIOLOGIC92557 9259392590 9259592591 V500892592 V501092594 V5020CONSULTATIONS99241 9924499242 9924599243OPHTHALMOLOGY92002 9201292004 92014SPECIAL SERVICES / REPORTS99058OTORHINOLARYNGOLIC SERVICES92506PSYCHIATRIC90801 90807 90812 90847 9087590802 90808 90813 90849 9087690804 90809 90814 90857 9089990805 90810 90815 90862 9090190806 90811 90846 90865 90911Section 6 / Page 4


PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramIntroductionWithin this section of The Health Plan Provider Manual is important information regarding thepreauthorization and referral process, disease management, care and case management support,as well as information about medical management oversight, staff and committees, and qualityimprovement initiatives.The goal of The Health Plan Medical Management Program is to ensure the provision ofappropriate health care services to its members, while addressing the effectiveness and quality ofthe care. The delivery of health care services is monitored and evaluated to identifyopportunities for improvement. The program provides for a systematic process to promote theaccess of medically appropriate care in a timely, effective, and efficient manner across thenetwork through case/care management, pre-authorization/referrals, admission/concurrent reviewand disease management and quality improvement programs.Section 7 / Page 2

THE HEALTH PLANPRE-AUTHORIZATION / PRE-NOTIFICATION REQUIREMENTSPLEASE NOTE: There are additional procedures that require preauthorization for EMPLOYER-FUNDED PLANS (ASO).Please contact the Customer Service Departments at The Health Plan, St. Clairsville, OH, (888) 816-3096 or (740) 695-7910for assistance on handling of authorization for employer-funded product lines.Inpatient CareAll Elective, Urgent, and Emergent Inpatient CareSkilled Nursing and Rehabilitation Inpatient CareAll Tertiary Care / Out of Network / Out of Area CareDiagnostic Testing and StudiesAll requests for MRI of the shoulder, knee, hip, extremity,elbow, ankle, foot, wrist, and the spine(cervical, thoracic, lumbar) – no exemption status grantedCT / MRI (other than listed above) / MRA *CT Angiography for CADSPECT MPI (Myocardial Perfusion Imaging)*PET Scan / PET / CT Fusion ScanVirtual Colonoscopy – CT ColonographyProceduresAutomatic Implantable Cardiac Defibrillator / WearableCardioverter Defibrillator / CRT-DBariatric SurgeryBone Anchored Hearing Aid (BAHA) / Cochlear ImplantsBrachytherapy for Treatment of CancerCosmetic Procedures (reduction mammoplasty,rhinoplasty, blepharoplasty, sclerotherapy, otoplasty,scar revision, abdominoplasty, panniculectomy, etc.)HysterectomyKyphoplasty / VertebroplastyProphylactic MastectomyAll Sleep Apnea SurgeriesAmbulatory ServicesAmbulatory Blood Pressure MonitoringCardiac Outpatient Monitoring / Mobile Real-TimeCapsule Endoscopy – Esophageal pH monitoring (Bravo)Continuous Glucose MonitoringDialysis – Out-of-PlanAll Genetic, Pharmocogenetic, & Pharmacodynamic TestingInfertility TreatmentIntensive Cardiac Rehabilitation (Ornish / Pritikin)Low Vision RehabilitationMonitored Anesthesia Care (MAC) for GI EndoscopicsOncotype DX AssayPodiatric Services* after 2 visits / calendar yr.Skin Substitutes (e.g. Dermagraft, Apligraft)Sleep Studies* - All unattended Sleep StudiesSurgical / Invasive Varicose Vein TreatmentTMJ – Diagnostics and TreatmentAll Tertiary Care / Out of Network / Out of Area CareUrinary / Fecal Incontinence ClinicWound Care Clinic (after initial eval) / Hyperbaric OxygenAncillary Providers and ServicesAmbulance / Ambulette – Non-EmergentAudiologists (Independent Practices) All Evals & TestingChiropractic Care – Children (< age 18) and/or out ofnetwork care only; limitations per benefit plan & contractHome Health Services / HospiceInfusion TherapyInsulin Pumps and SuppliesSpeech Therapy – All visits; PT / OT after 20 visitsOrthotics or Prosthetics ≥ $500All Molded-to-Patient Model & Custom FabricatedProsthetics / OrthoticsWheelchairs and AccessoriesDurable Medical Equipment ≥ $500 (rental or purchase)and as required per Health Plan Fee Schedule go towww.healthplan.org for complete informationBehavioral Health ServicesCare coordinated through The Health PlanBehavioral Health Unit – Contact Information on ReverseAddictionology Outpatient Mental HealthCounselor / Therapist PsychiatryInpatient Mental Health PsychologyPre-auth not required for initial evaluation or crisis visitPre-auth required for initial 6 visits, but no TreatmentPlan requiredTreatment Plan must be submitted to continue carebeyond 6 visitsCrisis Encounter Forms requested within 48 hrs. ofcrisis interventionPre-auth required for Neuro-Psych & Psych TestingPre-auth required for ECTPre-auth required for ABA & all services relatedto AutismHealth & Behavior Assessment(CPT 96150, 96151, 96152)Dental ServicesEmergency Extractions for Mountain Health Trust (MHT) /Mountain Health Choices (MHC) / West Virginia MedicaidMembers: Preauthorization is only required for extractionof 3 or more teeth and all wisdom teeth extractions. For 1or 2 extractions, the claim should document that theservices were urgent / emergent. Pre-authorization required except for those physicians / providers currently exempt from review; periodic retrospective review willbe completed to assure compliance with standards of care and medical appropriateness guidelines.Updated September 2013

Specialty PharmacyTo preauthorize Specialty Pharmacy,New TechnologyPreauthorization required – for complete information andPA Forms please go to link belowhttp://www.healthplan.org/Content.aspx/prior-authorization-formsColony Stimulating DrugsRheumatoid Arthritis Drugs (systemic)Crohn’s DiseaseGrowth HormonesMultiple Sclerosis DrugsPsoriasis Drugs (systemic)Oral Chemotherapy AgentsDrugs to treat Pulmonary Arterial HypertensionIron Replacement TherapyKalydeco for Cystic FibrosisFor a complete list, see Specialty Medications athttp://www.healthplan.org/pdf/SpecialtyPharmacy2013_10_14_13.pdfTraditional drugs requiring preauthorizaton:See list under 2013 Drug Formularies athttp://www.healthplan.org/Content.aspx/drug-coverageinformationor via Epocrates.Artificial Uninary SphincterAutologous Chondrocyte ImplantationBioimpendance / Biventricular Pacemaker / CRT-DBone Morphogenetic Protein (BMP)Botulinum Toxin InjectionsCarotid Artery StentingChemoembolizationCryosurgery for Renal MassesDSEK and DSAEK for Corneal Endothelial DegenerationEnhanced External Counterpulsation (EECP)HALO 360 Coagulation SystemIntensity Modulated Radiation Therapy (IMRT)Intrastromal Corneal Ring Inserts (Intacs)Implantable / Insertable Loop RecorderGamma Knife / Stereotactic RadiosurgeryGastric Electrical StimulationLeft Ventricular Assist Device (LVAD)ProstaScintProvenge Immunotherapy for Prostate CancerRadiofrequency Ablation for Chronic Back PainSelective Internal Radiation TherapySacral Nerve Stimulation / Spinal Cord StimulatorTransperineal Template Guided Saturation Biopsy of theProstate (CPT 55706)X STOP Interspinous Process Decompression SystemXiaflex InjectionsReferral Line:Admissions:Elective admissions, non-emergent referrals, diagnostics, imaging and procedure pre-authorizationsAvailable 8:00am to 5:00 pm • Monday through FridaySt. Clairsville, OhioMassillon, Ohio(800) 526-7511 (888) 830-4370(740) 695-7905 (330) 830-4370The Health Plan PPO Products Line: (855) 577-7123 or (740) 699-6273ASO / Employer - Funded Product Line: (888) 816-3096 or (740) 695-7910Notification of urgent and emergent admissions to participating facilities (In-Plan)Fax:St. Clairsville, OhioMassillon, Ohio(800) 304-9101 (888) 830-4370(740) 695-7918 (330) 830-4370To submit clinical information for review:St. Clairsville, OhioMassillon, Ohio(888) 329-8471 (888) 450-6024(740) 695-5297 (330) 830-4380Behavioral Health Unit: For referrals, care coordination, and continuing behavioral health services:Physician Access Line:Provider Websites:Toll – Free 24 hrs / day 7 days / week (877) 221-9295Secure Fax (866) 616-6255 or (740) 699-6255EMERGENT BEHAVIORAL HEALTH ISSUES and contacting the Medical Director after hours(866) NURSEHP (866) 687-7347. Available 24 hours a day / 7 days a week – Physician Access onlywww.healthplan.org - Open website; links to password secure Provider Website for eligibility,claims, reference materials and provider support informationADDITIONAL SERVICES MAY REQUIRE PREAUTHORIZATION.Due to changes in medical technology, the accessibility of diagnostic equipment and services in an office / outpatient setting, as well as updated methods of performingprocedures, there may be additional services that will require prior authorization. Please contact The Health Plan prior to performing services related to newtechnology. Periodic review of provider utilization data may eliminate or require the need for medical appropriateness review and preauthorization of additional services anddiagnostic studies.Updated September 2013

The Health Plan Medical Management ProgramOUT-OF-PLAN REFERRALSFor elective admissions or transfers to tertiary facilities call:(800) 526-7511 or (740) 695-7905Available M-F, 8:00 AM – 5:00 PMPROVIDER PROCEDURAL MANUAL 2014For all urgent / emergent admissions or transfers to tertiary facilities call:(866) NURSEHP (866) 687-7347Available 24 hours / 7 days a weekOUT-OF-PLAN (Tertiary Referrals)The information below is provided to better assist you in locating an appropriate physician at our tertiary level hospitals. If you should have any questionsregarding tertiary facilities, do not hesitate to call The Health Plan Medical Department at (800) 624-6961 or (740) 695-7643.Akron General Medical Centerwww.akrongeneral.orgPhysician Ready Access(800) 362-2462Available 24 hrs / 7 days a weekCabell Huntington Hospitalwww.cabellhuntington.org(304) 526-2000Patient Transfer Center(877) 531-2CHH (877) 531-2244Available 24 hrs / 7 days a weekCharleston Area Medical Center (CAMC)www.camc.orgTransfer Center Physician Access Line(877) 226-2273Available 24 hrs / 7 days a weekChildren’s Hospital Medical Center of Akronwww.akronchildrens.orgCommunications Center(800) 221-5437Available 24 hrs / 7 days a weekChildren's Hospital of Pittsburghwww.chp.edu/CHP/Home(412) 692-PEDS (412) 692-7337Available 24 hrs / 7 days a weekCleveland Clinic Foundationwww.clevelandclinic.org(800) 553-5056Available 24 hrs / 7 days a weekMount Carmel Health Systemswww.mountcarmelhealth.com(614) 234-6000• Mount Carmel East(614) 234-6000Section 7 / Page 5• Mount Carmel West(614) 234-5000• Mount Carmel St. Ann's(614) 898-4000• Mount Carmel New Albany Surgical Hospital(614) 775-6600All Available 24 hrs / 7 days a weekNationwide Children’s Hospital(Formerly Columbus Children’s Hospital)www.nationwidechildrens.org(800) 875-KIDS (800) 875-5437Available 24 hrs / 7 days a weekOhio State Universityhttp://medicalcenter.osu.edu(800) 293-5123Available 24 hrs / 7 days a weekALL TERTIARY CARE MUST BE PRE-AUTHORIZEDSumma Health Systemwww.summahealth.org(330) 375-3000• Summa Akron City Hospital• Summa St. Thomas HospitalUniversity Hospitals Case Medical Centerwww.uhhospitals.org(800) 552-8338 or (216) 844-7553Available M-F, 8:30 AM – 4:30 PMfor non-emergent issues(216) 844-1111After hours and weekendsWest Penn Allegheny Health Systemwww.wpahs.org(412) 578-5000After hours and weekends• Allegheny General Hospital(888) 660-4884Available 24 hrs / 7 days a week• West Penn Hospital(412) 362-8677Available M-F, 7 AM – 6 PMWest Virginia University Hospitalswww.health.wvu.edu(800) WVA-MARS (800) 982-6277Available 24 hrs / 7 days a week

PROVIDER PROCEDURAL MANUAL 2014The Health Plan of the Upper Ohio Valley, Inc.Medical Management Department Telephone ListReferrals/Pre-Authorizations 1-888-830-43701-330-830-43708:00 a.m. to 5:00 p.m.Admissions to In-Plan FacilitiesUrgent or Emergent24 / 7 availability-reverts tovoice mail after hoursAdmissions to Tertiary orOut of Plan FacilitiesDuring Business Hours8:30 a.m. to 5:00 p.m.MassillonSt. Clairsville1-888-830-43701-330-830-43701-888-830-43701-330-830-4370Fax 1-888-450-60241-330-830-4380General Information 1-877-236-22891-330-834-2200Medical Directors 1-877-236-2289 ext. 22071-330-834-2200 ext. 2207Social Worker 1-877-236-2289 ext. 23041-330-834-2200 ext. 2304Disease Management 1-800-624-6961 ext. 7620 / 61101-740-695-7620Quality Improvement Department 1-800-624-6961, ext. 61131-740-695-3585Secretaries 1-877-236-2289 ext. 22071-330-834-2200 ext. 2207Section 7 / Page 61-800-526-7511 or1-740-695-79058:00 a.m. to 5:00 p.m.1-800-304-9101 or1-740-695-79181-800-526-7511 or1-740-695-79051-888-329-84711-740-695-52971-800-624-69611-740-695-35851-740-695-7643 or 76441-800-624-6961 ext. 7643 / 76441-740-699-6125 or1-800-624-6961, ext. 61251-800-624-6961 ext. 7620 / 61101-740-695-76201-800-624-6961, ext. 61131-740-695-35851-740-695-7643 or 76441-800-624-6961 ext. 7643 / 7644After HoursUrgent/Emergent Issues1-866-NURSEHP (Toll Free)(1-866-687-7347)1-866-NURSEHP (Toll Free)(1-866-687-7347)1-866-NURSEHP (Toll Free)(1-866-687-7347)

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramAdmission / Concurrent Review ProcessPre-authorization of elective admissions is performed to confirm eligibility, benefits, andmedical appropriateness of services to be rendered and level of care to be utilized. The processis initiated by the member’s Primary Care Physician or referring participating specialist with theMedical Department’s nurses. This includes acute care, rehabilitation, skilled nursing facilitiesand units, and long term care facilities.Pre-authorization notification of urgent/emergent admissions, by the admitting physician orfacility, is required at the time of, or as soon as practically possible after admission. This activityis performed for early discussion of member’s needs as related to the admission or alternativehealth care services. This includes acute care, rehabilitation, skilled nursing facilities and units,and long term care facilities.All out-of-plan and tertiary requests require a referral and pre-authorization. Clinicalinformation is reviewed for availability of service within the in-plan network, urgent/emergentsituation or other extenuating circumstances and should be supplied by the Primary CarePhysician or appropriate in-plan specialist (If referring within their specialty). This includesacute care, rehabilitation, skilled nursing facilities and units, and long term care facilities.Concurrent review is the process of continued reassessment of medical appropriateness forcontinuing inpatient care. Any member identified with potential discharge planning needs isreferred by the Medical Department’s hospital review nurse to care/case management, diseasemanagement or the social worker as appropriate for early intervention. Concurrent review isperformed on-site and telephonically and involves communication with physicians, hospital URand social workers, and family members as necessary. Anytime a quality of care issue isidentified or suspected, the case is referred to The Health Plan Quality Improvement Departmentfor review.Please indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan.Section 7 / Page 7

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramPre-Authorization / Referral ManagementPrimary Care Physicians are responsible for directing care to Specialty Care Physicians.The Health Plan does not require referral notification in most instances.Please refer to the complete listing of services that require pre-authorization and/ornotification found at the beginning of this section, in the Quick Reference Guide. Rememberthat additional services may require prior authorization based on specific plan requirements of somegroups, especially those that are Self-Funded or Employer-Funded. Also, due to changes in medicaltechnology and the accessibility of diagnostic equipment and services in an office/outpatient setting,as well as updated methods or approaches to performing procedures and services, there may beadditional service that will require medical review. Contact The Health Plan if you have concernregarding a particular procedure or test.The following is an overview of services that require pre-authorization:Ancillary services require pre-authorization by the Medical Department through the referralprocess. Some services that require pre-authorization include home health, hospice, durablemedical equipment with a cost of $500 or more, and well as all customizations and add-onsregardless of cost. In addition, all DME repairs and replacements require pre-authorization.Diagnostic testing and Imaging studies require pre-authorization and medical appropriatenessreview, including but not limited to, MRI/MRA and CT scans, PET and PET/CT Fusion scan,SPECT MPI, and Cardiac CT angiography.All out-of-plan and tertiary requests require a referral and pre-authorization. Clinicalinformation is reviewed for availability of service within the in-plan network, urgent/emergentsituation or other extenuating circumstances and should be supplied by the Primary CarePhysician or appropriate in-plan specialist (If referring within their specialty). Please refer toThe Health Plan list of Tertiary Providers to assist you in directing members to appropriateproviders.All genetic testing requires prior authorization. This includes, but not limited to, allprognostic gene expression profiling techniques, all gene and molecular expression assays, andall genetic testing for inherited susceptibility for a disease.When genetic testing is being considered, it is imperative that the testing be authorized prior tocompleting laboratory requisitions. Information needed to preauthorize testing includes:Patient displays clinical features or is at direct risk of inheriting the mutation in question.Result of the test will directly impact the treatment being delivered to the patientDocumentation of a comprehensive history, physical examination, genetic counseling asindicated, and completion of conventional diagnostic studies.Genetic tests should be completed at an inplan laboratory.Section 7 / Page 8

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramAuthorization is obtained via telephone or fax. A Genetic Testing Review Form can be foundin the Appendix A of Section 7 to assist you in pre-authorizing these services.Additional services that require prior authorization include procedures that may have limitedcoverage under the plan benefits and/or cosmetic in nature. Also, high cost procedures and newtechnologies that have specific coverage guidelines should be pre-authorized to assure medicalappropriateness and compliance with established standard of care guidelines. Please contact theHealth Plan Customer Service if you have any concern regarding coverage of any service.Please refer to the Behavioral Health Department and Pharmacy Department sections of thismanual for specific information regarding the process for referrals and prior authorization ofthose services.Any referral that does not meet medical appropriateness review by the nurse reviewer is referredto the Medical Director for review determination. The Medical Director may contact the primarycare physician, consulting physician, or specialist for case discussion. Availability of serviceswithin the provider network and alternative levels of care for services may be offered asappropriate to the member’s needs. “Member driven” referrals that you cannot justify asmedically necessary should not be initiated.Refer to Appeals Process, which is found in this section of the Practitioner Manual, to assist youin the event of prospectively non-authorized services.Please indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan.Section 7 / Page 9

PROVIDER PROCEDURAL MANUAL 2014Requests for Second OpinionThe Health Plan Medical Management ProgramMost “Second Opinion” evaluations may be achieved within the member’s local network.In the event the services requested are not available locally, a tertiary level “second opinion”may be considered.When requesting a second opinion at a tertiary facility, please understand that this requestauthorizes an evaluation visit only and all further visits, surgery, treatment, and testing arenot authorized.Once the evaluation is completed, the consulting physician should send his/her report back to thereferring physician, who will then discuss findings with the member.Please indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan.Review Exemption Status of ProvidersPeriodic review of provider utilization data may require or eliminate the need for medicalappropriateness review and preauthorization of a particular medical service and diagnostic study.Trends within the health care industry may also warrant changes in the review protocols established.The Health Plan has established a review exemption policy that allows providers who havedemonstrated compliance with medical appropriateness guidelines, the preauthorization process,and compliance with quality improvement practice guidelines and standards of care, to berelieved of certain review processes. This review exemption status, know as gold-carding, isonly applicable to the specific service as indicated by the notification to the provider and doesnot imply that the physician is exempt from all preauthorization processes. In these instances,the provider will be considered “gold-carded” for a particular diagnostic study or service and notlonger be required to preauthorize that particular service.Currently, The Health Plan has assigned gold-carding status to many network providers whohave demonstrated compliance in medical appropriateness review of CT, MRI/MRA, and well asSPECT MPI and Sleep Studies. Annual review of utilization, as well as medical record audits,will be conducted to ensure compliance continues once review exemption is established.Urgent Care Centers are not eligible for review exemption gold-carding unless they also serve asthe Primary Care Physician. Diagnostics order as part of an Urgent Care encounter, when indeedurgent (within 24 hours of the visit supported by an appropriate diagnosis) may not requirepreauthorization based on urgent care guidelines. Diagnostic testing that is to be done outside ofthat 24 hour period should be directed by the Primary Care Physician.Physician Extenders, Physician Assistants and Nurse Practitioners, are also not eligible forreview exemption. Diagnostic testing should be ordered by the collaborating physician.NOTE: There may be specific group requirements that may override this exemption status,particularly those under the self-funded plans.Section 7 / Page 10

Standing ReferralsPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramIt is The Health Plan’s policy to facilitate ongoing specialist care for the benefit of appropriatemembers. This goal is accomplished by the use of standing referrals. This would apply whenthe Primary Care Physician, in consultation with a specialist, identifies the need for continuingspecialty care, over a short period of time, for resolution of a condition that is notlife-threatening, degenerative, or disabling.The Primary Care Physician is responsible for initiating the standing referral and supplyingappropriate member history. A treatment plan is formulated by both physicians and the member.The plan of care is subject to review by the Medical Department.The number of visits shall be evaluated based upon the treatment plan and shall be limited to asix (6) month period of time.In order to assure appropriate coordination of care, the specialist shall provide the Primary CarePhysician with regular reports on the care provided to the member.The Primary Care Physician is responsible for providing updated reports and treatment plans toThe Health Plan’s Medical Department for review prior to extension of the standing referral.Specialist Coordination of Health Care ServicesIt is the policy of The Health Plan to facilitate ongoing specialist care and coordination for thebenefit of appropriate members. This would apply when the Primary Care Physician, inconsultation with a specialist, identifies the need for specialty care over an extended period oftime for a chronic condition that is life-threatening, degenerative, or disabling.The Primary Care Physician is responsible for initiating the specialist coordination referral andsupplying appropriate member history. A treatment plan is formulated by both physician and themember. The plan of care is subject to review by the Medical Department.Upon approval of the specialist coordination referral, the specialist is authorized to provide andrefer for health care services in the manner of the Primary Care Physician.In order to assure appropriate coordination of care, the specialist shall provide the Primary CarePhysician with regular reports on the care provided to the member.For the specialist to continue to coordinate care, the Primary Care Physician is required torequest an extension of the specialist coordination referral every six (6) months and to provideupdated reports and treatment plans to support medical appropriateness.Section 7 / Page 11

Review CriteriaPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramNationally recognized clinical criteria are utilized to perform reviews for medicalappropriateness allowing for consideration of the needs of the individual member, theircircumstances, medical history, and availability of care and services within The Health Plannetwork. Input is sought annually or as needed in the review of criteria from physicians inthe community and those who serve as members and Associate Medical Directors of thePhysician Advisory Committees. In cases where specific clinical expertise is needed toperform a particularly specialized review, experts outside The Health Plan may be used.InterQual® ReviewThe Health Plan utilizes McKesson InterQual Criteria as a screening guideline to assist thenurse reviewers with respect to medical appropriateness of health care services. Anyparticipating provider may, upon request, review the specific criteria used in an activeclinical review process of a procedure requiring the use of InterQual .You may call The Health Plan Medical Department if you have a general InterQualquestion or a question regarding a particular case. Also, a Health Plan nurse can visit youroffice or you may come to The Health Plan to review the criteria. InterQual reviewworksheets are available upon request.InterQual may be utilized to assist in the review of the following surgical andradiological procedures:MRIMRACT ScansTMJ RepairRhinoplasty/SeptoplastyUvulopalatopharyngoplasty (UPPP)BlepharoplastyHysterectomyPlease indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan.A Health Plan Referral Worksheet for Information Necessary to Obtain Referral can befound in the Appendix A of Section 7 is merely intended as an aid to assist the office in thephone-in or website referral process.Section 7 / Page 12

Podiatric ServicesPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramAuditing of medical appropriateness and utilization of Podiatric care will be completedperiodically with the intention of releasing those podiatrists found to be compliant with theseguidelines from the preauthorization requirements.Prior authorization is obtained via telephone or fax. A Podiatry Precertification Form can befound in the Appendix A of Section 7 to assist you in pre-authorizing these services.Initial referrals and visits/consultations:Initial consult/visit with a participating plan podiatrist does not require a referral from theprimary care physician or prior authorization/notification to The Health Plan.Members will have up to two (2) allowed visits per calendar year.New consults will not be permitted within six (6) months of a previous consult/visit withoutprior authorization.Subsequent Visits:Subsequent visits, treatments, and surgery following a consult require submission of atreatment plan and prior authorization.Some of the following services may require pre-authorization:ProceduresDMEMedicationsSurgeryFollow-Up VisitsChanges in treatment plans from those initially authorized will need to be pre-authorized.This would include new diagnoses not authorized on prior treatment plan. (Example: diabeticfoot care visits authorized with a new problem in the interim, i.e. foot ulcer or infected nail/toe).Members may not be billed for services that were provided without the required preauthorization,unless the provider made the member aware that the service was non-covered priorto providing the service, using an “advanced beneficiary notice”.Determination of Scope of Podiatry Practice Services:Scope of provider practice and appropriateness of podiatric procedure will be determined byThe Health Plan upon review of hospital privileges.Claims will be reviewed for appropriateness of services based on supporting diagnosis andsubmitted treatment plans.Future credentialing of podiatrists:Effective January 1, 2006, all contracting podiatrists will be required to have board certificationand hospital privileges. This will only affect new podiatrists’ applications for credentialing.Use of radiology in the podiatrist office:X-rays in the office are allowed for bony diagnosis and post-operative follow-up only.All other requests for radiology services must be pre-authorized by the Medical Department.Section 7 / Page 13

Chiropractic CarePROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramAll Chiropractic Care requires preauthorization. Authorization is obtained via telephone orfax. A Chiropractic Treatment Plan can be found in the Appendix A of Section 7 to assistyou in pre-authorizing these servicesInitial evaluations require an authorized referral from The Health Plan as directed by thereferring physician/provider.Follow-up care will be authorized upon medical review of a treatment plan from the treatingchiropractor – sample treatment plan can be found on the following page.The Health Plan may cover up to 3 modalities plus the visit.Only 1 unit of each modality will be covered at each visit.Radiology procedures are authorized at those offices having submitted documentation of theequipment being used and the qualifications of the personnel performing the x-rays.Radiology procedures in the office are limited to the x-rays covered under contractualagreement and must be supported by diagnosis.Please verify all co-pay and benefit information through Customer Service, as they mayvary by group and line of business.Section 7 / Page 14

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramAppealsThe Health Plan has well established policies and procedures for the prompt, comprehensive, andtimely review of appeals.Communication is an essential component of the utilization process and as such, the processinvolves effective communication between physicians and The Health Plan. Communication isthe key to complete prior authorizations, concurrent reviews, and care/case managementprocesses. Most issues are resolved to mutual satisfaction in this manner.The Health Plan’s process for appeals is member and physician friendly. The process allows forthe physician or other authorized representative to act on the member’s behalf. The MedicalDirector is available to discuss a utilization management decision with the member’s physicianat any point in the review process.The Health Plan’s policies and procedures address pre-and post-service appeals, expeditedappeals and appeals to an external independent review organization.The referral notification contains the specific reasons for the non-authorization inlayperson language for the member. Specific clinical information can be provided for thepractitioner’s review.The Health Plan explains on the notification that the Medical Director is available and how tocontact the Medical Director to discuss the decision.The benefit provision, guideline, protocol or criteria used to make the decision is referenced.The notification informs the member they can receive a copy of the actual benefit provision,guideline, protocol or criteria used to make the decision, upon request.The appeal rights are explained on the notification including the member’s right to representationand their right to submit written comments, documents or other pertinent information relevant tothe appeal.The time frames for decision making are explained in the notification.A description of the expedited appeal process is part of the notification.Section 7 / Page 15

Provider’s Name: ________________________________________________________Patient’s Name: __________________________________________________________Health Plan ID#:_______________________NOTE:ADVANCE BENEFICIARY NOTICE of NONCOVERAGE (ABN)If Health Plan doesn’t pay for ________________________ below, you may have to pay.The Health Plan does not pay for everything, even some care that you or your health care provider have goodreason to think you need. We expect The Health Plan may not pay for the __________________below.Service: Reason The Health Plan May Not Pay: EstimatedCost:WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the ____________________ listed above.NOTE: If you choose Option 1 or 2, we may help you to use any other insurance that you mighthave, but The Health Plan cannot require us to do this.OPTIONS:Check only one box. We cannot choose a box for you Option 1. I want the _________________ listed above. You may ask to be paid now, but I also wantThe Health Plan billed for an official decision on payment, which is sent to me on an Explanation of Benefits(EOB). I understand that if The Health Plan doesn’t pay, I am responsible for payment, but I can appeal to TheHealth Plan by following the directions on the EOB. If The Health Plan does pay, you will refund any payments Imade to you, less co-pays or deductibles. Option 2. I want the _________________ listed above, but do not bill The Health Plan. Youmay ask to be paid now as I am responsible for payment. I cannot appeal if The Health Plan is not billed. Option 3. I don’t want the ____________ listed above. I understand with this choice I am notresponsible for payment, and I cannot appeal to see if The Health Plan would pay.Additional Information:This notice gives our opinion, not an official Health Plan decision. If you have other questions on this notice or HealthPlan billing, call 1-800-624-6961 (1-800-622-3925/TTY). Signing below means that you have received and understand thisnotice. You also receive a copy.Signature:Date:Y0038_11_149; File & Use 03/02/2011Updated 2011, ReviewedUpdated 12/2012, 2011, 12/2013, Updated Reviewed 12/11/2014 20112012

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramCare Management – Manage individual patients as designated, normally on a short-termbasis, mainly episodic or situational, such as those SecureCare members identified by HRA,and members identified through discharge survey.The care management program is also individualized to the member and coordinates resourcesacross the continuum to minimize costs while improving quality of care. Care management is apro-active approach that focuses on promotion of health education, and member empowermentthrough self-maintenance.Members are identified through established care management criteria, referrals from other areasof medical management, member / family or physician, and other departments within The HealthPlan, health risk assessments, and discharge surveys. In addition, both physicians and membersmay contact the Medical Management Department via telephone or at www.healthplan.org, tosee if a particular patient could benefit from Care Management Services.The care managers can take elective, urgent, or emergent admission notifications; orchestrateskilled nursing admissions or intermediate care placement direct from home for most members.They will coordinate and authorize home health visits or home infusion services, acquire durablemedical equipment after business hours, and secure the assistance of the Licensed Social Worker.Medical Care Management1. Multiple Co-Morbidities as Identified2. Re-admitted Patients within 7 or 30 Days asIdentified by Readmit Report3. Identification through High Cost Report4. Identification by HRA[Health Risk Assessment]for SecureCare Members5. Enrollment in Clinical Trials6. Identification through Discharge Survey7. Diabetes, CHF, or COPD Not Eligible for DM8. Redirection / Transition UPMC FacilityAdmissions & Concurrent Reviews9. MHT Children with Special Health CareNeeds as Identified10. Pediatric Diabetics as Identified by a Report11. Adult Type 1 Diabetics as Identified12. Admissions with Length of Stay [LOS] of15 Days or Longer13. Members on Wound Vacs & HBO14. Palliative Care / Hospice Needs15. Pulmonary Hypertension16. Adult Type 1 Diabetics on Insulin Pumps17. Intensive Cardiac Rehabilitation18. Six Month Follow-up of Members Enrolledin IMATCH ProgramSection 7 / Page 17

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramBehavioral Health Care Management1. Primary Substance Abuse, other thanOpiates2. Multiple Co-Morbidities or High RiskCo-Morbidity with Short Term, Non-Bio-Based Behavioral Health Diagnosis,Identified by Depression Survey or Referral,not Suitable for Case Management3. Enrollment in Clinical Trials4. Identification through Discharge Survey5. All Members Seeing Out ofNetwork Providers6. Redirection / Transition of Members forOON to IP Providers7. Crisis Encounter Follow-Up8. Antidepressant Medication ManagementFollow-UpCase Management – Manage individual patients normally on long-term basis who areidentified to be at high risk due to high costs, catastrophic illness, or injury and/or complexdelivery of care.The case management program is an individualized, patient-specific process of coordinatingresources and creating flexible, quality, cost effective health care options. The process isdependent upon collaboration between treating physicians, members and their family, orsignificant others.Identification of members is primarily through catastrophic injury and illnesses, high costutilization, health risk assessment, or the pre-authorization/referral, and concurrent reviewprocess. Referrals for case management may also come from other sources such as family,physician, hospital staff, and other departments within The Health Plan via health screening andoutreach programs.Registered nurses perform the case management function. They coordinate care and resources,provide alternatives to hospital care, facilitate care across the continuum, and prevent duplicationand fragmentation of health care services. They manage individual patients normally on a longtermbasis who are identified to be at high risk due to high costs or catastrophic illness or injury.Work with the 20% of the people who use 80% of health care resources.The processes of case management include: case identification and referral, case screening andassessment, case implementation, case monitoring and case closure. Please contact the HealthPlan Case Management Department at 1-800-624-6961. ext 7643 or 7644, or enroll membersonline at www.healthplan.org.Section 7 / Page 18

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramMedical Case Management1. Transplant - Organ and Bone Marrow; IncludesEvaluations, Pending and Post Transplants2. Catastrophic Neuromuscular Diseases suchas Myasthenia Gravis, Multiple Sclerosis,Amiotrophic Lateral Sclerosis3. Traumatic Brain Injury4. Cystic Fibrosis5. New Spinal Cord Injury6. Critical or Major Burns – 1st or 2nd degreeburns covering more than 25% of adult’sbody or more than 20% of child’s or a 3rddegree burn on more than 10% bodysurface area or burns involving hands, feet,face, eyes, or genitals.7. HIV8. Ventilator Cases in Home Setting9. Major Congenital Anomalies such as AtrialSeptal Defect, Valve Stenosis and Atresia,Pulmonary Artery Stenosis, Patent DuctusArteriosas, Spina Bifida, Metabolic Defects10. Premature Birth (Extreme) 28 Weeks or Less11. High Cost Ongoing Complex Care needs asidentified on weekly paid hospital claimsreport greater than $20,00012. Pediatric Cancers in Active Treatment13. MHT Children / Enrollees with SpecialHealth Care Needs14. HemophiliaBehavioral Health Case Management1. Multiple Co-Morbidities or High RiskCo-Morbidity (Chronic Medical Conditionwith Behavioral Health Diagnosis),Identified by Depression Survey or Referral2. Dual Diagnosis / Schizophrenia3. Attempted Suicides or Homicides4. Stays Longer than 30 Days as Identified bythe LOS > 15 Day Report5. MDD, not qualifying forDisease Management6. Substance Abuse Diagnosis with MentalHealth Diagnosis7. Inpatient Admission, not qualifying forDepression Disease Management8. Outpatient Treatment of Opioid Addiction9. Psychosis10. High Cost Ongoing Complex Care needs asidentified on the Weekly Paid HospitalClaims Report Greater than $20,000.00Cases with diagnoses 2, 3, 5, and 9 are designated as Complex Cases on the BH Assessment Screen,as well as any others at the discretion of the Case Manager.Section 7 / Page 19

Social Work ServicesPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramSocial Work Services are available to assist Health Plan members and their families withsocio-economic, psychosocial, personal, and environmental issues, which can predisposeillness or interfere with obtaining the maximum benefit from medical care.The Social Worker coordinates with health care providers and The Health Plan MedicalDepartment staff to identify community resources that will assist the member to resume life inthe community or learn to live within the limits of a disability in an effort to restore themember to an optimal level of social and health adjustment.Services provided by The Health Plan Social Worker may include:Financial counselingAssisting in applying for financial aid programsAssessing need and qualifications for pharmacy assistance programsHome visits to evaluate and assess the needs of the memberEducating members on resources available to them and their familiesCoordinating referrals to ancillary support, personal care, and nursing home placementProviders identifying social-economic needs of a Health Plan member may contact theSocial Worker to discuss possible assistance programs and support services.Section 7 / Page 20

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramDisease Management & Health Promotion ProgramsThe Health Plan’s Disease Management and Health Promotion Programs are multi-disciplinaryand continuum-based systems developed to proactively identify populations with, or at risk for,chronic medical conditions. Populations currently being managed include members withasthma, diabetes, chronic heart failure, and chronic obstructive pulmonary disease. The HealthPlan’s pregnant members are also monitored with the intent to identify those at high risk forpremature delivery.Disease management programs support the practitioner-patient relationship and plan of care;emphasize the prevention of exacerbations and complications using evidence based practiceguidelines and patient empowerment strategies. The Health Plan programs continuouslyevaluate clinical, humanistic, and economic outcomes with the goal of improving overallhealth status. The essential elements of disease management include understanding thecourse, clinical implications, and trajectory of specific diseases; identifying and targetingpatients likely to benefit from intervention; focusing on prevention; and working towardresolution of resource-intense problems.Each management program includes condition monitoring that is ongoing and proactive.This allows the member, the practitioner, and the disease manager to assess how well thecondition is being managed. Monitoring is done with regular clinical assessments withsurveillance of pharmacological management, lifestyle management, and assessment of themember’s understanding of the condition itself as well as the related co morbid conditionslikely to affect overall health status.Member adherence to the program’s treatment plan is an integral part of disease management.Members are followed to determine their success with self-management, self-monitoringactivities, and medication compliance. High-risk members are called at periodic intervals.Detailed questions are asked about the member’s condition and information is gathered regardinghealth status, treatment plan adherence, functional status, and quality of life. A specific plan ofcare is developed based on the findings from a clinical assessment and functional inventory.Ongoing monitoring by the disease manager ensures timely intervention when a change in riskstatus is identified. The frequency of outbound calls to participants by the case manager isdetermined by the severity of symptoms. This may result in daily contact in times of high risk orconcern. When home care is needed in high risk-cases, the disease manager works with thepractitioner and a home care agency to coordinate necessary care and services.In all instances, disease management and health promotion programs must consider otherhealth conditions that directly affect the member’s overall health status. A multi-disciplinaryapproach to disease management enables the disease manager to develop a treatment planthat includes condition monitoring of co morbid conditions frequently associated withchronic medical conditions.Section 7 / Page 21

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramBecause lifestyle issues are strongly linked with chronic disease and high-risk pregnancy,strategies to address current lifestyle and the need to modify behavior is addressed in everyprogram. Whether members need interventions addressing issues such as smoking cessation orweight loss management, the disease manager is able to address readiness to change and toprovide additional resources to affect needed change.The Health Plan’s Disease Management and Health Promotion Program elements include:Identification of evidence-based standards of care, best practices, evidence-basedIntervention strategies, and targeted outcomesIdentification of the member and assessment of health statusProactive intervention to include the application of appropriate therapies and systematicsurveillance of appropriateness of medication, education and counseling about dailyself-management, and symptom managementTracking of the member’s clinical and functional status over timeAssessment of effectiveness of treatment and sharing of knowledge gained to achieveoptimal member outcomesAttention to all program elements and improvements in all of these areas will likely lead toimproved outcomes for the many who are at risk or who suffer chronic diseases.Please contact the Health Plan Disease Management Department at 1-800-624-6961. ext 7620or 6110, or enroll members online at www.healthplan.org.Section 7 / Page 22

Diabetes ProgramPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramThe Diabetes Program is designed to modify risk factors associated with diabetes as well asslow the progression of microvascular and macrovascular complications. This is accomplishedby promoting treatment plan compliance through education, counseling, and support.Members with diabetes require long-term, continual health care to maintain appropriateglycemic control and to decrease the risk of long-term complications such as neuropathy,nephropathy and blindness. Program goals include:Glycemic controlReduction of risk factorsOptimization of functional capacityPrevention of microvascular and macrovascular complicationsFacilitation and enhancement of the patient/doctor relationshipMember identification is conducted by ICD-9 analysis of ambulatory and inpatient claimsand inpatient DRG 294 and 295. Diagnosis codes include: 250.XX, 357.2, 362.0, 366.41,and 648.0. Other methods of identification include health risk screening and direct referralby the primary care physician or specialist. Member stratification is based on severity ofillness and comorbid conditions.The diabetes program relies on the population based HEDIS® 1 Comprehensive Diabetes Caremeasures for outcomes analysis. The same measures are also used at the individual member levelfor those members stratified as high risk and who participate in The Health Plan’s telephonicdiabetes management program. Primary attention is given to assisting the member in reachingand then maintaining glycemic control. Daily self blood glucose monitoring and quarterly A1ctesting are the criteria used to monitor glycemic control. Additional criteria include lipidmonitoring and control, dilated eye exam performance, and monitoring of kidney function.Population based disease management strategies include the annual eye exam coupon programas well as appropriate educational mailings throughout the year. The provision of diabeticsupplies and glucometers for self-monitoring of blood glucose and other diabetes benefits areimportant components of the program.High risk members receive telephonic disease management intervention from a diabetes nursespecialist who provides individualized interventions that include the evaluation of appropriatemedication use, education and counseling about self-management, surveillance of symptoms,and consideration of other health conditions based on nationally recognized ADA guidelines.1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).Section 7 / Page 23

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramCondition monitoring and surveillance are ongoing and proactive. Calls are scheduled atperiodic intervals. Detailed questions are asked about the patient’s condition and informationis gathered about patient status, treatment plan adherence, functional status, and quality oflife. A specific plan of care is developed based on the American Diabetes Association’sStandards of Medical Care for Patients with Diabetes Mellitus. Ongoing monitoring bythe diabetes manager ensures timely intervention in the event of a change in risk status.The frequency of outbound calls to the member is determined by the severity of symptoms.This may result in daily contact in times of high risk as well as consultations withthe physician. When home care is needed, the nurse works with the home care agency tocoordinate the necessary care and services.A major component of the Diabetes Program is the empowerment of the memberthrough education. A variety of topics are addressed in both initial and reinforcementteaching. Patient education materials are provided to each patient throughout the programand are used in the teaching process. A thorough education of the disease process andrecognition of symptoms of hyperglycemia and hypoglycemia are included. Each membercontact includes a review of medications and medication compliance. Lifestyle issues areaddressed through education and include the importance of exercise, diet, proper selfmanagementskills and, when indicated, smoking cessation interventions. Members are alsoreferred to certified diabetes educators and the Ohio Valley Pharmacy Care Network,(Certified pharmacists in diabetes education) to increase member understanding of thedisease process and enhance self-management skills.A successful diabetes program is dependent on the coordination of health care services.The role of the physician is vital and this program is intended to complement the medicalcare each member receives from his/her physician. The goal of The Health Plan is to foster acollegial relationship between the physician and the care manager to coordinate the necessarycare for the member. Evidence based guidelines are available and recommended for use bythe physician to medically manage their patients with diabetes. The Health Plan DiabetesFlowchart based on The Health Plan Guidelines and ADA Standards of Medical Care ismailed annually to physicians for use to document diabetes care.Section 7 / Page 24

Chronic Heart FailurePROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramThe chronic heart failure program is designed to modify cardiovascular risk factors and slowdisease progression. This is accomplished by promoting treatment plan compliance througheducation, counseling, and support. Program goals include:• Reversal of, or stabilization of symptoms of chronic heart failure• Optimization of functional capacity• Improvement in quality of life• Reduction in frequency of hospitalization• Facilitation and enhancement of the patient/doctor relationshipMember identification is conducted by ICD-9 analysis of ambulatory and inpatient claims andinpatient DRG 127. Diagnosis codes include: 398.1, 402.91, 425.1, 425.4, 428.0, 428.1,and 428.9. Other methods of member identification include health risk screening and directreferral by the primary care physician or cardiologist. Member stratification is based onseverity of illness using New York Heart Association classification.The chronic heart failure program relies on population-based measures of assessment of leftventricular function, ace inhibitor use, and hospitalization utilization. The same measures areused at the individual member level for those members stratified as high risk and who participatein The Health Plan’s telephonic chronic heart failure program. Primary attention is paid to theapplication of appropriate pharmacological therapies including the use of ace inhibitors and betablockers,enhancement of self-management skills, and systematic surveillance of those withsymptomatic heart failure to prevent hospitalization.Population based disease management strategies include targeted educational mailingsthroughout the year. High risk members receive telephonic disease management interventionfrom a chronic heart failure nurse specialist who provides individualized interventions thatinclude the evaluation of appropriate medication use, education, and counseling about dailyself-management, and member recognition of early signs and symptoms of heart failurerequiring intervention. Enrolled members receive home scales, referrals for nutritionaleducation to address dietary compliance, referrals for home oxygen/respiratory therapy whenindicated, and immunizations. Consideration of other health conditions, such as diabetes andchronic obstructive pulmonary disease are included in the management program.Condition monitoring and surveillance are ongoing and proactive. Calls are scheduled atperiodic intervals. Detailed questions are asked about the patient’s condition and information isgathered about patient status, treatment plan adherence, functional status, and quality of life.A specific plan of care is developed based practice guidelines from the ACC/AHA Guidelines forthe Evaluation and Management of Chronic Heart Failure in the Adult. Ongoing monitoring bythe chronic heart failure manager ensures timely intervention when a change in risk statusis identified. The frequency of outbound calls to members by the nurse is determined by themember’s severity of symptoms.Section 7 / Page 25

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramThis may result in daily contact in times of high risk or concern as well as consultations withthe physician. When home care is needed, the nurse works with the physician and home careagency to coordinate the necessary care and services.A major component of the chronic heart failure program is the empowerment of the memberthrough education. A variety of topics are addressed in both initial and reinforcement teaching.Patient education materials are provided to each patient throughout the program and are used inthe teaching process. A thorough education of the disease process and the recognition ofsymptoms are included in the teaching process. These warning signs are reviewed with eachassessment call along with a review of medications and medication compliance. Lifestyle issuesare addressed through education and include the appropriateness of exercise, diet, selfmanagementskills and, when indicated, smoking cessation interventions. Patients areencouraged to keep a record of their daily weight and to notify the physician if they experience aweight gain of two pounds in one day or three pounds in one week.A successful chronic heart failure program is dependent on the coordination of healthcare services. The role of the physician is vital and this program is intended to compliment themedical care the member is receiving from his/her physician. The goal of the managementprogram is to foster a collegial relationship between the physician and the care manager inorder to coordinate the necessary and appropriate care for the member. Evidence basedguidelines are available, distributed regularly, and recommended for use by the physician tomedically manage their patients with chronic heart failure.Section 7 / Page 26

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramChronic Obstructive Pulmonary Disease ProgramThe chronic obstructive pulmonary disease program is designed to modify risk factors associatedwith COPD as well as slow the progression of the disease. This is accomplished by promotingtreatment plan compliance through education, counseling, and support. Members with COPDrequire long-term, continual health care to maintain functional status and to help eliminatedisease exacerbations. Program goals include:Slowing the progression, or stabilization of symptoms of COPDOptimization of functional capacityImprovement in quality of lifeReduction in frequency of hospitalizationFacilitation and enhancement of the patient/doctor relationshipMember identification is conducted by ICD-9 analysis of ambulatory and inpatient claims andinpatient DRG 88. Diagnosis codes include: 491, 491.0, 491.1, 491.2, 491.20, 491.21, 491.8,491.9, 492, 492.0, 492.8, 493.2, and 496. Other methods of member identification include healthrisk screening and direct referral by the primary care physician or pulmonologist. Memberstratification is based on severity of illness and frequency of hospitalization with exacerbations.The chronic obstructive pulmonary disease program relies on population-based measures ofhospitalization utilization and emergency services utilization. The same measures are also usedat the individual member level for those stratified as high risk and who participate in The HealthPlan’s telephonic COPD management program. Primary attention is given to the evaluation ofappropriate medication use, education and counseling about daily self-management, andrecognition of early COPD exacerbations.Population based disease management strategies include targeted educational mailingsthroughout the year. High risk members receive telephonic disease management interventionfrom a COPD nurse specialist who provides individualized interventions that include theevaluation of appropriate medication use, education and counseling about daily selfmanagement,and recognition of early signs and symptoms of COPD exacerbation requiringintervention. Enrolled members receive home scales if needed, smoking cessation interventionsif indicated, referrals for nutritional education, referrals for home oxygen/respiratory therapywhen indicated, pulmonary rehabilitation, and immunizations. Consideration of other healthconditions, such as diabetes and chronic heart failure are included in the management program.Initial management of acute exacerbations include identification of precipitating factors(e.g., infection, volume overload, pulmonary thromboembolism, environmental changes, oroveruse of sedating medication) and tailoring drug therapy according to:The degree of reversible bronchospasmPrior therapy at a stable baselineRecent pharmacotherapy and prior medication toxicityPresence of contraindications to specific medicationsSpecific therapies indicated by the precipitating cause of the exacerbationSection 7 / Page 27

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramCondition monitoring and surveillance are ongoing and proactive. Calls are scheduled atperiodic intervals. Detailed questions are asked about the member’s condition and information isgathered about health status, treatment plan and adherence, functional status, and quality of life.Ongoing monitoring by the COPD manager ensures timely intervention when a change in riskstatus is identified. The frequency of outbound calls to participants by the nurse is determinedby the member’s severity of symptoms. This may result in daily contact in times of high risk orconcern as well as consultations with the physician. When home care is needed, the nurse willwork with the physician and home care agency to coordinate the necessary care and services.A major component of the COPD Program is the empowerment of the member througheducation. A variety of topics are addressed in both initial and reinforcement teaching.Patient education materials are provided to each patient throughout the program and are usedin the teaching process. A thorough education of the disease process and recognition ofsymptoms are included in the teaching process. These warning signs are reviewed eachassessment call along with a review of medications and medication compliance. Educationalso includes the appropriateness of exercise, diet, self management skills, the proper use ofmetered dose inhalers and, when indicated, smoking cessation interventions.A successful COPD program is dependent on the coordination of health care services. The roleof the physician is vital and this program is intended to compliment the medical care the memberis receiving from his/her physician. The goal of the management program is to foster a collegialrelationship between the physician and the case manager in order to coordinate the necessary andappropriate care for the member. Evidence based guidelines are available and recommended foruse by the physician to medically manage their patients with COPD.Section 7 / Page 28

Prenatal Care ProgramPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramThe Prenatal Care Program is designed to improve pregnancy outcomes, reduce neonatalhospitalizations, and reduce all costs associated with pre-term birth and other complicationsof pregnancy. This is accomplished by providing prenatal education, promoting safe healthbehaviors, and enhancing the management of maternity care for women identified at high riskfor premature labor and delivery. Program goals include:Reduction in the incidence of preterm birthsReduction in the incidence of low birth weight babiesReduction in the number of neonatal intensive care unit daysProvision of improved prenatal education, promotion of safe health behaviors, andenhanced management of maternity care for women identified as high risk forpremature labor and delivery.Member identification and enrollment is initiated once a pregnant member is identified or areferral is received. Referrals may come from the physician, The Health Plan OutreachProgram, self-referral, and claims data. Physicians are provided a prenatal risk-screeningtool to forward to The Health Plan. Postcards are also provided to the physician office foruse in member self-enrollment.Outcomes monitoring is continuous and reported regularly. These reports include:Rate of preterm deliveriesRate of low birth weight deliveriesRate of cesarean sections deliveriesNICU days/1,000 birthsNICU length of stayRate of smoking at enrollment and at deliveryRate of prenatal care in the first trimesterRate of check-up after deliveryThe targeted time for enrollment of all members is between 12 to 15 weeks gestation.A telephonic assessment of the clinical and psychosocial status of the member is completedby outreach staff at enrollment and again at week 24. Consideration is given to otherhealth conditions. The assessment tool, along with the prenatal risk screen completed bythe physician, is reviewed by the program nurse. The mother-to-be is placed in theappropriate low risk pregnancy group or the high-risk pregnancy group to be case managed.Section 7 / Page 29

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramA late referral education component is available for those women enrolled after 34 weeksgestation. A partial program is offered for those individuals who decline to enroll in thecomplete program but who want to receive educational materials.The identification of low-risk pregnant women early in pregnancy is designed with the intentof improving the outcome of the pregnancy. Educating the pregnant woman on healthylifestyle measures reduces risk factors throughout the pregnancy. The low risk pregnantwoman receives an initial assessment, a second trimester assessment, a third trimesterassessment, and postpartum assessment conducted by the Outreach Department. The finalcall ensures the well being of mother and child.High-risk pregnancies are monitored and managed aggressively as early as possible andcontinuously throughout the pregnancy. This group receives general educational mailings aswell as specific educational materials based on assessment findings. All participants receiveproactive calls from the prenatal care nurse. The prenatal care nurse promotes positiveoutcomes for the pregnancy through individualized interventions. A specific plan of care isdeveloped based on the risk status. Ongoing monitoring by the prenatal care coordinatorensures timely intervention in the event of a change in risk status. The frequency ofoutbound calls to participants by the prenatal care nurse is determined by the severity ofpregnancy risks and complications. This may result in daily contact in times of high risk orconcern. When home care is needed in high risk-cases, the prenatal care nurse works withthe physician and home care agency to coordinate the necessary care and services.A major component of the program is to educate the pregnant woman on proactive andhealthy lifestyle measures that reduce risk factors throughout the pregnancy. This isachieved by providing mailings of educational materials addressing prenatal care, birthalternatives, and newborn care as well as verbal education during assessments focusing onpregnancy wellness and patient-specific risk factors. Lifestyle issues are addressed such asillegal drug use and smoking. Smoking cessation interventions are a major focus for thosemembers who are identified as smokers or recent smokers. Standard education materialsare available for all members and risk-specific written educational materials are providedfor specific pregnancy issues. ACOG and March of Dimes are the resources for riskspecific educational materials.All identified pregnant members receive an initial mailing in the first trimester and the thirdtrimester. Smoking cessation is offered telephonically as a major component of the program.A successful prenatal care program is dependent on the coordination of healthcare services.The role of the physician is vital and this program is intended to compliment the medicalcare the member is receiving from her physician. The goal of The Health Plan is to foster acollegial relationship between the physician and the prenatal care nurse to coordinate thenecessary healthcare to promote a healthy mother and a healthy baby.Section 7 / Page 30

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramMedical Department Staff and Committee OverviewMedical DirectorThe Medical Directors of The Health Plan provide leadership and direction for all utilizationmanagement and quality improvement activities. The Medical Directors play an important rolein the development of the Quality Management Program and supervise quality improvementplans and initiatives. The Medical Directors participant with the Executive Management Teamand periodically report quality and utilization activities and present the annual evaluation of theQuality Management Program to the Board of Directors. One of the Medical Directors serves asChairman for each of the following committees:Quality Improvement CommitteeCredentialing CommitteeUtilization Management Steering CommitteePhysician Advisory CommitteeTransplant and New Technology CommitteeThe Medical Directors are solely responsible for non-authorization decisions based onmedical necessity. They will communicate with primary care physicians, attendingphysicians and specialist reviewers as necessary for case discussions.Other responsibilities of the Health Plan Medical Directors include:Decision-making regarding medical appropriateness of care and servicesSecond review of appealsPhysician education regarding practice patternsProviding hospital on-site reviewOne of The Health Plan Medical Directors is available 24 hours a day, seven days a week bybeeper or by telephone. This includes coverage for vacations, illnesses, meetings out of the area,or any circumstance when one Medical Director is not available.The Physician Advisory Committee is a collaborative committee established to receive inputfrom the physician community to guide The Health Plan in its decision-making related tomedical policy affecting coverage and reimbursement for physician services and to discuss issuesrelated to relationships and interactions between and among physicians, their patients, and theHealth Plan.These issues may include, but are not limited to: (a) improvement of health care and clinicalquality through the establishment of clinical and quality guidelines; (b) improvement ofcommunications, relations, and cooperation between physicians and The Health Plan; and/or (c)matters of a clinical or administrative nature that impact the interaction between physicians andthe Health Plan.Section 7 / Page 31

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramIn addition, physicians serving the PAC may also serve as specialty reviewers, based on boardcertification and field of expertise. The Physician Advisory Committee functions as a Subcommitteeof the Medical Directors’ Oversight Committee (MDOC). The MDOC, which iscomprised of The Health Plan Medical Director is responsible for the oversight of the PhysicianAdvisory Committee.Members of the Committee shall include a representative sample of specialty areas that mayinclude Family Practice, Behavioral Health, Internal Medicine, Obstetrics and Gynecology,Orthopedics, Pediatrics, Surgery and Medical Sub-specialists serve a term of three (3) years andmay be asked to serve consecutive terms.Meetings may be held as actual on-site meetings at a central or regional locations withtelecommunications accessibility. PAC members may also review guidelines, InterQual, andother policy and procedural changes related to his/her expertise via mailings. Web-basedmeetings may also be utilized when appropriate.The Focus Group CommitteeThe Focus Group was established to provide internal interdepartmental discussions of issues andconcerns regarding member education, quality of care initiatives, utilization and appropriatenessof care, and develop coordinated efforts in implementing improvement plans.Members of the committee shall include Directors of Utilization Management/MedicalManagement, Director of Pharmacy Services, Director of Customer Service, Director of ClaimsProcessing, Assistant Director of Quality Improvement, Manager of Disease Management,Health Data Analyst, Member Advocate for Mountain Health Trust Program (WV Medicaid).Medical Directors’ Oversight CommitteeThe Physician Advisory Committees are a subcommittee of the Medical Directors’ OversightSteering Committee. The Oversight Committee is comprised of The Health Plan MedicalDirectors from all the regions to oversee the activities of the regional medical advisorycommittees and ensure issues are dealt with in a timely and appropriate manner.A key function of the committee is monitoring results of regional activities for consistencyacross the individual regions.The Medical Directors work together to avoid duplication of effort and facilitate the sharing ofinformation as appropriate. A Nurse Manager assists the Committee in the role of facilitator.Section 7 / Page 32

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramTransplant & New Technology CommitteeThe Transplant and New Technology Committee evaluates new medical technologies and thenew application of existing technologies including medical procedures, drugs, devices, andtransplants to determine medical efficacy and appropriateness of treatment in standard medicalpractice. Professionals included on the committee are the Medical Directors, Director ofPharmacy, General Counsel, Chief Financial Officer, Directors of Medical Management,Director of Claims, and other Managers within the Medical Department.The Transplant and New Technology Committee is responsible for the development of Coverageand Review Guidelines to assist in determinations of medical appropriateness based on currentsupporting documentation available at the time of the review or request of a particulartechnology or service. Resources utilized in the committee review process may include:Centers for Medicare and Medicaid Services (CMS) coverage policies (National and Local)Winifred S. Hayes, Inc. independent technology assessmentsFederal and state regulatory agency guidelines and mandatesClinical outcome studies and data in peer-reviewed published medical literaturePositions of nationally recognized health professional societies and collegesManaged care organizationsTechnology and research agenciesOpinions of physicians and practitioners in relevant clinical areasPeriodically, and upon request, the Committee will revisit and revise previously rendered reviewguidelines to establish if changes or updates are needed based on updated information on thetechnology, procedure, or service. The T&T Committee will notify practitioners of alltechnologies reviewed in The Health Plan Provider Newsletter and its determinations regardingcoverage. Please also refer to the documented preauthorization requirement list found withinSection 7 of the manual as well.Please contact The Health Plan Medical Department for information regarding criteria/inclusions,contraindications/exclusions, and limitations of coverage, as well as preauthorization requirementsthat may apply to specific technologies, therapeutic approaches and services. Information for reviewconsideration may be forwarded to the Committee via e-mail: T&T@healthplan.org.Section 7 / Page 33

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramPharmacy & Therapeutics CommitteeThe Pharmacy and Therapeutics Committee has responsibility for the formulation and adoptionof policies regarding the appropriate evaluation, selection, procurement, distribution, use, andsafety of drug therapies. The Committee recommends and assists in the development ofprograms and policies for participating practitioners in all areas pertaining to drug therapy forThe Health Plan membership. The Committee’s composition includes physicians, pharmacists,and representation from The Health Plan. The Pharmacy and Therapeutics Committee reportsquarterly to the Quality Improvement Committee.Annual Program EvaluationThe Utilization Management Program and the Quality Management Program are evaluated onan annual basis. A written summary is prepared from the evaluation process that includesutilization and quality management activities during the year, achievement of goals, andrevisions for the upcoming year.The Annual Program evaluation is approved by the Executive Management Team (EMT) &Quality Improvement Committee.Section 7 / Page 34

Physician VariancesPROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramThe Health Plan has established a program by which it can monitor and assess compliance withUtilization Management protocols. This program has been implemented within various high volume regions.Several utilization factors have been identified, as integral to the program and compliance with thesefactors is key to management of utilization considerations. In order to provide a system for monitoringcompliance, variances from utilization protocols will be logged and severity weights assigned based uponthe type of variance. These variances and cumulative weights (as indicated in the TABLE 1) will be trackedover time for appropriate intervention action(s) as described in TABLE 2. Severity levels are cumulative ona rolling twelve (12) month basis.The physician will receive written notification from The Health Plan’s Medical Director regarding eachvariance. An opportunity will be provided for written appeal and submission of clinical information inaccordance with the Utilization Management Program appeals process. All variances and interventions willremain part of the physician’s profile to be monitored on an ongoing basis.Table 1TYPE OF VARIANCE1. Failure to properly notify The Health Plan of an in-plan admission where theadmission is deemed after the fact to be medically appropriate.2. Failure to properly notify The Health Plan of an in-plan admission where theadmission is deemed after the fact to be medically inappropriate.3. In-plan admissions which occur even though admission was determined uponnotification to be medically inappropriate.4. Continued stay or excessive stay of patient in an in-plan facility, which isdetermined to be medically inappropriate.5. Failure to properly notify and/or obtain authorization for a tertiaryadmission/service where the service is deemed after the fact to be unavailablethrough an in-plan provider.6. Failure to properly notify and/or obtain authorization for a tertiaryadmission/service where the service is deemed after the fact to be availablethrough an in-plan provider.7. Failure to properly notify and obtain authorization for an out-of-planadmission/service where the service is deemed after the fact to be unavailablethrough an in-plan or tertiary provider.8. Failure to properly notify and obtain authorization for an out-of-planadmission/service where the service is deemed after the fact to be availablethrough an in-plan tertiary provider.9. Failure to obtain advance authorization for an elective CT or MRI where theservice is determined after the fact to be medically appropriate.10. Failure to obtain advance authorization for an elective CT or MRI where theservice is determined after the fact to be medically inappropriate.11. Failure to obtain advance authorization for a PET scan where the service isdetermined after the fact to be medically appropriate.12. Failure to obtain advance authorization for a PET scan where the service isdetermined after the fact to be medically inappropriate.Section 7 / Page 35SEVERITYWEIGHT1444266101234

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Medical Management ProgramBased upon total severity level at the time of an occurrence, interventions will be handled as indicated inTABLE 2 below.Table 21 to 2 Written notification from The Health Plan Medical Director of the variance(s) and denial of anyof the physician’s (his/her own or related member of practice) professional fees related to thevariance procedure/service/admission.3 to 5 Written notification from The Health Plan Medical Director of the variance(s) and denial of thephysician’s professional fees related to the variance procedure/service/admission, and aneducational visit by The Health Plan Medical Director or Associate Medical Director6 to 8 Written notification from The Health Plan Medical Director of the variance(s), denial of thephysician’s professional fees related to the variance procedure/service/admission, and a nonrefundablewithhold from all payments of 2% for one quarter provided that additional points arenot accumulated during that quarter. If additional points are accumulated:Further educational visits by The Health Plan Medical Director or AssociateMedical Director will be required.Withholding shall continue for quarterly periods until a quarter is completedwithout additional accumulation of points.9 to 10 Written notification from The Health Plan Medical Director of the variance(s), denial of thephysician’s professional fees related to the variance procedure/service/admission, and a nonrefundablewithhold from all payments of 5% for two quarters provided that additional points arenot accumulated during that period.Greaterthan 10Educational visits by The Health Plan Medical Director or Associate Medical Director will berequired and entire record will be forwarded to the Medical Advisory Committee and The HealthPlan Executive Management Team for further recommendations regarding actions.Accumulation of greater than 10 points in any 12-month period will result in referral to TheHealth Plan Executive Management for corrective action including suspension, limitation, orpermanent removal of status as a Health Plan provider.Section 7 / Page 36

PROVIDER PROCEDURAL MANUAL 2014Appendix AMedicalForms, Tools, & WorksheetsSection 7 / Page 37

MOLECULAR PATHOLOGY REQUEST FORMALL MOLECULAR PATHOLOGY / GENETIC / GENOMIC TESTINGREQUIRES PRIOR AUTHORIZATIONIncluding but not limited to: Prognostic gene expression profiling techniquesGene and molecular expression assaysTesting for inherited susceptibility for a diseaseComplete form and fax to either location:St. Clairsville, OhioMassillon, Ohio1-888-329-8471 1-888-450-60241-740-695-5297 1-330-830-4380Date of request: _______________________________Member Name:Member Health Plan ID#:Requesting Physician Name:Practice/Group Name:Physician Phone Number:Physician Office Contact Name:Molecular Pathology Test(s) requested & CPT codes:Member Date of Birth:Health Plan Provider ID#:Physician Fax Number:Facility/Lab to perform test:Diagnosis:Check one: symptomatic (diagnostic) asymptomatic (predictive) carrierGenetic Counseling: The patient was provided information regarding the test and its implications, offeredgenetic counseling when applicable, and the informed consent is documented in the medical record completed anticipated not completedClinical information pertinent to the genetic test(s) request (attach additional office notes as necessary):How will results of testing impact care:You may also provide clinical information via the telephonic referral Line which is available 8:00am to 5:00 pm Mon - FriSt. Clairsville, OhioMassillon, Ohio1-800-526-7511 1-888-830-43701-740-695-7905 1-330-830-4370Updated February 2014

Health Plan Referral WorksheetTODAY’S DATE: ( Please PRINT )Patient’s Name:Patient’s ID#:Patient’s Birthdate:Name of Referring Physician:(Your Provider’s Name)Referring Physician’s ID#:Your Name:(For verification, please print)Name of Provider being referred to or hospital admitted to:Physician:Address:Phone # to reach you:Hospital:Address:Expected or approximate date of service:Number of visits requested:(Note initial Specialist in-plan referral only valid for two visits)Reason (diagnosis) for the service:(Include ICD-9 codes)Treatment to be rendered:(Services expected to be rendered & CPT codes)Other pertinent supporting documentation:(Including other testing, consultations,significant medical history, medicalappropriateness criteria, etc.)The above worksheet is merely intended as an aid to assist the office in the phone-in or website referral process.Section 7 / Page 39

The Health Plan of the Upper Ohio ValleyHomeTown Health Network***CONFIDENTIAL****Request for Precertification of Podiatry ServicesSample Treatment Plan FormEnrollee Name:ID Number:Primary Care Physician:HMO SecureCare POS/PPO Medicaid Other*Service Requested: Outpatient Surgery DME Office Treatment/VisitsX-rays/RadiographsOther*Primary Diagnosis:Secondary Diagnosis:ICD9:CPT:*Number of Visits Requested:Is this request after a consult? Yes No Is member diabetic? Yes NoHas pt had an authorized procedure? Yes NoOffice note attached? Yes NoHas patient had a previous podiatry consult in the last 6 months? Yes No*Treatment Plan (may attach consult or office note):Please be advised: Routine Foot Care Including Treatment of Corns and Calluses as well asNail Care / Treatment may not be a covered benefit for the member.* REQUIRED INFORMATIONPhysician Name:Office Contact Person:HP Fax 740-695-5297 HT Fax 330-830-4380888-329-8471 888-450-6024Podiatry Precertification FormSection 7 / Page 40Phone:Fax:

THE HEALTH PLAN(Please Print)MEMBER INFORMATIONMEMBER’S LAST NAME: FIRST: MIDDLE: HEALTH PLAN ID:DATE CARE BEGAN:NUMBER OF VISITS CALENDAR YEAR-TO-DATE:HAVE YOU PREVIOUSLY SUBMITTED A MEDICAL NECESSITY STATEMENT FOR THIS TREATMENT PLAN? YES NOETIOLOGY AND ONSET:HISTORYDATE OF X-RAYS: SPINAL AREA: VIEWS:MOST RECENT OBJECTIVE PHYSICAL FINDINGS (+ / -) AND THE DATE OF THE LATEST EXAM:INITIAL:CURRENT:COMPLAINTS / SYMPTOMS (NARRATIVE DESCRIPTION)NEUROMUSCULOSKELETAL:COMPLICATION FACTOR(S):COMMENTS:DIAGNOSIS(ES) (NARRATIVE DESCRIPTION)SUBLUXATION CODE:TYPE AND LEVEL:EXACERBATION OR RE-INJURY (DESCRIPTION AND DATES):ACTIVE TREATMENT REGIMEN:TREATMENT PLANNUMBER OF VISITS ANTICIPATED:RESPONSE TO TREATMENT TO DATE:VISIT FREQUENCY:PROGNOSIS AND/OR RESOLUTION:DOCTOR’S NAME: TELEPHONE: FAX:( ) ( )DOCTOR’S SIGNATUREDATESection 7 / Page 41

The Health PlanOncologic PET/CT Review ToolFAX TO 1-888-329-8471 (St. Clairsville) or FAX TO 1-888-450-6024 (Massillon)Patient name:___________________________________ Health Plan ID#________________________________Physician name:_________________________________ Telephone #___________________________________Indicate test(s) requested: CPT Description78608 Brain imaging, positron emission tomography (PET); metabolic evaluation78609 Brain imaging, positron emission tomography (PET); perfusion evaluation78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)78812 Positron emission tomography (PET) imaging; skull base to mid-thigh78813 Positron emission tomography (PET) imaging; whole body78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) forattenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)78815 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) forattenuation correction and anatomical localization imaging; skull base to mid-thigh78816 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) forattenuation correction and anatomical localization imaging; whole bodyPlease complete the information below:Type of CancerMRI / CT completed: no___________ Proven by biopsy or Suspected yes – results______________________________________________1. PET requested as part of the Initial Treatment Strategy: To determine if suspicious lesion is cancer______Pulmonary nodule ______Other (specify)___________________________________ To detect an occult primary tumor:______In patient with known/suspected metastatic disease______In patient with suspected paraneoplastic syndrome Initial Staging of confirmed, newly diagnosed cancer2. PET requested as part of the Subsequent Treatment Strategy: Monitoring Response during the following treatment:______Chemotherapy ______Radiotherapy ______Other (type)__________________________ Restaging after completion of the following therapy______Chemotherapy ______Radiotherapy ______Other (type)__________________________ Suspected Recurrence of a previously treated cancer:Site of suspected recurrence:_______________________________________________________Based on the following clinical findings:_____________________________________________ Surveillance of a previously treated cancer in a patient with no known residual disease (this is a non-coveredindication)Additional History or Instructions:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PROVIDER PROCEDURAL MANUAL 2014QualityManagement ProgramSection 8 / Page 1

PROVIDER PROCEDURAL MANUAL 2014Table of ContentsINTRODUCTION .................................. 3QUALITY OF CLINICALCARE INDICATORS .............................. 5QI VARIANCE PROCESS ....................... 9CUSTOMERSATISFACTION INDICATORS .............. 10QUALITY OF CARE &SERVICE INDICATORS ....................... 11CLINICAL PRACTICE GUIDELINES &STANDARDS FOR CARE & SERVICE .... 13MEDICAL RECORD FOCUS ................. 15ADVANCE DIRECTIVES ...................... 15WELLNESS & HEALTHPROMOTION EDUCATION ................ 18PROVIDER EDUCATION INITIATIVES ... 23QI INFORMATION SHEET .................. 25ACCESSIBILITY .................................. 26AVAILABILITY / GEOACCESS .............. 26CONTINUITY &COORDINATION OF CARE ................. 26EMERGENCY ROOM USE ................... 27AACCREDITATION ............................... 28ADVANCE DIRECTIVES FLOW CHART .. 29ADVANCE DIRECTIVES ...................... 30APPROPRIATE CODING, TESTING &TREATMENT FOR CHILDREN WITHUPPER RESPIRATORY INFECTIONS(URI) & PHARYNGITIS ....................... 31ASTHMA – ADULT & CHILDREN ........ 32ASTHMA REFERRAL FORM ................ 33BBLOOD LEAD SCREENING FORMEDICAID / MHT 2 YEAR OLDS ......... 34BODY MASS INDEX (BMI)CODING UPDATES & TIPS .................. 35BODY MASS INDEX (BMI) CHARTS ..... 36BODY MASS INDEX (BMI) CHILDREN . 38BMI PERCENTILE CHARTFOR BOYS 2‐20 YEARS ....................... 39BMI PERCENTILE CHARTFOR GIRLS 2‐20 YEARS ...................... 40BMI: PEDIATRIC WEIGHTASSESSMENT, NUTRITION &PHYSICAL ACTIVITY COUNSELING ...... 41CCHART STICKERS AVAILABLE ............. 42DDIABETIC DILATED FUNDUSEXAMINATION FORM ....................... 43DIABETES MELLITUSPRACTICE RECOMMENDATIONS& FLOW SHEET .................................. 44EECS / OPTUM MEDICAL RECORDREVIEW FOR MEDICARE (CMS) ......... 45ELECTRONICMEDICAL RECORDS (EMR) ................. 46ENVELOPE OF LIFEEMERGENCY MEDICAL INFORMATION.. 47FFAXING & MAILING DOCUMENTS ..... 49HHEDIS CODING GUIDE 2012 ............... 50HEDIS ............................................... 54IIMMUNIZATION REGISTRY ............... 65MMEDICAL RECORD AUDIT TOOL ........ 66MEDICATION LIST ............................. 67OOBESITY REFERRAL FORM ................ 68ONSITE OFFICE REVIEWS .................. 69PPAIN ASSESSMENT SHEET ................. 70PATIENT HISTORY FORM .................. 71PHYSICIAN OVERSIGHT .................... 73PRESCRIPTION AGREEMENT& NARCOTIC USE CONTRACT ............ 74PRESCRIPTION DRUGABUSE & REPORTING ....................... 75PREVENTIVE HEALTH FLOW SHEET ... 77PROBLEM LIST .................................. 78SSIGNATURE LOG ............................... 79SMOKING CESSATIONREFERRAL FORM .............................. 80VVACCINE ADMINISTRATIONRECORD FOR CHILDREN & TEENS ..... 81VA CLINICS & HEALTH FAIRS ............. 83WWEBSITE .......................................... 84Section 8 / Page 2

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramIntroductionThe Health Plan Quality Management Program uses data collection, measurement, and analysisto identify and track clinical and service quality of care issues. When opportunities forimprovement are noted, The Health Plan takes action. A Quality Improvement Project orInitiative is put in place using a multidisciplinary approach. Barriers are identified andinterventions based on recognized industry standards are established to improve performance.Systematic follow-up is carried out to assess the effectiveness of the interventions.Goals & ObjectivesThe goals and objectives of The Health Plan Quality Management Program are as follows:• Establish standards and processes for measuring, evaluating, and improving the quality ofcare and services provided to members in the following areas: Quality of Clinical Care Indicators (Inpatient)• Medical and Behavioral Health Inpatient Variance Investigation• Inpatient Never- Event (NE) Investigation to include: Serious Reportable AdverseEvents (SRAE) and Hospital Acquired Conditions (HAC) (Medicare/CMS Driven) Customer Satisfaction Indicators• Member Complaint Investigation• Physician Change Report Reviews• CAHPS (Consumer Assessment of Healthcare Providers & Systems) Survey(Commercial, SecureCare and MHT) Quality of Care and Service Indicators• HEDIS (Healthcare Effectiveness Data and Information Set)• CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey• Health Plan Clinical Practice Guidelines• Health Plan Standards for Patient Records and Access to Care and ServicesMedical Record AuditAppointment and After-Hours Availability Audit Provider Credentialing, Recredentialing, and Peer Review• Physician Profiling• Physician Focusing Quality of Care and Service Projects• HEDIS / CAHPS Driven Quality of Care Projects• Performance Improvement Projects (PIPs) – Medicaid Driven• Quality Improvement Projects (QIPs) – Medicare Driven• Employ a multi-disciplinary approach to identify areas where improvement is needed.• Implement and monitor corrective action plans.Section 8 / Page 3

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management Program• Meet or exceed our customer's expectations• Demonstrate improvement in the quality of medical care and services provided tomembers as a result of quality improvement initiatives• Continue to strive to improve quality with annual review and revision of QualityImprovement documents such as the Quality Management Program, Quality ManagementWork Plan, Quality Management Evaluation, and the QM Policies and Procedures.• Demonstrate compliance with external Quality Improvement regulators and programs The National Committee for Quality Assurance (NCQA) Centers for Medicare and Medicaid Services (CMS) Delmarva – External Review Organization for WV DHHR West Virginia and Ohio Department of Insurance Click here to see Accreditation• Demonstrate Wellness and Health Promotion Education• Demonstrate Provider Education InitiativesSection 8 / Page 4

PROVIDER PROCEDURAL MANUAL 2014Quality of Clinical Care IndicatorsThe Health Plan Quality Management ProgramThe following Quality of Clinical Care Indicators have been defined and established by theQuality Improvement Committee for use by Hospital Reviewers (Utilization Review Nurses) todetermine quality of care rendered in inpatient, outpatient, and ancillary care facilities.MEDICAL / SURGICAL VARIANCE CODES‣ Unplanned admission after outpatient procedure and/or surgery – immediate‣ Unplanned admission after outpatient surgery within 7 days‣ Readmission in 7 days (Inpatient and/or Observation)‣ Readmission in 24 hours (Inpatient and/or Observation)‣ Readmission in 30 days (Inpatient and/or Observation)‣ Complication after delivery, surgery, or procedure(Except object left in after surgery-*NEVER EVENT-NA)‣ Return to surgery or delivery room‣ Unplanned injury or removal of an organ or structure during surgery‣ Drug reaction, toxicity, or error‣ Cardiac and/or respiratory complication/arrest‣ Neurological complication/deficit‣ Nosocomial infectionExcept- Surgical site infection -mediastinitis after CABG-NEVER EVENT-NG;- Catheter associated urinary tract infections - NEVER EVENTS-ND;- Vascular catheter associated infections-NEVER EVENT-NF;- Surgical site infection following certain orthopedic procedures-NEVEREVENT-NJ;- Surgical site infection following Bariatric Surgery for Obesity-NEVEREVENT- NK)‣ Unanticipated fetal demise in 3rd trimester‣ Unanticipated fetal demise - birth to 6 months‣ Unanticipated maternal death during pregnancy or post-partum‣ Unanticipated death – other‣ Delay in care and consult‣ Abnormal lab, X-ray, or tests not addressed‣ Medically unstable at discharge‣ OtherSection 8 / Page 5

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramPlease Use Never Event Codes for the Following:‣ Adverse event – fall or accident –*USE NEVER EVENT CODE for Injuries‣ Adverse event – equipment problem –*USE NEVER EVENT CODE‣ Adverse event – transfusion reaction – *USE NEVER EVENT CODECode changes reflect ongoing updates in CMS / Medicare GuidelinesBEHAVIORAL HEALTH VARIANCE CODESBeginning in 2008 with the creation of the in-house Behavioral Health Unit, codes specific tobehavioral health were included for the following:‣ Inpatient suicide attempt‣ Inpatient successful suicide‣ Behavioral Health readmission within 7 days‣ Behavioral Health readmission within 30 days‣ Safety Issues (Ex: Unauthorizedsmoking/lighters; Unauthorized use of drugs;Physical/Sexual Abuse‣ Elopement‣ Complication during/after a procedure‣ Delay/absence of care‣ Injurious behavior to self/others‣ OtherSection 8 / Page 6

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramNEVER EVENT AND HOSPITAL ACQUIRED CONDITIONS/HEALTH CARE ACQUIREDCONDITIONSAcute Care Only-All Lines of BusinessIn 2008, the Health Plan began tracking NEVER EVENTS as defined by Medicare. In 2011,Never Events were also termed Serious Reportable Adverse Events (SRAEs) and HospitalAcquired Conditions (HACs). The Health Plan continues to investigate all SRAEs and HACs asNever Events (NEs).http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/HACFactsheet.pdfNEVER EVENTS include:‣ NA – Preventable event – Foreign object retained after surgery. Unintended retention of aforeign objest in a patient after surgery or other invasive procedure.‣ NB – Serious preventable event – air embolism. Any death or serious injuries associatedwith intravascular air embolism that occurs while being cared for in a healthcare setting.‣ NC – Serious preventable event – blood incompatibility Patient death or serious injuryassociated with unsafe administration of blood products.‣ ND – Catheter-associated urinary tract infections‣ NE – Pressure ulcers-Stage III & IV (decubitus ulcers) Acquired afteradmission/presentation to a healthcare setting.‣ NF – Vascular catheter associated infection‣ NG – Surgical site infection – mediastinitis after coronary artery bypass surgery(CABG)-within 30 days‣ NH01 – Hospital acquired injuries – falls and fractures‣ NH02 – Hospital acquired injuries – dislocations‣ NH03 – Hospital acquired injuries – intracranial injury‣ NH04 – Hospital acquired injuries – crushing injury‣ NH05 – Hospital acquired injuries – burns‣ NH06 – Hospital acquired injuries – other unspecified effects of external causes‣ NH07- Hospital acquired Post Operative Death in normal healthy patient (ASA Category 1)‣ NI – Manifestations of poor glycemic control (diabetic ketoacidosis,,nonketotichyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis,secondary diabetes with hyperosmolarity)‣ NJ-Surgical site infections following certain orthopedic procedures,(Spine,Neck,Shoulder, Elbow-within 365 days)i.e.: Infection/Inflammation reaction due to orthopedic device,Section 8 / Page 7

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management Program‣ NK – Surgical site infection – following bariatric surgery for obesity (Laparoscopicgastric bypass, Gastroenterostomy, Laparoscopic gastric restrictive surgery-within 30days)‣ NL – Deep vein thrombosis and pulmonary embolism following certain orthopedicprocedures (total knee / total hip replacements) DVT has occurred in acute hospital anddiagnosed during hospital stay.‣ *NM – Surgery / Invasive procedure on wrong body part‣ *NN – Surgery / Invasive procedure on wrong patient‣ *NO – Wrong Surgery / Invasive procedure on a patient‣ NP-Surgical site infections following Cardiac Implantable Electronic Device (CIED)‣ NQ-Latrogenic Pneumothorax with venous catherization (Latrogenic:caused by thediagnosis, manner, or treatment of a physician)True Never EventsAll other N codes fall under the category of SRAEs and HACs per CMS guidelinesSection 8 / Page 8

QI Variance ProcessPROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramWhen any of the above indicators are identified by a Utilization Review Nurse in theMedical Department or by a member complaint to Customer Service, they areelectronically forwarded to the Quality Improvement Department. A case is opened andassigned a number and medical records are ordered as indicated. The records arereviewed by a QI Coordinator, the Medical Director, or a Peer Review Practitioner asindicated. (If immediate review is necessary, the case is brought directly to the attention ofthe Medical Director).A letter of inquiry can also be addressed to a specific provider or facility for furtherclarification of the issue.If the Medical Director or peer review practitioner determines that medical or behavioral healthcare administered was inappropriate, the case will be presented to the Quality ImprovementCommittee for review. This committee will then determine if a *Corrective Action Plan isnecessary.In addition, outlier Facilities or Providers are noted through variance tracking & trending.Facility or Provider focusing may be initiated based on this tracking & trending, and underthe direction of the Quality Improvement Committee.A Corrective Action Plan may be requested for any treatment, procedure, or servicewhere a practitioner is not practicing medicine in a manner that is in keeping withreasonable and prevailing standards of care or medical ethics. If the QI Committeedetermines that a corrective action is needed, the practitioner will be notified in writing.Corrective actions may vary according to the situation and may include any of the following:• Written warning to the practitioner.• Discussion with the practitioner.• Placing the practitioner under a focused review per medical record or claim data reviews.• Requiring the practitioner to enter into a preceptor relationship with another practitioner.• Requiring the practitioner to complete continuing medical education specific to thetreatment, procedure, or service in question.• Limiting the practitioner's privileges or authority to perform certain procedures.If the requested corrective action is not met to the satisfaction of the QI Committee, a requestwill be made to prohibit the practitioner from accepting new Health Plan members, and couldlead to termination of the practitioner's contract.Use of the Health Plan Corrective Action Policy seldom occurs, which indicates that ourprovider network grants excellent care and service to our members. Thank you for partneringwith us in providing outstanding care for our members.Section 8 / Page 9

PROVIDER PROCEDURAL MANUAL 2014Customer Satisfaction IndicatorsInvestigation and tracking of:The Health Plan Quality Management Program• Member complaints registered with the Customer Service Department Reasons given for dissatisfaction include:• Quality Of Care Issue• Physician Accessibility or Availability Issue• Practitioner Office Site Issue• Attitude/Service By Provider/Staff• Claim Problem• Service by The Health Plan• Health Information Line issue• Primary Care Physician changes initiated by the member Reasons given for PCP changes include:• Dissatisfaction with Medical Management• Communication Issues• Physician Office or Staff Issues• After-hours Accessibility issues• CAHPS Survey Results for SecureCare, Commercial, and MHT membersSection 8 / Page 10

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramQuality of Care & Service IndicatorsHEDIS® (Healthcare Effectiveness Data & Information Set)The HEDIS audit contains a core set of performance measures that provide information aboutcustomer satisfaction, specific health care measures, and structural components that ensurequality of care. Annually, The Health Plan reports on Effectiveness of Care measures set forthby HEDIS that include the following and may involve onsite medical record review:• Childhood Immunization Status• Lead Screening in Children• Well – Child Visits in the First 15 months of Life• Well – Child Visits in the Third, Fourth, Fifth and Sixth Years of Life• BMI/Weight/Height Assessment and Counseling for Nutrition and PhysicalActivity for Children and Adolescents• Adolescent Immunization Status (Meningococcal, Tdap)• Adolescent-HPV/Females• Adolescent Well – Care Visits• Appropriate Testing for Children with Pharyngitis• Appropriate Treatment for Children with Upper Respiratory Infection• BMI/Weight – Adult• Colorectal Cancer Screening• Breast Cancer Screening• Cervical Cancer Screening• Non-recommended Cervical Cancer Screening in adolescent females16-20 years• Chlamydia Screening in Women 16-24 years of age• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis• Prenatal and Post – Partum Care• Frequency of Ongoing Prenatal Care• Weeks of Pregnancy at Time of Enrollment in the MCO• Glaucoma Screening in Older Adults• Care for Older Adults• Persistence of Beta-Blocker Treatment After a Heart Attack• Controlling High Blood Pressure• Cholesterol Management for Patients with Cardiovascular Conditions• Comprehensive Diabetes Care• Use of Appropriate Medications for People with Asthma• Medication Management for People with Asthma• Use of Spirometry Testing in the Assessment and Diagnosis of COPD• Pharmacotherapy Management of COPD Exacerbation• Medical Assistance with Smoking CessationSection 8 / Page 11

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management Program• Disease-modifying anti-rheumatic drug therapy for Rheumatoid Arthritis• Osteoporosis Management in Women who had a Fracture• Use of Imaging Studies for Low Back PainThe HEDIS® audit takes place between January and June of the review year and administrativedata is used when applicable. The Health Plan Quality Improvement Department will makeevery effort to coordinate onsite medical record audits at the convenience of the provider andoffice staff. Our nurse(s) will need access to a power source for laptop data entry.Section 8 / Page 12

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramClinical Practice Guidelines & Standards for Care & ServiceThe Health Plan develops Clinical Practice Guidelines to help practitioners make decisions aboutappropriate health care for specific clinical circumstances. Practice guidelines are based onnationally recognized clinical literature and expert consensus, and reflect industry best practices.The following is a list of the current Health Plan Guidelines: Guidelines for Preventive Health• Management of Diabetes Mellitus Click here to see Diabetic Dilated Fundus Examination Form• Management of Congestive Heart Failure• Management of Chronic Obstructive Pulmonary Disease• Management of Asthma – New 2009 Click here to see Asthma Referral Form Click her to see Asthma-“Knowledge is Power / Kidz Taking Control projectoverview• Management of Depression• Guidelines for the Treatment of Substance Abuse• Management of Acute Low Back Pain – New 2011• Pain Management Program and Opiate/Opioid Management• Standards for Patient Records (See Medical Record Section Below) Click here to see Medical Record Audit Tool Sheet• Standards for Access to Care and Services Click here to see Accessibility, Availability (Geoaccess), Continuity andCoordination of Care, and Emergency Room Use SheetThe Quality Improvement Department establishes new practice guidelines as opportunities forimprovement are identified. Existing guidelines are reviewed and updated at a minimum of twoyears and more frequently if changes occur. When existing guideline are revised or newguidelines are put in place, you will receive a postcard from the QI department. The postcardwill give you information on how to access the guidelines on the Health Plan website.Section 8 / Page 13

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramCompliance with “Clinical Practice Guidelines” and “Standards for Care and Service” isassessed on a yearly basis using HEDIS® data or medical record audits. The goal is to measureoutcomes of care, to identify practitioner variations in diagnosis and treatment, and to identifyopportunities for improvement.For a copy of the current Clinical Practice Guidelines or for questions related to guidelines, callthe Quality Improvement Department of The Health Plan at 740-695-7659.Section 8 / Page 14

PROVIDER PROCEDURAL MANUAL 2014*Start* Medical Record FocusThe Health Plan Quality Management ProgramQuality of care is enhanced when a member’s medical record is organized and complete.To assist our Providers in this area, the Standards for Patient Records Guideline has beenadopted and distributed. Click here to see the Medical Record Audit Tool SheetAreas that have been targeted for improvement in 2009 – 2014: Click here to see updated forms in the QI Forms and Informational Material Section.Click below to see the following documents: Signature Validation (Signature Log) Preventive Health Focus (Preventive Health Flow Sheet) Problem and Medication Tracking (Problem and Medication Lists) Advance Directive Patient Education Sheet Advance Directive Flow ChartAdvance DirectivesHealth plans, hospitals, and other institutional healthcare providers face a number ofresponsibilities under the Patient Self-Determination Act of 1990. This federal law requires allinstitutional providers delivering Medicare or Medicaid services to comply with severalrequirements related to advance directives.• Primary Care Physicians are required to ask each Health Plan member, 18 years of age andolder, if he/she has an advance directive.• The physician must document the member’s response in the medical record.Under federal law, Medicare Advantage plans must maintain written policies regarding advancedirectives. Medicare Advantage plans cannot discriminate against any person based on whetheror not the individual has an advance directive. Physicians whose moral or religious beliefsprevent them from full support of a patient’s advance directive may transfer the patient to afacility or provider who will support the directive.Section 8 / Page 15

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramAll Health Plan physicians should be familiar with the Patient Self-Determination Act and honorpatients’ wishes as described in their advance directives. The Health Plan encourages itsenrollees to discuss their advance directives and any treatment options with their Primary CarePhysician, and will provide important information about advance directives to members,physicians, and other providers. The Health Plan has resources available for physicians andenrollees to assist them in completing advance directivesProvider’s Role• Ask each Health Plan patient over the age of 18, if he/she has an advance directive anddocument the answer in the medical record. If the member does not have an advancedirective, that should be noted and the physician and office staff should encouragediscussions with that member to help them understand advance directives and theimportance of such documents. Physician support of this effort is required.• Honor the wishes of a member as outlined by an advance directive and not discriminateagainst any member based on the existence or content of his/her advance directive.• Transfer a member whose advance directives you refuse to follow.Compliance with advance directive policies is part of The Health Plan’s quality review process.Annual audits will be conducted to ensure compliance.• If the member has signed an Advance Directive, a copy should be retained in the medicalrecord. Effective 2009 – All Health Plan Medical Record audits will require that eachpatient 18 years or older have documentation on their chart that Advance Directives havebeen discussed, reviewed and/or updated at a minimum of every three years to ensurecompliance with Federal Guidelines.Section 8 / Page 16

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramIn regards to Advance Directives, The Health Plan will:• Include information about Advance Directives in the Member Handbook. Provide Advance Directive information on The Health Plan website atwww.healthplan.org.• Educate new members regarding Advance Directives during the Outreach phone contact. Include articles in the Member Newsletters regarding Advance Directives.Click below to see the following newsletters: HealthWise Secure Connection Healthy Sense Member• Provide Advance Directive Stickers for use on your medical records. Provide an Advance Directive Patient Education Sheet in the QI forms section for yourstaff to give to your patients to educate them in regards to Advance Directives.Click below to see the following documents: Advance Directive Patient Education Sheet Advance Directives Flow ChartSection 8 / Page 17

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramWellness & Health Promotion EducationThe Health Plan Quality Improvement Department provides preventive health educationalactivities, which can help reduce the incidence of illness and disease for members. The goal ofour wellness and health promotion interventions is to decrease the health risks of members and toimprove their overall health.Employer and/or School Based Wellness programs can be designed to allow for baseline and remeasurementcomparison for each participant as well as overall, aggregate data results.Our Member Wellness Initiatives, Outreach Education, and Health Promotion programs include:Personal Health Risk Assessment A Health Risk Assessment (HRA) is completed on SecureCare members upon enrollment.Members are referred to catastrophic case management, care management, and diseasemanagement programs based on the results. Reassessment is ongoing; and member-specificrisk-stratified reports are reviewed monthly with referrals to care / case management,pharmacy, social services, and disease management as indicated. All adult Health Plan members can take an on-line Health Risk Assessment. This self-guidedtool provides the member with an overall health risk assessment, including readiness tochange status and ways to improve health. Other risk assessments offered are diabetes andcardiac. (Each on-line test takes no more than 10 minutes to complete).The Health Plan Website @ www.healthplan.org / Wellness Services offers the followingfeatures for members: Information Request Referral where members may request various educational materialsbe mailed to them. Monthly Wellness Information featuring short educational and informative pieces withlinks to various websites on specific topics. Health Risk Assessment (see description above). Interactive Health Tools which include health calculators and health screenings. Preventive Health Guidelines to help ensure members obtain the recommendedpreventive services in the timeframes included.Section 8 / Page 18

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramClinics / Health Fairs Annual Flu and Pneumonia Clinics Diabetic Care Clinics – Assist Disease Management as needed Participation in Community Health Fairs to include free lab screenings Free screenings onsite at The Health Plan (lipid profile, glucose, HbA1C, Blood Pressure,BMI, Body Fat, and counseling regarding results) Free lab screenings at predetermined Pharmacies for targeted diabetic membersEducational Programs at Schools, Worksites and in the Community Provided by QualifiedRNs and LPNs (Collaboration with Medical Department) American Lung Association “Freedom from Smoking” program Click here to see Smoking Cessation Referral Form• Brochures available for use in your office. American Lung Association “Not-On-Tobacco” – A youth oriented smokingcessation program Teen Outreach regarding tobacco, drug and alcohol awareness Teen Outreach regarding nutrition Coaching members on overall wellness/components of health Evaluate and educate members on knowing and understanding their individual preventivescreening results-“Understanding Your Numbers” Weight Management Classes Stress Management Classes Chronic Disease Education regarding hypertension, heart disease, and diabetes. Bullying “Team Health Plan” – employee participation in run, walk and wellness based eventsSchool / Employer Based Health and Wellness Training Modules Located on a password protected area of The Health Plan website is an easy to use formatthat offers the following training topics: Fitness Nutrition Education Tobacco Cessation / Use Prevention Mental Health IssuesSafety Education Preventive Health-Knowing Your Numbers Preventing Illness / Staying Healthy Cold and Flu Season Pharmacy / Medication Safety Educationwww.schools.healthplan.org to register for this programSection 8 / Page 19

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramMember Empowerment Projects – Providing education on managing health conditions andleading a healthy lifestyle. “Knowledge is Power / Kidz Taking Control” Asthma Project Click here to see Asthma Referral Form 5210 Childhood Obesity Prevention Program (WV Collaboration) Click here to see Obesity Referral Form, BMI (Body Mass Index) Charts,BMI-Pediatric Weight Assessment, Nutrition Counseling, & Physical Activity Form Back Pain Initiative – QI / Medical Department Collaborative ProjectReports are generated based on claims with a diagnosis of back pain.These members are contacted by phone for education.Educational material is mailed to the member. Click here to see “Pain Assessment Sheet”, “Prescription Agreement & NarcoticUse”, “Prescription Drug Abuse Sheet”, and Prescription Reporting System(Prescription Drug Database)” Wellness and Health Education Call Center• Phone outreach to encourage member participation in preventive care.• Discussion regarding barriers to good health.• Discussion regarding steps that can be taken to prevent illness and improve health.• Discussion to encourage members to comply with their doctor’s orders.• Discussion to encourage members to visit The Health Plan Website.• Discussions regarding the management of disease such as diabetes and hypertension.• Reminders for the member to see their doctor on a routine basis for follow-up care.• Reminders for the member to get routine labs (HBA1C, LDL, and microalbumin).• Reminders for the member to take their medication as ordered by their doctor.• Outreach phone calls to individuals 18 years and older target the following preventivehealth services:‣ Well-Care visit yearly‣ Breast Cancer Screening to include clinical breast exam and mammography‣ Cervical Cancer Screening / PAP test‣ Chlamydia screening‣ HPV Immunizations‣ Cholesterol Testing‣ Glucose TestingSection 8 / Page 20

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management Program‣ Osteoporosis Testing‣ PSA Testing‣ Colorectal Cancer Screening to include stool for occult blood and colonoscopy‣ Adult Vaccines Including Influenza (Flu) vaccines, Pneumonia vaccines, and Tetanusbooster‣ Antibiotic Use / Avoidance‣ Beta Blocker use after a MI‣ Smoking Assessment, Readiness to Quit, and Referral to Smoking Cessation• Follow up educational mailings: “Together Everyone Lives a Healthier Lifestyle” “Year to Date Preventive Health Checklist”www.healthplan.org/index.php/health-a-wellness/wellness-resourcesSection 8 / Page 21

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramOngoing Educational Mailings – *Also available on Web Site. Newborn Welcome Packet to include:• “What To Do When Your Child Is Sick” “Baby Keepsake Booklet” Immunization Initiative• 6 month reminder postcard• 18 month reminder postcard• 4-6 year old (preschool) coloring book Birthday card reminders for Preventive Health Screenings and Immunizations• 1 year old birthday card• 12 year old birthday card• Women’s birthday card – 18 +• Men’s birthday card – 18 + ER diversion (Collaborative with Outreach)• Outreach Representatives in Government Programs contact members for educationalpurposes when they have 3 ER and/or Urgent Care Visits in 90 days• Back pain (collaboration with Medical) and URI focus Yearly Calendar mailing to Secure Care members EMI-Emergency Medical Information Form-target mailing to Secure Care Click here to see EMI Form – “Envelope of Life” Preventive Health Guidelines-annually with re-enrollment Click here to see Preventive Health Flow Sheet Click here to see information on the Immunization Registry Click here for Centers for Disease Control and Prevention at www.cdc.gov Member Newsletter – mailed 3x/year Click here to see HealthWise, Secure Connection (Secure Care), and Healthy Sense(MHT) Newsletters Target Mailings “Together Everyone Lives a Healthier Lifestyle”Co-Pay Waivers Co-pay waiver for commercial & SecureCare members receiving diabetic eye examsSection 8 / Page 22

PROVIDER PROCEDURAL MANUAL 2014Provider Education InitiativesThe Health Plan Quality Management Program• ER / Narcotic / Back Pain Initiative Click here to see Prescription Drug Abuse Click here to see Prescription Drug Database Click here to see Prescription Agreement and Narcotic Use Contract (2012-2013) Click here to see Pain Assessment Sheet (2011-2013)• Provider Education Information packets distributed during HEDIS® Audit, MedicalRecord Audit, and available on Web Site Click here to see QI Forms and Informational Material Section• Tobacco awareness education meetings Click here to see Smoking Cessation Referral Form• Provider newsletter – quarterly mailing in collaboration with the Provider Relations Department Click here to see Provider Focus Newsletter• BMI-Body Mass Index Mailing to PCPs and Pediatricians (Summer 2011)In light of the nationwide obesity epidemic, the Health Plan is encouraging providers tomonitor their patient’s BMI. Body Mass Index (BMI) is a reliable indicator of total body fat,which is related to the risk of disease and death. In 2009, The National Committee forQuality Assurance included two new measures in the HEDIS® data set: “Adult BMIAssessment” and “Weight Assessment and Counseling for Nutrition and Physical Activity forChildren and Adolescents”. Providers are asked to document a BMI for each patient at leastonce annually in the medical record, and to use an ICD-9 V-Code for BMI on the claim. Click here to see BMI Chart Click here to see BMI Coding Sheet Click here to see BMI – Pediatric Weight Assessment, Nutrition Counseling, andPhysical Activity Form Click here to see BMI Percentile Chart for Boys 2-20 Years Click here to see BMI Percentile Chart for Girls 2-20 Years Click here to see Obesity Referral FormSection 8 / Page 23

PROVIDER PROCEDURAL MANUAL 2014QualityImprovementForms&Informational MaterialsSection 8 / Page 24

2013-2014QI Information SheetDear Provider,St. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365Phone: 1.800.624.6961Hearing Impaired1.800.622.3925Fax: 740.695.5297www.healthplan.orgHomeTown Office100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816PH: 1.877.236.2289Hearing Impaired1.877.236.2291Fax: 330.837.6869www.healthplan.orgThe following forms and informational materials are provided to assist you in areas that have been identified as opportunities forimprovement by the Quality Improvement Department. All sample forms included are provided as a tool and not a requirement. Feel freeto use them or adapt them to meet the individual needs of your office.● Accessibility, Availability (Geoaccess), Continuity andCoordination of Care, and Emergency Room Use(Updated 2013)● Accreditation – NCQA, HEDIS, CMS, and Delmarva (2012)● Advance Directive Flow Chart (2012)● Advance Directive Patient Education Sheet (2012)● Appropriate Coding, Testing and Treatment for Children withUpper Respiratory Infections (URI) and Pharyngitis (2012)● Asthma – Adults and Children – “Knowledge is Power / TakeControl” Project Overview (New 2013)● Asthma Referral Form – “Knowledge is Power / Take Control”Project (New 2013)● Blood Lead Screening (2012)● Body Mass Index (BMI) Coding Updates and Tips (2012)● Body Mass Index (BMI) Chart (Adult) (2012)● Body Mass Index (BMI) Chart (Adult-Grayscale) (2012)● Body Mass Index (BMI) Chart (Children) (2012)● Body Mass Index (BMI) Percentile Chart forBoys / Girls 2-20 Years● Body Mass Index (BMI – Pediatric Weight Assessment,Nutrition Counseling, and Physical Activity Form (2012)● Chart Stickers Available (Advance Directive, Allergy, andHealth Plan)● Diabetic Dilated Fundus Examination Form● Diabetic Mellitus Recommendations & Flow Sheet (2012)● ECS/OPTUM Medicare Record Review for -Medicare -CMS(Updated 2013)● Electronic Medical Records (EMR) (New 2013)● Envelope of Life (Emergency Medical Information)(Updated 2013)● Faxing and Mailing (Updated 2013)● HEDIS® – 2014 Coding Guide● HEDIS® – Coding and Documentation Hints (New 2013)● HEDIS® – Helpful Hints for Office Staff (New 2013)● HIPAA Privacy Rule regarding HEDIS®● Immunization Registry – West Virginia & Ohio(Updated 2013)● Medical Record Audit Tool● Medication List● Obesity Referral Form – “Obesity Prevention Program”● Onsite Office Reviews – HEDIS® and Medical RecordAudits (New 2013)● Pain Assessment Sheet (2011)● Patient History Form● Physician Oversight (Updated 2013)● Prescription Agreement and Narcotic Use Contract (2012)● Prescription Drug Abuse (2012)● Prescription Drug Database (2012)● Preventive Health Flow Sheet● Problem List● Signature Log● Smoking Cessation Referral Form –“Freedom from Smoking”● Vaccine Administration Record forChildren & Teens (2011)● VA Clinics and Health Fairs (Updated 2013)● Website @ www.healthplan.orgIf you have any questions please contact the Quality Improvement Department at 1-800-624-6961, Ext. 7659 or 740-695-7659, Mondaythrough Friday, 8:30 a.m. until 4:30 p.m.Thank you for your assistance in helping us meet our goal of providing excellent care and service to our members.Sincerely,Shelly Rouse, M.B.A.Assistant Director of Quality Improvement & WellnessSection 8 / Page 25

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramAccess - After-Hours & AppointmentThe Quality Improvement Department monitors physician accessibility which includes a PCP’savailability after business hours and for preventive, routine (non-preventive), non-urgent(symptomatic), urgent or emergent appointments.In the event of an urgent medical issue, your patients should be able to access care 24 hours aday/365 days a year. When your patient needs to contact you outside of normal office hours,they would first call your office phone number. An answering machine message should directthem in how to reach you or a physician covering for you. They can also be referred to ananswering service number. A physician or designated covering practitioner should return a callto the member within 1 hour. This process should be in place any time the office is closed suchas after-hours, weekends, and holidays. We encourage you or your office staff to call your officeafter business hours to assure that the message on your machine relays the information that isintended.During normal business hours, if there is an answering machine, there must be an option to leavea call-back message. An answering machine message that states “we are busy,” “call back later,”or one that has not been switched from the after-hours message, is inappropriate.Appointment and After-hours accessibility is monitored through the “Appointment AccessibilitySurvey,” phone surveys, member satisfaction surveys, and the member complaint process.Further information on accessibility is included in the Standards for Access to Care andServices Guideline.Ava / GeoAccessThe Health Plan monitors the care and services that our members receive on an ongoing basis.As part of this, we look at the number of Primary Care Physicians and Specialists in regards totheir proximity to our members as well as the ratio of physicians to members. A report is runutilizing zip codes and includes the total number of members, total number of providers, theaverage driving distance, and the percentage of providers per member within the given drivingdistances. Problem areas and barriers are identified and shared with our Provider Relationsdepartment. These documents are available for your review upon request by calling theQI department.Continuity & Coordination of CareThe goal of continuity and coordination of care is the seamless transition of patient care from onesetting to another. It includes all aspects of a member’s care and all of the providers involved inthat care. The Primary Care Physician is the most appropriate connector. A member’scommunication with their PCP will enhance their overall health and enable their PCP to directtheir care so that all appropriate medical providers are involved. We encourage our members tokeep their PCP informed of any change in their medical condition including visits to the anintermediate, skilled, or rehab facility; an inpatient or outpatient center; an emergency room orurgent care setting; a VA clinic, Health Fair, mental health care provider, or specialist; as well asany tests, medications, or treatments that were recommended.Section 8 / Page 26

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramWe also strongly encourage Specialist providers to mail or fax medical updates to the PCP forinclusion in the member’s chart. If your office has not received these reports, we encourage youand your staff to contact these entities and to include the information in the patient’s medicalrecord.For improved continuity and coordination of care, we suggest the following:- Phone consultation or conference calls when multiple doctors are involved in themember’s care.- Concise documentation in the medical record to show that PCP/Specialist consultationhas occurred.- Mail or fax medical updates to the PCP and other specialists involved in the patients care.For improved continuity and coordination of care for our Behavioral Health members, ourBehavioral Health providers are encouraged to discuss with their patients the importance ofsharing their behavioral health care issues with their PCP. A release form is available by callingthe Behavioral Health Unit at 1-800-624-6961, ext. 7301 or 695–7301.Coordinated care ensures optimal patient safety.Emergency Room UseMany members who use the emergency room on a regular basis would be better served in theirPrimary Care Physician’s office. Their PCP knows their medical and pharmacy history andwould prescribe the most beneficial and appropriate care. In order to help those who are notestablished with a PCP, the Health Plan identifies members with frequent emergency room visitsfor non-emergent care. Once identified, attempts are made to educate the member of theimportance of seeing their doctor on a regular basis and of calling their primary care physicianfor urgent health care issues.If a patient does experience a true emergency or life-threatening condition that results in anEmergency Room visit, we also educate our members of the importance of seeing their PCP forfollow-up and of notifying the Health Plan at 1-800-624-6961 within 48 hours.A reduction in emergency room visits helps control health care costs and ensures that themember is receiving the best care possible.If you have any questions or need further information on these topics, call the QI department at1-800-624-6961 ext 7659, or 1-740-695-7659.Section 8 / Page 27

PROVIDER PROCEDURAL MANUAL 2014AccreditationNCQA (National Committee for Quality Assurance)As an NCQA-certified MCO with an Commendable rating, The Health Plan of the Upper OhioValley maintains and meets the highest standards of care and service set forth by this agency.NCQA accreditation occurs every three years.HEDIS® (Healthcare Effectiveness Data and Information Set)HEDIS® data is collected annually by a combination of administrative (claims) data andonsite medical record data abstraction. Each HEDIS® measure has a total score valueand is a considerable percentage of our points towards NCQA accreditation.CAHPS (Consumer Assessment of Healthcare Providers and Systems)CAHPS survey was created by CMS for the purpose of monitoring and improvingthe quality of care provided to members. It collects information on an enrollee’sexperience and satisfaction with health care during the previous year.CMS (Centers for Medicare and Medicaid Services)As a contracted Medicare health plan, we also must meet standards of care and services set forththrough the Centers for Medicare and Medicaid Services. These surveys are typically conductedannually. Your care to our SecureCare members is measured through these standards andcontributes to our continuing contract with CMS.HOS (Health Outcomes Survey) – HOS Survey was developed by CMS for thepurpose of monitoring and improving the quality of care provided to MedicareBeneficiaries. It asks questions about an enrollee’s health status over a period oftwo years.DelmarvaDelmarva is the oversight organization for the West Virginia Bureau of MedicalServices/Mountain Health Trust contract with The Health Plan. Delmarva provides standards ofcare and service that we must abide by to continue the contract. We are surveyed annuallyagainst our performance to these standards. Your care to MHT members is measured throughthese standards and contributes to continuing a contract with BMS.West Virginia and Ohio Department of InsuranceSection 8 / Page 28

Advance DirectivesFlow ChartName: ____________________________________DOB: _____________________________________Has the patient completed Advance Directives?(Living Will and/or Durable Power of Att orney for Healthcare)YesNoPlace copy onchart.______________Date______________SignatureYESDoes the patienthave a copy withthem or is there acopy on themedical record?NODoes the patientwant additionaladvance directiveinformation?YESNO_______________Date_______________SignatureRequest a copy frompatient/family.InformationProvided:Referred to TheHealth Plan forinformation:_______________Date_________________DateOnce received, placecopy on chart._______________Signature_________________Signature__________________Date__________________Signature_____________________________________Physician NotifiedPERMANENT PARTOF THE MEDICALRECORD_____________________________________SignatureDateAdditional information can be obtained at www.healthplan.orgForms should be updated every three years to meet compliance.(This form is not intended for Behavioral Health use.)

PROVIDER PROCEDURAL MANUAL 2014Advance DirectivesAdvance Directives: Patient Education SheetGetting Healthcare Preferences in Writing and in the Medical RecordWill your doctor or family member know what to do if you become ill or unable to makedecisions about medical care?Advance Directives are written statements, which are completed in advance of serious illness,and address how you want medical decisions made. An advance directive allows you to stateyour choices for health care or to name someone to make those choices if you are unable. Thetwo most common forms of advance directives are:• "Living Will" and• "Durable Power of Attorney for Health Care"A Living Will generally states the kind of medical care that a patient wants (or does not want) ifthey become unable to make their own decision. It is called a "Living Will" because it takeseffect while they are still living. Most states have their own living will forms, each somewhatdifferent. It may also be possible for a patient to complete and sign a pre-printed living will formavailable in their own community, draw up their own form, or simply write a statement of theirpreferences for treatment. A patient may also wish to speak to an attorney to be certain theyhave completed the living will in a way that their wishes will be understood and followed.A Durable Power of Attorney for Health Care is a signed, dated and witnessed paper naminganother person (such as a husband, wife, daughter, son or close friend) as the patient’s "agent"or "proxy" to make medical decisions for them if they should become unable to make them forthemselves. A patient can include instructions about any treatment they want to avoid. Somestates have specific laws regarding a Health Care Power of Attorney and provide printed forms.Visit www.healthplan.org for further information and website links that will provide documentsneeded based on the state in which an individual resides: www.caringinfo.org. Members mayalso contact The Health Plan Customer Service at (888) 847-7902 for additional information onhow to obtain Advance Directives.It is also important that you give your PCP a copy of your Advance Directives for their chart.Section 8 / Page 30

PROVIDER PROCEDURAL MANUAL 2014Antibiotics are NOT appropriate for the sole diagnosis ofUpper Respiratory Infections in children.If antibiotics are prescribed for aURI due to a secondary condition,please remember to code for those condition(s) and toclearly document the presence of these in the medical record.(Ex: Acute Sinusitis (461), Chronic Sinusitis (473),Acute Tonsillitis (463), Bacterial Infection (041.9),Acute Bronchitis (466), Diabetes (250), Asthma 493),Otitis Media (382), History of Fever (780.60), Influenza (487.1),Streptococcal Sore Throat (034.0), Enlargement of Lymph Nodes (785.6)or Congenital Heart / Lung Disease)Children diagnosed with pharyngitis should receive aGroup A Streptococcus test before an antibiotic is given.(Preferred Strep Test CPT Codes:87070, 87071, 87081, 87430, 87650-87652, 87880)It is also important to include any secondary diagnosis on the claimand to document the rationale for the antibiotic.Appropriate Coding, Testing & Treatment for Children with Upper Respiratory Infections(URI) & PharyngitisSection 8 / Page 31

PROVIDER PROCEDURAL MANUAL 2014AsthmaAdult & Child Asthma Project “Knowledge is Power / Take Control“To help improve the quality of life for people with asthma, the Health Plan continues to offer theirAdult & Child asthma project entitled, “Knowledge is Power / Take Control”. The goal of theproject is to help our members or a parents/guardian, learn about asthma, how to control it, andwhat to do during an asthma attack.When a member is identified with a diagnosis of asthma, they are called by a Wellness and Healthoutreach representative. After a few brief questions, they are mailed educational information, acoupon, and an asthma action plan. They are asked to take their coupon and asthma action plan totheir next office visit. The coupon is to be signed by the physician to confirm that the member hasa diagnosis of asthma and has kept the appointment. The coupon is then returned to the Health Planby the member or the parent/guardian in a self-addressed, stamped envelope. Upon receipt of thecompleted coupon, the member, parent, or guardian will receive a call from the QualityImprovement Department of The Health Plan to complete a brief assessment of their asthma. Uponcompletion of that assessment, they are sent an age appropriate asthma tool kit and a gift forparticipation. The asthma tool kit includes a peak flow meter, an optichamber (spacer), educationalmaterials, and a carrying case.We also encourage our providers to educate your patients regarding the components of asthma,including proper techniques for peak flow meters and/or optichambers, their asthma action plan,and the pharmacological therapy that may be required for management As that provider, youreducation and teaching efforts help determine how well patients with asthma assume responsibilityfor their own well being and self managed care. Medication management education for patientsand/or parents of children should include:Update asthma action plan if any changes have been madeEmphasis on the difference between “Rescue/Quick Relief” medications and“Controller/Long Term Control” medications and have a clear understanding ofwhen each should be used.The importance of proper dosage and frequency of medications. Have the patientbring in their inhalers, diskus, and spacer or valved holding chambers to theirappointment to check the patient’s inhalation technique through direct observation.Explain the importance of keeping routine follow up appointments to assess changesin asthma severity and/or symptoms, make necessary medication adjustments,reinforce education, and address any questions and/or concerns they may have.For more information, contact Michelle Poland in the Quality Improvement Department at(800) 624-6961, ext. 7664 or (740) 695-7664.Section 8 / Page 32

St. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365Phone: 1.800.624.6961Hearing Impaired1.800.622.3925Fax: 740.695.5297www.healthplan.orgHomeTown Office100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816PH: 1.877.236.2289Hearing Impaired1.877.236.2291Fax: 330.837.6869www.healthplan.orgASTHMA PROJECTAdults & Children With Asthma“Knowledge is Power / Take Control”REFERRAL FORMPlease complete the information below to refer your patient, to The Health Plan’s asthma program.Fax to (740) 695-5297Attn:Michelle Poland, R.N., M.S.N., QI / Wellness DepartmentFrom:Date:Re:Asthma Project ReferralPatient InformationIf a child, please list Parent or Guardian NameName:HP ID#:DOB:Home Address:City: State: Zip:Home Phone#: Alternate Phone Number :Has the patient had: Pulmonary Function Testing YES NO Date:Allergy Testing YES NO Date:Please indicate if your patient utilizes: Action Plan Nebulizer Peak Flow Optichamber / SpacerPlease list current Asthma Medications:The Health Plan Quality Improvement’s asthma program is designed to educate adults and children’s parents orguardians regarding the various aspects of asthma thus learning to control their asthma. The Health Plan provideseducational information, a peak flow meter, and optichamber / spacer for all patients with a diagnosis asthma whowish to participate in the project. The Asthma Program is offered by The Health Plan on an ongoing basis and is free forHealth Plan members.For more information you may contact Michelle Poland, R.N., M.S.N., Health Plan Senior Quality ImprovementCoordinator, at (800) 624-6961, Ext. 7664 or (740) 699-7664, Monday-Friday 8:00 a.m. to 4:30 p.m.Asthma Referral FormSection 8 / Page 33

PROVIDER PROCEDURAL MANUAL 2014Blood Lead Screening forMedicaid / MHT 2 Year OldsA blood lead screen (CPT 83655) is required for all Medicaid/ MHT children on or before their2 nd birthday. This test can be ordered by a Pediatrician or by the Primary Care Physician.EPSDT Periodicity Schedule:http://www.dhhr.wv.gov/healthcheckClick on the link below for more information on this important test:www.wvdhhr.org/mcfh/lead/ScreeningPlan.pdfSection 8 / Page 34

PROVIDER PROCEDURAL MANUAL 2014Body Mass Index (BMI) Coding Updates &Tips That Minimize the Need for On-SiteChart AuditsBMI (Body Mass Index) is an estimate of body fat based on height and weight. A BMI of 25indicates that the patient is overweight and a BMI of 30 indicates obesity.A BMI can easily help you identify patients who are at risk for diseases such as heart disease,high blood pressure, diabetes, gallstone, and breathing problems.If a patient has a BMI of 25 or more, we encourage you to counsel them in the areas ofconvenience foods, portion size, and physical activity. We also encourage you to begin theprocess of routinely monitoring the patient’s lipid profile.With obesity being a major health concern across the nation, we are asking for your assistance inreporting and gathering information on Body Mass Index (BMI).We are now required by many governing bodies to report BMI, and this information is alsorequired for our annual HEDIS ® audit. In order to decrease the number of chart pulls and onsitereviews in your office, we encourage you to use the following codes:V85.0 – BMI less than 19, adult V85.3 – BMI between 30-39, adultV85.30 – BMI 30.0-30.9, adultV85.1 – BMI between 19-24, adult V85.31 – BMI 31.0-31.9, adultV85.32 – BMI 32.0-32.9, adultV85.2 – BMI between 25-29, adult V85.33 – BMI 33.0-33.9, adultV85.21 – BMI 25.0-25.9, adult V85.34 – BMI 34.0-34.9, adultV85.22 – BMI 26.0-26.9, adult V85.35 – BMI 35.0-35.9, adultV85.23 – BMI 27.0-27.9, adult V85.36 – BMI 36.0-36.9, adultV85.24 – BMI 28.0-28.9, adult V85.37 – BMI 37.0-37.9, adultV85.25 – BMI 29.0-29.9, adult V85.38 – BMI 38.0-38.9, adultV85.39 – BMI 39.0-39.9, adultV85.4 – BMI 40 and over, adultV85.41 – BMI 40.0-44.9, adultV85.42 – BMI 45.0-49.9, adultV85.43 – BMI 50.0-59.9, adultV85.44 – BMI 60.0-69.9, adultV85.45 – BMI 70 and over, adultTo obtain BMI charts for use in your office, visit the Health Plan website underProvider Services / Access Provider Files and Forms. You can also call the QI Department at(800) 624-6961, Ext. 7659 or (740) 695-7659.You can also encourage your patients to visit our website @ www.healthplan.org/Members/Health and Wellness/Wellness ResourcesSection 8 / Page 35

Body Mass Index (BMI) ChartsPATIENT NAME:BODY MASS INDEX – (BMI)DATE OF BIRTH:DateHeightWeightBMIThe formula below can be used if your patient does not fall within the parameters of the chart.BMI Formula = [Weight (lbs) ÷ Height in inches 2 ] x 703≤19 = Underweight 20-24 = Normal 25-29 = Overweight 30-39 = Obese 40+ = Morbidly ObeseWtHeight (in)(lbs) 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 7675 18 17 17 16 16 15 15 14 14 13 13 12 12 12 11 11 11 10 10 10 10 9 980 19 19 18 17 17 16 16 15 15 14 14 13 13 13 12 12 11 11 11 11 10 10 1085 20 20 19 18 18 17 17 16 16 15 15 14 14 13 13 13 12 12 12 11 11 11 1090 22 21 20 19 19 18 18 17 16 16 15 15 15 14 14 13 13 13 12 12 12 11 1195 23 22 21 21 20 19 19 18 17 17 16 16 15 15 14 14 14 13 13 13 12 12 12100 24 23 22 22 21 20 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 13 12105 25 24 24 23 22 21 21 20 19 19 18 18 17 16 16 16 15 15 14 14 14 13 13110 27 26 25 24 23 22 22 21 20 20 19 18 18 17 17 16 16 15 15 15 14 14 13115 28 27 26 25 24 23 23 22 21 20 20 19 19 18 18 17 17 16 16 15 15 14 14120 29 28 27 26 25 24 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15125 30 29 28 27 26 25 24 24 23 22 22 21 20 20 19 18 18 17 17 17 16 16 15130 31 30 29 28 27 26 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16135 33 31 30 29 28 27 26 26 25 24 23 23 22 21 21 20 19 19 18 18 17 17 16140 34 33 31 30 29 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18 17145 35 34 33 31 30 29 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18150 36 35 34 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 18155 37 36 35 34 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 20 20 19 19160 39 37 36 35 34 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 20 20165 40 38 37 36 35 33 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 20170 41 40 38 37 36 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21175 42 41 39 38 37 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22 21180 43 42 40 39 38 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22185 45 43 41 40 39 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23190 46 44 43 41 40 38 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23195 47 45 44 42 41 39 38 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24200 48 46 45 43 42 40 39 38 37 36 34 33 32 31 30 30 29 28 27 26 26 25 24205 49 48 46 44 43 41 40 39 38 36 35 34 33 32 31 30 29 29 28 27 26 26 25210 51 49 47 45 44 43 41 40 38 37 36 35 34 33 32 31 30 29 29 28 27 26 26215 52 50 48 47 45 44 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26220 53 51 49 48 46 45 43 42 40 39 38 37 36 35 34 33 32 31 30 29 28 28 27225 54 52 50 49 47 46 44 43 41 40 39 38 36 35 34 33 32 31 31 30 29 28 27230 55 53 52 50 48 47 45 44 42 41 40 38 37 36 35 34 33 32 31 30 30 29 28235 57 55 53 41 49 48 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29240 58 56 54 52 50 49 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31 30 29245 59 57 55 53 51 50 48 46 45 43 42 41 40 38 37 36 35 34 33 32 32 31 30250 60 58 56 54 52 51 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30255 61 59 57 55 53 52 50 48 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31260 63 60 58 56 54 53 51 49 48 46 45 43 42 41 40 38 37 36 35 34 33 33 32265 67 62 59 57 56 54 52 50 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32270 65 63 61 58 57 55 53 51 49 48 46 45 44 42 41 40 39 38 37 36 35 34 33275 66 64 62 60 58 56 54 52 50 49 47 46 44 43 42 41 39 38 37 36 35 34 33280 68 65 63 61 59 57 55 53 51 50 48 47 45 44 43 41 40 39 38 37 36 35 34Quality Improvement Dept @ The Health Plan: (740) 695-3585 ext. 7659 -or - (800) 624-6961 ext. 7659

BODY MASS INDEX (BMI)PATIENT NAME: _________________________________ DATE OF BIRTH: ___________DateHeightWeightBMIThe formula below can be used if your patient does not fall within the parameters of the chart.BMI Formula = [Weight (lbs) ÷ Height in inches 2 ] x 703≤19 = Underweight 20-24 = Normal 25-29 = Overweight 30-39 = Obese 40+ = Morbidly ObeseWtHeight (in)(lbs) 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 7675 18 17 17 16 16 15 15 14 14 13 13 12 12 12 11 11 11 10 10 10 10 9 980 19 19 18 17 17 16 16 15 15 14 14 13 13 13 12 12 11 11 11 11 10 10 1085 20 20 19 18 18 17 17 16 16 15 15 14 14 13 13 13 12 12 12 11 11 11 1090 22 21 20 19 19 18 18 17 16 16 15 15 15 14 14 13 13 13 12 12 12 11 1195 23 22 21 21 20 19 19 18 17 17 16 16 15 15 14 14 14 13 13 13 12 12 12100 24 23 22 22 21 20 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 13 12105 25 24 24 23 22 21 21 20 19 19 18 18 17 16 16 16 15 15 14 14 14 13 13110 27 26 25 24 23 22 22 21 20 20 19 18 18 17 17 16 16 15 15 15 14 14 13115 28 27 26 25 24 23 23 22 21 20 20 19 19 18 18 17 17 16 16 15 15 14 14120 29 28 27 26 25 24 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15125 30 29 28 27 26 25 24 24 23 22 22 21 20 20 19 18 18 17 17 17 16 16 15130 31 30 29 28 27 26 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16135 33 31 30 29 28 27 26 26 25 24 23 23 22 21 21 20 19 19 18 18 17 17 16140 34 33 31 30 29 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18 17145 35 34 33 31 30 29 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18150 36 35 34 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 18155 37 36 35 34 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 20 20 19 19160 39 37 36 35 34 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 20 20165 40 38 37 36 35 33 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 20170 41 40 38 37 36 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21175 42 41 39 38 37 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22 21180 43 42 40 39 38 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22185 45 43 41 40 39 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23190 46 44 43 41 40 38 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23195 47 45 44 42 41 39 38 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24200 48 46 45 43 42 40 39 38 37 36 34 33 32 31 30 30 29 28 27 26 26 25 24205 49 48 46 44 43 41 40 39 38 36 35 34 33 32 31 30 29 29 28 27 26 26 25210 51 49 47 45 44 43 41 40 38 37 36 35 34 33 32 31 30 29 29 28 27 26 26215 52 50 48 47 45 44 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26220 53 51 49 48 46 45 43 42 40 39 38 37 36 35 34 33 32 31 30 29 28 28 27225 54 52 50 49 47 46 44 43 41 40 39 38 36 35 34 33 32 31 31 30 29 28 27230 55 53 52 50 48 47 45 44 42 41 40 38 37 36 35 34 33 32 31 30 30 29 28235 57 55 53 41 49 48 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29240 58 56 54 52 50 49 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31 30 29245 59 57 55 53 51 50 48 46 45 43 42 41 40 38 37 36 35 34 33 32 32 31 30250 60 58 56 54 52 51 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30255 61 59 57 55 53 52 50 48 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31260 63 60 58 56 54 53 51 49 48 46 45 43 42 41 40 38 37 36 35 34 33 33 32265 67 62 59 57 56 54 52 50 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32270 65 63 61 58 57 55 53 51 49 48 46 45 44 42 41 40 39 38 37 36 35 34 33275 66 64 62 60 58 56 54 52 50 49 47 46 44 43 42 41 39 38 37 36 35 34 33280 68 65 63 61 59 57 55 53 51 50 48 47 45 44 43 41 40 39 38 37 36 35 34Quality Improvement Dept @ The Health Plan: (740) 695-3585, Ext. 7659 -or- 1-800-624-6961, Ext. 7659

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪Step 1: Determine the BMIIf your patient does not fall within the parameters of the chart below, use this formula to calculate BMI:Weight (lbs.) ÷ Height (inches) ÷ Height (inches) x 703 = BMIWeight In Pounds20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 19026 20.8 31.2 41.6 52 62.4 72.8 83.2 93.6 104 114 125 135 146 156 166 177 187 19828 17.9 26.9 35.9 44.8 53.8 62.8 71.7 80.7 89.7 98.6 108 117 126 135 143 152 161 17030 15.6 23.4 31.2 39.1 46.9 54.7 62.5 70.3 78.1 85.9 93.7 102 109 117 125 133 141 14832 13.7 20.6 27.5 34.3 41.2 48.1 54.9 61.8 68.7 75.5 82.4 89.2 96.1 103 110 117 124 13034 12.2 18.2 24.3 30.4 36.5 42.6 48.7 54.7 60.8 66.9 73 79.1 85.1 91.2 97.3 103 109 11636 10.8 16.3 21.7 27.1 32.5 38 43.4 48.8 54.2 59.7 65.1 70.5 75.9 81.4 86.8 92.2 97.6 10338 9.74 14.6 19.5 24.3 29.2 34.1 38.9 43.8 48.7 53.6 58.4 63.3 68.2 73 77.9 82.8 87.6 92.5Height In Inches40 8.79 13.2 17.6 22 26.4 30.8 35.2 39.5 43.9 48.3 52.7 57.1 61.5 65.9 70.3 74.7 79.1 83.542 7.97 12 15.9 19.9 23.9 27.9 31.9 35.9 39.9 43.8 47.8 51.8 55.8 59.8 63.8 67.7 71.7 75.744 7.26 10.9 14.5 18.2 21.8 25.4 29 32.7 36.3 39.9 43.6 47.2 50.8 54.5 58.1 61.7 65.4 6946 6.64 9.97 13.3 16.6 19.9 23.3 26.6 29.9 33.2 36.5 39.9 43.2 46.5 49.8 53.2 56.5 59.8 63.148 6.1 9.15 12.2 15.3 18.3 21.4 24.4 27.5 30.5 33.6 36.6 39.7 42.7 45.8 48.8 51.9 54.9 5850 5.62 8.44 11.2 14.1 16.9 19.7 22.5 25.3 28.1 30.9 33.7 36.6 39.4 42.2 45 47.8 50.6 53.452 5.2 7.8 10.4 13 15.6 18.2 20.8 23.4 26 28.6 31.2 33.8 36.4 39 41.6 44.2 46.8 49.454 4.82 7.23 9.64 12.1 14.5 16.9 19.3 21.7 24.1 26.5 28.9 31.3 33.8 36.2 38.6 41 43.4 45.856 4.48 6.73 8.97 11.2 13.5 15.7 17.9 20.2 22.4 24.7 26.9 29.1 31.4 33.6 35.9 38.1 40.4 42.658 4.18 6.27 8.36 10.4 12.5 14.6 16.7 18.8 20.9 23 25.1 27.2 29.3 31.3 33.4 35.5 37.6 39.760 3.91 5.86 7.81 9.76 11.7 13.7 15.6 17.6 19.5 21.5 23.4 25.4 27.3 29.3 31.2 33.2 35.2 37.162 3.66 5.49 7.32 9.14 11 12.8 14.6 16.5 18.3 20.1 21.9 23.8 25.6 27.4 29.3 31.1 32.9 34.764 3.43 5.15 6.87 8.58 10.3 12 13.7 15.4 17.2 18.9 20.6 22.3 24 25.7 27.5 29.2 30.9 32.666 3.23 4.84 6.46 8.07 9.68 11.3 12.9 14.5 16.1 17.8 19.4 21 22.6 24.2 25.8 27.4 29 30.7Step 2: Graph/Calculate the BMI PercentileOnce the BMI has been determined, use that figure along with the child’s age, to graphthe BMI percentile on the CDC body mass index-for-age percentiles chart. Or, if you haveInternet access, simply go to http://apps.nccd.cdc.gov/dnpabmi/ to calculate BMI percentile.▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪For more information about BMI, log onto http://www.bmicharts.netQuality Improvement Dept @ The Health Plan: (740) 695-3585, Ext. 7659 -or- 1-800-624-6961, Ext. 7659

2 to 20 years: BoysBody mass index-for-age percentilesNAMERECORD #Date Age Weight Stature BMI* CommentsBMI3534333231953029BMI27262524232221201918171615141312kg/m 2 AGE (YEARS)2827262524232221201918171615141312kg/m 290857550251052 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20Published May 30, 2000 (modified 10/16/00).SOURCE: Developed by the National Center for Health Statistics in collaboration withthe National Center for Chronic Disease Prevention and Health Promotion (2000).http://www.cdc.gov/growthcharts

2 to 20 years: GirlsBody mass index-for-age percentilesNAMERECORD #Date Age Weight Stature BMI* CommentsBMI3534333295313028BMI90kg/m 2 AGE (YEARS)kg/m 22727262585 2625242375 24232222502121202519201918171051817161516151413141312122 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2029Published May 30, 2000 (modified 10/16/00).SOURCE: Developed by the National Center for Health Statistics in collaboration withthe National Center for Chronic Disease Prevention and Health Promotion (2000).http://www.cdc.gov/growthcharts

Name: DOB: Date:Height:Weight:BMI Percentile:(2-17 years) Based on the CDC’s BMI-for-age Growth charts, which indicates the relative position of the patient’s BMInumber among others of the same sex and age.BMI:BMI kg/m2 Coding tips: BMI percentile: ICD-9 Diag: V85.5--or--(acceptable for 16-17 year olds)(acceptable for 16-17 year olds)Counseling or referral for nutrition educationDiscussion of current nutrition behaviors (eating habits, dieting behaviors)Checklist indicating nutrition was addressedEducational materials given on nutritionIndividuals counseled: Child Parent Guardian Other Coding tips: ICD-9 V65.3Counseling or referral for physical activityDiscussion of current physical activity behaviors (exercise, participation in sports activities,exam for sports participation)Checklist indicating physical activity was addressedEducational materials given on physical activityIndividuals counseled: Child Parent Guardian Other Coding tips: ICD-9 V65.41Section 8 / Page 41

PROVIDER PROCEDURAL MANUAL 2014Chart Stickers AvailableAdvance Directives, Health Plan, and Allergy chart stickers are available foruse by your office at no cost by calling the Provider Relations Department.St. Clairsville: (800) 624-6961 Extension 6248 or (740) 699-6248HomeTown: (877) 236-2289 Extension 2265 or (330) 834-2265These stickers are helpful in identifying your Health Plan patients, those withallergies, and if they have Advance Directives. They will also help your officemeet the requirements listed in our “Standards for Patient Record” Guideline.If you would like a copy of these guidelines, please call the Quality ImprovementDepartment at 1-800-624-6961, ext 7659 or 1-740-695-7659.Advance DirectivesHealth Plan PatientAllergyADVANCE DIRECTIVESOFFERED (DATE) ____________LIVING WILL yes ____ no __MEDICAL POWER OF ATTORNEY yes ____ no __HEALTH PLAN PATIENTLIST ALLERGIES:HEALTH PLANPATIENTNKA:Section 8 / Page 42

DILATED FUNDUS EXAMINATION(for the diabetic patient)PLACE MEMBERLABEL HEREPatient: DOB: HP ID#:Primary Physician: Gender: Exam Date:Date of Diabetes Diagnosis:Date of Last Ophthalmology/Optometry Exam:Visual Acuity: Right eye Left eye ________LABS: Recent glucose Date ___________________ HbA 1c Date ______________________EXAMINATION RESULTS RIGHT EYE LEFT EYE1) No diabetic retinopathy2) Background diabetic retinopathy3) Proliferative diabetic retinopathy4) Is clinically significant macular edema present? Yes No Yes No5) Are high risk characteristics present? Yes No Yes No6) Are there other worrisome findings present?If so, please specify in the space provided below.Yes No Yes No7) Is laser treatment indicated? Yes No Yes NoIf so, please specify type: Focal PRP Focal PRP8) Is other treatment indicated?If so, please specify in the space provided below.Yes No Yes NoRecommended follow-up date: _______________________________________________________________Other findings: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Other recommendations or comments:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ophthalmologist/Optometrist Signature: ____________________________ Date: ___________________Ophthalmologist/Optometrist Name (Please print): _____________________________________________Report sent to Primary Care Physician (initial):Report sent to The Health Plan (initial):Diabetic Dilated Fundus Examination FormSection 8 / Page 43Date:Date:

The Health PlanDiabetes Mellitus Practice Recommendations and Flow SheetPATIENT: Member ID #:01/2014DATE OF BIRTH:PHYSICIAN:Examination/Test Schedule Dates and Results1. Complete History and Physical(Include risk factors, exercise, and diet)Initial visitDateResult2. BMI. Every regular diabetes visit DateResult3. Blood Pressure:• Systolic

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramECS / OPTUM Medical Record Review for Medicare (CMS)As part of an ongoing project, The Health Plan has hiredECS / OPTUM (Ingenix / OPTUM / EnterpriseConsulting Solutions, Inc) to conduct chart reviews forour Medicare Members. The purpose of these reviews isto determine if additional diagnoses can be submitted toCMS that were not submitted on the original claim. ManyElectronic Medical Record (EMR) systems do not allowfor a high frequency of diagnoses to be billed to theHealth Plan, therefore, this review allows us to gatheradditional data for reporting and payment.The ECS / OPTUM Chart Review is also conducted todetermine trouble areas with charting and to help educateproviders if problems arise. Some areas of concern areinappropriate signatures and a lack of credentials on thepatient record. To assure that the Physician’s signature iscompliant with CMS Guidelines, each office should have a Signature Log on file. Click here for Signature LogThe volume of charts reviewed by ECS/ OPTUM is dependent upon the number of Medicarepatients the provider has seen within the year.Physician offices often ask what the difference is between ECS / OPTUM and HEDIS®.The HEDIS® chart audit collects data for “Health Care Performance Measurement” and theECS / OPTUM audit is concerned with finding additional diagnoses and assessing compliancewith CMS charting specifications.To obtain a Signature Log for your office, or for questions regarding the HEDIS® Review,please call the QI department at (800) 624-6961, ext 7659.For more information on the ECS / OPTUM chart review, call Vicki at (800) 624-6961,ext 7622.Section 8 / Page 45

PROVIDER PROCEDURAL MANUAL 2014ELECTRONIC MEDICAL RECORDS (EMR)Electronic Medical Records often solve the problem of chart illegibility.However, many EMR systems often lack notations regarding the following:Advance Directives- notation that information was given regarding Living Will and/or MedicalPower of Attorney- a scanned copy of Advance Directive in the EMRAllergies- notation of Adverse Reactions to the allergenBody Mass Index (adult) and BMI percentile (pediatric)- a height and weight must be obtained for the EMR to calculate theseConsultant and lab reports- must be scanned and dated in the EMR for the date of the visit or testFollow-up visit notationImmunization record-enter up-to-date information for children and adultsMedication list- include new medications ordered- include an end date when a medication has been discontinuedProblem list- include new problems noted- include an end date if a problem has resolvedPreventive health- notation that these were discussed and offered- notation when these occurredTobacco, alcohol, and drug use assessments- assessment as to if the patient is a user- notation that indicates that doctor-to-patient counseling occurredIn regards to scanning documents into your EMR system:- all scanned items should be entered and dated by the test or visit dateIn regards to printing documents from your EMR system:- all documents found in your EMR system should be printable- each printable page should include the patient’s name, date of birth, date of service,and physician’s name- EX: if a document is 7 pages long, each page should be printable as a single documentand should be marked as “page 3 of 7”Section 8 / Page 46

THE HEALTH PLAN OF THE UPPER OHIO VALLEYENVELOPE OF LIFE*Completion of this form will provide valuable information to medical personnel suchas an EMT, Paramedic, or an Emergency Room Doctor in the event of an emergency.Name:Date of Birth:Address: City: State: ZIP:Phone: Blood Type: Male FemalePrimary Language Spoken:Religion/Church Affiliation:Do you wear? (check all that apply): Glasses Contact Lenses Dentures/Partials Hearing Aid(s)Are you ? (check all that apply): Blind Deaf Hard of Hearing PregnantNormal Mental Status (check one): Alert/Oriented Alert/Some Impairment Confused/DisorientedDo you have Advance Directives?: Yes No Living Will (location):Medical Power of Attorney Name: Phone:EMERGENCY CONTACTSName: Phone: Relationship:Name: Phone: Relationship:Medication Allergies?: No Yes List:ALLERGIESFood/Latex/Other All:ergies?:NoYesList:Stroke(s) Cancer Paralysis/Weakness Bladder DisorderNervous Disorder Liver Disorder Gastrointestinal Disorder Bleeding DisorderOther List:MEDICAL CONDITIONS(check all that apply)Diabetes Heart Disease High Blood Pressure ArthritisKidney Disease Seizures Lung Disease/Asthma ConfusionMEDICAL DEVICES(check all that apply)Pacemaker Brand:Defibrillator Brand:Prosthetics (including hip & knee replacements)Hemodialysis Catheter Shunt Location:Location:StentsGreenfield FilterCerebral ShuntOxygen TherapyPeritoneal Dialysis Catheter Location: Other (list below):(continued on back)

PROVIDERSPreferred Hospital:Primary Care Physician:Specialist:Specialist:Phone:Phone:Phone:Phone:INSURANCEMedicare #: Medicaid #:Primary Insurance:MEDICATIONSGroup: Policy #:Medication Name Strength Dosage Time(check all that apply)AM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMAM Noon PMMedications continued on a separate page?:Where in your residence do you keep your medications?YesNoOTHER INFORMATIONList any other information, including recent surgeries and/or infections in the last 12 months, which may be useful toemergency responders:SignatureDate of Birth

PROVIDER PROCEDURAL MANUAL 2014Faxing & Mailing DocumentsThe Health Plan Quality Management ProgramWhen faxing or mailing a document to The Health Plan, please makesure that you use a cover page and clearly designate the nameand department to whom you are sending the document.There are numerous departments in our buildings and manyof them share the same fax machine, so this step is vital inmaintaining HIPAA Guidelines and in keeping yourdocuments from ending up in the wrong department.St. Clairsville Fax: (740) 695-8103 or(740) 695-5297Massillon Fax: (330) 830-4380Morgantown Fax: (334) 598-3914Section 8 / Page 49

Code Measure Title LOBs Description2014 HEDIS Coding GuideEffectiveness of CarePREVENTION AND SCREENINGABA Adult BMI Assessment ALL Percentage of members 18-74 who had their BMI andweight documented at an outpatient visitWCCWeight Assessment and Counseling forNutrition and Physical Activity for Childrenand AdolescentsComm/MHTCIS* Childhood Immunization Status Comm/MHTPercentage of members 3-17 who had an outpatientvisit with a PCP or OB/GYN which included evidence ofBMI documentation with corresponding height&weight,counseling for nutrition and/or counseling for physicalactivityPercentage of children two years of age withappropriate childhood immunizationsICD-9 Diag : V85.0-V85.5Coding(Identifying Numerator)BMI Percentile: ICD-9 Diag : V85.5Nutrition Counseling: CPT : 97802-97804, ICD-9 Diag : V65.3,HCPCS : S9470, S9452, S9449, G0270-G0271Physical Activity Counseling: IDC-9 Diag : V65.41,HCPCS : S9451DTaP: CPT : 90698, 90700, 90721, 90723IPV: CPT : 90698, 90713, 90723MMR: CPT : 90707, 90710Measles & Rubella: CPT : 90708Measles: CPT : 90705, ICD-9 Diag : 055Mumps: CPT : 90704, ICD-9 Diag : 072Rubella: CPT : 90706, ICD-9 Diag : 056Hib: CPT : 90645-90648, 90698, 90721, 90748Hepatitis B: CPT : 90723, 90740, 90744, 90747, 90748,HCPCS : G0010, ICD-9 Diag : 070.2, 070.3. V02.61VZV: CPT : 90710, 90716, ICD-9 Diag : 052, 053Pneumococcal Conjugate: CPT : 90669, 90670, HCPCS : G0009Category IICodes-CPTIMA* Immunizations for Adolescents Comm/MHTPercentage of adolescents 13 years of age withappropriate immunizationsHPV Human Papillomavirus Vaccine for FemaleAdolescentsComm/MHTPercentage of female adolescents 13 years of age whohad three doses of HPV vaccine between 9th and 13thbirthdaysLSC* Lead Screening in Children Medicaid Percentage of children 2 years of age screened for leadpoisoningBCS* Breast Cancer Screening ALL Percentage of women 40-69 years of age who had amammogramCCS* Cervical Cancer Screening Comm/ Percentage of women 21-64 years of age who had aMHT Pap testCOL* Colorectal Cancer Screening Comm/MedicareCHL Chlamydia Screening in Women Comm/MHTPercentage of members 50-75 years of age who hadappropriate screening for colorectal cancerSexually active women 16-24 with annual chlamydiascreeningHepatitis A: CPT : 90633, ICD-9 Diag : 070.0, 070.1Rotavirus (2 dose schedule): CPT : 90681Rotavirus (3 dose schedule): CPT : 90680Influenza: CPT : 90655, 90657, 90661, 90662, HCPCS : G0008Meningococcal: CPT: 90733, 90734Tdap: CPT : 90715Td: CPT : 90714, 90718Tetanus: CPT : 90703Diphtheria: CPT : 90719CPT : 90649, 90650CPT : 83655CPT : 77055-77057, HCPCS : G0202, G0204, G0206,ICD-9 Proc : 87.36, 87.37CPT : 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175, HCPCS : G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091FOBT: CPT : 82270, 82274 HCPCS : G0328Flexible Sigmoidoscopy: CPT : 45330-45335, 45337-45342, 45345HCPCS : G0104 ICD-9 Proc : 45.24Colonoscopy: CPT : 44388-44394, 44397, 45355, 45378-45387,45391, 45392, HCPCS : G0105, G0121,ICD-9 Proc : 45.22, 45.23, 45.25, 45.42, 45.43CPT : 87110, 87270, 87320, 87490-87492, 87810HEDIS Coding Guide-2014 Page 1 of 6

Code Measure Title LOBs Description2014 HEDIS Coding GuideGSO* Glaucoma Screening Older Adults Medicare Percentage of members 65 or older who received aglaucoma eye exam (no prior history)Coding(Identifying Numerator)CPT : 92002, 92004, 92012, 92014, 92081-92083, 92100, 92120,92130, 92135, 92140, 99202-99205, 99213-99215, 99242-99245,HCPCS : G0117, G0118, S0620, S0621Category IICodes-CPTRESPIRATORY CONDITIONSCWP* Appropriate Testing for Children WithPharyngitisComm/MHTPercentage of children ages 2-18 diagnosed withpharyngitis, prescribed an antibiotic and tested for strepCPT : 87070, 87071, 87081, 87430, 87650-87652, 87880URI*AAB*Appropriate Treatment for Children WithUpper Respiratory InfectionAvoidance of Antibiotic Treatment forAdults with Acute BronchitisComm/MHTComm/MHTPercentage of children 3 months-18 years diagnosedwith ONLY upper respiratory infection diagnosis andNOT dispensed an antibioticPercentage of adults 18-64 years diagnosed with acutebronchitis who were NOT dispensed an antibioticAntibiotic PrescriptionsAntibiotic PrescriptionsSPR*PCEASM*Use of Spirometry Testing in theAssessment and Diagnosis of COPDPharmacotherapy Management of COPDExacerbationUse of Appropriate Medications for Peoplewith AsthmaALLALLComm/MHTPercentage of members age 40 and older w/ COPDand spirometry testingMembers dispensed systemic corticosteroid &bronchodilator after COPD exacerbationPercentage of members 5-56 years with asthma andappropriately prescribed medicationsCPT : 94010, 94014-94016, 94060, 94070, 94375, 94620Dispensed Systemic Corticosteroid and BronchodilatorPrescriptions for Preferred Asthma Medications: antiasthmaticcombinations, antibody inhibitor, inhaled steroid combination, inhaledcorticosteroid, leukotriene modifier, mast cell stabilizer, methylxanthinesMMAMedication Management for People withAsthmaComm/MHTPercentage of members 5-64 years who remain on anasthma controller for at least 75% of their treatmentperiodFrequency of Prescribed Preferred Asthma Medications: antiasthmaticcombinations, antibody inhibitor, inhaled steroid combination, inhaledcorticosteroid, leukotriene modifier, mast cell stabilizer, methylxanthinesAMR Asthma Medication Ratio Comm/MHTPercentage of members 5-64 years with asthma whohad a ratio of controller medications to total asthmamedications of .5 or greaterAntiasthmatic combinations, antibody inhibitors, inhaled steriodcombinations, inhaled corticosteriods, leukotriene modifiers, mast cellstabilizers, methylxanthines; short acting, inhaled beta-2 agonistsCARDIOVASCULARCMC* Cholesterol Management for Patients WithCardiovascular ConditionsALLPercentage of members 18-75 who were dischargedalive for acute myocardial infarction, coronary arterybypass graft or percutaneous coronary interventions, orwho had a diagnosis of ischemic vascular diaseasewho had LDL-C screeningsCPT : 80061, 83700, 83701, 83704, 83721 3048F, 3049F,3050FCBP* Controlling High Blood Pressure ALL Percentage of members 18-85 with a diagnosis ofhypertension and whose blood pressure was controlledMost recent blood pressure must be

Code Measure Title LOBs Description2014 HEDIS Coding GuideCoding(Identifying Numerator)Category IICodes-CPTDIABETESCDC* Comprehensive Diabetes Care ALL The percentage of members 18-75 years of age withdiabetes (type 1 or type 2) who had each of theHbA1c Tests: CPT : 83036, 83037 3044F, 3045F,3046Ffollowing: 1) HbA1c, 2) LDL Screening,LDL- Screening: CPT : 80061, 83700, 83701, 83704, 837213) Nephropathy Screening, 4) Retinal Eye Exam,3048F, 3049F,3050F5) Blood Pressure control.Nephropathy Screening: CPT : 82042, 82043, 82044, 84156 3060F, 3061FEye Exams: CPT : 67028, 67030, 67031, 67036, 67039-67043, 67101,67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145,67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004,92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235,92240, 92250, 92260, 99203-99205HCPCS : S0620, S0621, S0625, S3000,2022F, 2024F,2026F, 3072FBlood pressure control: Systolic: 3074F,3075F, 3077F.Diastolic: 3078F,3079F, 3080FMusculoskeletalART Disease Modifying Anti-Rheumatic DrugTherapy for Rheumatoid ArthritisOMW*Osteoporosis Management in WomenWho Had FractureALL Percentage of members w/ RA dispensed a DMARD 5-Aminosalicylates, Alkylating agents, Aminoquinolones, Antirheumatics,Immunomodulators, Immunosuppressive agents,TetracyclinesMedicareLBP* Use of Imaging Studies for Low Back Pain Comm/MHTPercentage of women 67 years or older who suffered afracture and then a DEXA scan or osteoporosismedication within 6 months of incidentPercentage of members with a primary diagnosis of lowback pain who did not have an imaging study within 28days of diagnosisBEHAVIORAL HEALTHAMM* Antidepressant Medication Management ALL Percentage of members 18 years or older diagnosedwith depression and treated with antidepressant medsADD*Follow-Up Care for Children PrescribedADHD MedicationComm/MHTPercentage of children 6-12 with newly diagnosedADHD who received the appropriate follow-uptreatment and medicationCPT : 76977, 77078-77083, 78350, 78351, HCPCS : G0130,ICD-9 Proc : 88.98-or- Biphosphonates, Estrogens, Other approved agents, Sex hormonecombinationsCPT : 72010, 72020, 72052, 72100, 72110, 72114, 72120, 72131-72133, 72141, 72142, 72146-72149, 72156, 72158, 72200, 72202,72220Miscellaneous antidepressants, Monoamine oxidase inhibitors,Phenylpiperazine antidepressants, Psychotherapeutic combinations,SSNRI antidepressants, SSRI antidepressants, Tetracyclineantidepressants, Tricycline antidepressantsRate 1: Initiation Phase: CPT : 90791, 90792, 90804-90815, 90832-90834, 90836-90840, 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345,99347-99350, 99383, 99384, 99393, 99394, 99401-99404, 99411,99412, 99510 HCPCS : G0155, G0176, G0177, G0409-G0411, H0002,H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 -or- CPT : 90801, 90802,90816-90819, 90821-90824, 90826-90829, 90845, 90847, 90849,90853, 90857, 90862, 90875, 90876 with POS : 03, 05, 07, 09, 11-15,20, 22, 33, 49, 50, 52, 53, 71, 72 -or- CPT : 99221-99223, 99231-99233, 99238, 99239, 99251-99255 with POS : 52, 53Rate 2: C & M Phase: CPT : 98966-98968, 99441-99443HEDIS Coding Guide-2014 Page 3 of 6

Code Measure Title LOBs DescriptionFUH*Follow-Up After Hospitalization for MentalIllnessALL2014 HEDIS Coding GuidePercentage of discharges for members 6 years or olderwho were hospitalized for treatment of a mental healthdisorder and received appropriate follow-up visits within7 daysCoding(Identifying Numerator)CPT : 90791, 90792, 90804-90815, 90832-90834, 90836-90840, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397,99401-99404, 99411, 99412, 99510 HCPCS : G0155, G0176, G0177,G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040,H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 -or- CPT : 90801, 90802, 90816-90819, 90821-90824, 90826-90829,90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876 withPOS : 03, 05, 07, 09, 11-15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 -or-CPT : 99221-99223, 99231-99233, 99238, 99239, 99251-99255 withPOS : 52, 53Category IICodes-CPTMedication ManagementMPM* Annual Monitoring for Patients onPersistent MedicationsDDEPotentially Harmful Disease/DrugInteraction in ElderlyDAE* Use of High Risk Medications in theElderlyAccess/Availability of CareAAP Adults’ Access toPreventative/Ambulatory Health ServicesALLMedicareMedicareALLPercentage of members 18 years and older whoreceived select ambulatory medication therapy andtherapeutic monitoring.Percentage of members 65 years or older who haveevidence of an underlying disease, condition or heathconcern who were dispensed an ambulatoryprescription for a contraindicated medicationThe percentage of members over 65 years receivinghigh risk medicationThe percentage of members 20 years or older who hadan ambulatory or preventive care visit.Monitoring for members on Ace Inhibitors or ARBs: At least oneserum potassium and either a serum creatine or a blood urea nitrogentherapeutic monitoring testMonitoring for members on Digoxin: At least one serum potassiumand either a serum creatinine or a blood urea nitrogen therapeuticmonitoring testMonitoring for members on Diuretics: At least one serum potassiumand either a serum creatinine or a blood urea nitrogen therapeuticmonitoring testMonitoring for members on Anticonvulsants: At least one drugserum concentration level monitoring test for the prescribed drugMembers identified with falls or hip fractures: Dispensed anambulatory prescription for a tricyclic antidepressant or an antipsychoticor sleep agentMembers diagnosed with dementia or a dispensed dementiamedication: Dispensed an ambulatory prescription for a tricyclicantidepressant or anticholinergic agentMembers diagnosed with chronic renal failure: Dispensed anambulatory prescription for an NSAID or Cox-2 selective NSAIDMembers dispensed at least one high-risk prescription -or- at least twodifferent high-risk prescriptionsOffice or other outpatient services:CPT : 99201-99205, 99211-99215, 99241-99245Home Services: CPT : 99341-99345, 99347-99350Nursing Facility Care: CPT : 99304-99310, 99315, 99316, 99318Domiciliary, rest home, or custodial care services:CPT : 99324-99328, 99334-99337Preventive medicine: CPT : 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, HCPCS : G0344,G0402,G0438,G0439Ophthalmology and optometry:CPT : 92002, 92004, 92012, 92014General medical examination:ICD-9 Diag : V70.0, V70.3, V70.5, V70.6, V70.8, V70.9HEDIS Coding Guide-2014 Page 4 of 6

Code Measure Title LOBs DescriptionCAPChildren and Adolescents’ Access toPrimary Care PractitionersComm/MHTPPC* Prenatal and Postpartum Care Comm/MHT2014 HEDIS Coding GuidePercentage of members 12 months - 19 years who hada visit with a PCPADV Annual Dental Visit MHT Not ReportedIET* Initiation and Engagement of Alcohol and Comm/ Percentage of adolescent and adult members with aOther Drug Dependence TreatmentMHT new diagnosis of alcohol or drug dependencePercentage of deliveries of live births with appropriateprenatal and postpartum careCAT Call Answer Timeliness ALL Calls answered within 30 secondsUse of ServicesFPC Frequency of on-going prenatal care Medicaid Percentage of members who received expectedprenatal visitsW15 Well-Child Visits in the First 15 Months ofLifeComm/MHTNumber of well-child visits (0-6+) in first 15 months oflifeCoding(Identifying Numerator)Office or other outpatient services:CPT : 99201-99205, 99211-99215, 99241-99245Home Services: CPT : 99341-99345, 99347-99350Preventive medicine: CPT : 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429 HCPCS: G0438, G0439General medical examination: ICD-9 Diag : V20.2, V70.0, V70.3,V70.5, V70.6, V70.8, V70.9Initiation of AOD treatment: An inpatient admission, outpatient visit,intensive outpatient encounter or partial hospitalization within 14 days ofdiagnosisEngagement or AOD treatment: Initiation of AOD treatment and two ormore inpatient admissions, outpatient visits, intensive outpatientencounters or partial hospitalizations with any AOD diagnosis within 30days after date of the initiation encounter.Timeliness of prenatal care: a prenatal visit in the first trimester orwithin 42 days of enrollmentPostpartum care: a postpartum visit for a pelvic exam or postpartumcare on or between 21 and 56 days after deliveryCPT : 99381-99385, 99391-99395, 99461,ICD-9 Diag : V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9Category IICodes-CPTW34Well-Child Visits in the Third, Fourth, Fifthand Sixth Years of LifeComm/MHTPercentage of members 3-6 who received one or morewell-child visit with PCPCPT : 99381-99385, 99391-99395, 99461ICD-9 Diag : V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9AWC Adolescent Well-Care Visits Comm/MHTPercentage fo members 12-21 who received one ormore well-child visit with PCP or OB/GYNFSP Frequency of Selected Procedures ALL Summarizes utilization of frequently performedprocedures in order to identify potentially inappropriateutilizationAMB Ambulatory Care ALL Summarizes utilization of ambulatory careIPU Inpatient Utilization – GeneralALL Summarizes utilization of acute inpatient care andHospital/Acute CareservicesIAD* Identification of Alcohol and Other Drug ALL Summarizes members with an alcohol and other drugServicesclaim who received chemical dependency servicesCPT : 99383-99385, 99393-99395,ICD-9 Diag : V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9MPT* Mental Health Utilization ALL The number and percentage of members receivingmental health servicesABX Antibiotic Utilization ALL Summarizes outpatient utilization of antibioticprescriptionsCost of CareRDI Relative Resource Use for People With ALL The relative resources used by members with diabetesDiabetesRAS Relative Resource Use for People WithAsthmaComm/MHTThe relative resources used by members withpersistent asthmaRCARelative Resource Use for People withCardiovascular ConditionsALLThe relative resources used by members withcardiovascular conditionsHEDIS Coding Guide-2014 Page 5 of 6

Code Measure Title LOBs DescriptionRHYRCORelative Resource Use for People withUncomplicated HypertensionRelative Resource Use for People withChronic Obstructive Pulmonary DiseaseALLALL2014 HEDIS Coding GuideThe relative resources used by members withuncomplicated hypertensionThe relative resources used by members with COPDHealth Plan Descriptive InformationBCR Board Certification ALL The percentage of physicians whose board certificationis activeENP Enrollment by Product Line ALL Total number of members enrolled in the product lineCoding(Identifying Numerator)Category IICodes-CPTEBS Enrollment by State ALL Number of members enrolled by stateLDM Language Diversity of Membership Medicare/ A count and percentage of members enrolled with aMHT need for language interpreter services.RDM Race Ethnic Diversity of Membership Medicare/ A count and percentage of members enrolled by raceMHT and ethnicityHealth Plan StabilityYIB Years in Business ALL The number of years since licensureMeasures Collected Through CAHPS Health Plan SurveyFSA Flu Shots for Adults Ages 50-64 Comm/MedicarePercentage of members 50-64 years who received a flushotHOS Medicare Health Outcomes Survey Medicare Provides a general indication of the management ofmembersFRM Fall Risk Management Medicare Assesses different facets of fall risk management Discussing and Managing Fall RiskMUI Management Urinary Incontinence inOlder AdultsMedicare Assesses the management of urinary incontinence inolder adultsDiscussing Urinary Incontinence and Receiving Urinary IncontinenceTreatmentOTO Osteoporosis Testing in Women Medicare Percentage of women 65 years and older who receiveda bone density testPAO Physical Activity in Older Adults Medicare Assesses different facets of promoting physical activity Discussing and Advising Physical Activityin older adultsFSO Flu Shots in Older Adults Medicare Percentage of members 65 years and older whoreceived a flu shotPNU Pneumonia Vaccine Status Medicare Percentage of members 65 years and older whoreceived a pneumococcal vaccineMSC Medical Assistance With SmokingCessationSatisfaction with Experience of CareCPA CAHPS Health Plan Survey 4.0H, AdultVersionCPC CAHPS Health Plan Survey 3.0H, ChildVersionALLALLALLAssesses different facets of providing medicalassistance with smoking cessationProvides a general indication of how well theorganization meets members' expectationsProvides information on a parents' experience with theirchild's organizationAdvising Smokers to Quit, Discussing Smoking Cessation Medications,and Discussing Smoking Cessation StrategiesHEDIS Coding Guide-2014 Page 6 of 6

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramHEDIS® Coding and Documentation HintsThe information gathered during the HEDIS® review is used to compare the performance ofmanaged care plans nationally based on a widely used set of performance measures developed bythe National Committee for Quality Assurance (NCQA®) www.ncqa.org.While most of our HEDIS® rates remain in the higher percentiles when compared with managedcare plans nationally, we are always trying to identify ways to improve the quality of data.Please note the following diagnosis driven opportunities for improvement:HYPERTENSIONCoding:401, 401.0, 401.1, 401.9 Hypertensive Disease796.2 Elevated blood pressure without diagnosis of hypertension* This category is to be used to record an episode of elevated blood pressure in apatient who no formal diagnosis of hypertension has been made, or as anincidental finding.* If you bill a diagnosis code for Hypertension, update the Problem List and make sure thatdocumentation on the medical record supports the diagnosis.* If the member does not have Hypertension, please remove this diagnosis from the patient’shistory in your Electronic Medical Record (EMR), and notify your billing service.* If the blood pressure is elevated (above 130/80) during an office visit:- recheck and document a second reading before the patient leaves the office- schedule a follow-up visit for a BP re-check- review technique with your staff, especially in regards to patients with obesitySection 8 / Page 56

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramHEDIS® Coding and Documentation HintsDIABETESCoding:Pre-Diabetics-use these “rule out” codes when ordering labs or monitoring a patient● V18.0● 790.21● 790.29● 277.7Family history of diabetes mellitusImpaired fasting glucoseOther abnormal glucose including hyperglycemia NOS or prediabetes NOSDismetabolic syndrome X (use with another code for associated manifestationsuch as obesity or cardiovascular disease)HbA1c **Goal-HbA1c below 7 Timeline: Quarterly83036-83037Category II codes that indicate results: 3044F, 3045F, 3046FLDL-C Screening **Goal-LDL below 100 Timeline: Yearly80061, 83700-83701, 83704, 83721Category II codes that indicate results: 3048F, 3049F, 3050FNephropathy Screening/micro and macro-albuminTimeline: YearlyMicroalbumin-82042, 82043, 82044, 84156Category II codes that indicate results: 3060F-3061F* Microalbumin Dipstick Testing -CPT code 82044In-office Reagent test dipsticks with Micral from Roche, Clinitek®, or Bayer.These are different than those used to perform routine urinalysis.Macro-albumin-81000-81003, 81005,Category II code that indicates result: 3062F* Please note that there is no HP reimbursement for Category II codes.* All labs done in the office setting are billable.* The medical record should reflect if the patient was referred to a dietitian or anEndocrinologist. Please include correspondence or consults in the medical record (hard copyor scanned.)* Remind your diabetic patients yearly about the importance of seeing an Ophthalmologist orOptometrist for a Diabetic Retinal Eye Exam. This is a covered medical benefit for ALLdiabetic members regardless of vision benefits.Section 8 / Page 57

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramHEDIS® Coding and Documentation Hints* Contact specialists for a copy of the evaluation and the labs that they completed.* Consider prescribing an ACE inhibitor or an ARB to protect the renal and cardiovascularsystems.* Review and update the medication list during every visit.Claims that indicate that a member is a DiabeticThe Health Plan makes outreach calls to members when they are in need of preventive orwellness services. These phone calls are often targeted to specific populations based upon eithera new or consistently reoccurring diagnosis on physician and facility claims.The largest targeted population consists of members with a reoccurring diagnosis of diabetes, orthose with a prescription for a diabetic medication. When outreach phone calls are made to thosemembers, they often insist that they are not diabetic.* If a member is a diabetic, please take time to educate them about the condition and what itmeans for their health. The more frequently you converse with your patients on this matter,the more likely they are to obtain needed services and testing to properly manage their diseaseprocess.* If the member is not a diabetic, please remove this diagnosis from your electronic medicalrecord and notify your billing service.CARDIOVASCULARPost MI patients- Beta-blockers should be considered for at least 6 months post discharge as they havebeen proven to decrease the incidence of a subsequent heart attack by lowering theblood pressure and heart rate.Hyperlipidemia- routinely monitor blood cholesterol levels- encourage the member in diet, exercise, and medication management- maintain the cholesterol below 200, the LDL below 100, or the LDL below 70 if thereis a history of cardiovascular diseaseSection 8 / Page 58

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramHEDIS® Coding and Documentation HintsOBESITY AND TOBACCO USE INCREASE RISK FORCARDIAC AND DIABETIC DISEASETobacco Abuse 305.1- Per the CDC, “Smoking harms nearly every organ of the body, causingmany diseases, and affecting the health of smokers in general. Quitting smoking has immediateas well as long-term benefits....” For more information on the harmful effects of smoking,smokeless tobacco, and secondhand smoke, visit: http://www.cdc.gov/tobacco.* We encourage you to assess all patients for tobacco use and to counsel regarding cessation.Overweight (BMI 25-29---V85.2-V85.25)Obesity (BMI 30-39---V85.3-V85.39Morbid obesity (BMI 40+ ---V85.4-V85.45)* Record a BMI and consider a lipid profile, nutrition counseling, and activity counseling.For more information on helping your overweight and obese patients, visit:http://www.cdc.gov/obesity.CHILDHOOD OBESITY – PCP and PEDIATRICIAN OVERSIGHTChildhood obesity is a growing epidemic which can lead to an early onset of hypertension anddiabetes. In light of this major health issue, we encourage our PCPs to obtain a BMI percentile;and to assess the nutritional and activity status of the children in your practice. We alsoencourage you to counsel the child and their parents regarding how they can choose wisely andcombat obesity. This should be done by the child’s PCP of record, whether that is a FamilyPractitioner or a Pediatrician.A gender-specific (BMI) body mass index-for-age percentile chart is available athttp://www.cdc.gov/growthcharts; by visiting www.healthplan.org | Members | Health &Wellness | Prevention & Wellness Resources or by calling the QI department at 740-695-7659.BMI percentile: V85.5 (Body Mass Index; Pediatric)Nutrition Counseling: V65.3 (Counseling or referral for nutrition education; discussion ofcurrent nutrition behaviors such as eating habits and dieting behaviors; checklist indicatingnutrition was addressed; educational materials given on nutrition)Physical activity counseling: V65.41 (Counseling or referral for physical activity; discussion ofcurrent physical activity behaviors such as exercise, participation in sports activities, and anexam for sports participation; checklist indicating physical activity was addressed; educationalmaterials given on physical activity)Section 8 / Page 59

FEMALE PATIENTSPROVIDER PROCEDURAL MANUAL 2014Obstetric charts should include:The Health Plan Quality Management ProgramHEDIS® Coding and Documentation Hints- each prenatal visit- the correct delivery date and gestational age at delivery- a 6 week post-partum visitChlamydia screening yearly should be considered by the PCP, Pediatrician, or GYN for women16-24 years of age who are identified as sexually active. The specimen can be easily collected byurine testing (87491) or during a vaginal exam. This important screening is often neglectedwhen the PCP or Pediatrician assumes that the GYN is completing it. Therefore, it isimportant for the PCP or Pediatrician to discuss this sexually transmitted disease with the patient,to perform the urine test, or to refer the patient to their GYN for the screening.www.prevent.org/ChlamydiaScreeningRESPIRATORYCOPD (496)Chronic bronchitis (491)Emphysema (492)- spirometry or pulmonary function testing should be completed and documented in thechart- CPT-94010, 94014-94016, 94060, 94070, 94375, 94620URI, Pharyngitis, and Bronchitis- document the rationale for antibiotics- utilize secondary diagnosis codes as indicated, including those for chronic conditionsFlu and Pneumonia VaccinesThe flu is a contagious respiratory illness that can lead to hospitalization or death forthose with medical conditions such as heart disease, diabetes, asthma, or COPD. In lightof this, The Health Plan holds our annual fall flu clinics and strongly encourages ourmembers to receive their vaccine.If your patient attends one of our clinics, you will receive notification.Section 8 / Page 60

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramHEDIS® Coding and Documentation HintsA patient may also visit their physician’s office for a vaccine. Please make sure that themedical record clearly reflects that this vaccine was given or that they received theirvaccines elsewhere.POLY-PHARMACY is the use of excessive medications that often occurs when a patient visitsmultiple providers or pharmacies. The danger of poly-pharmacy is an increase in druginteractions and/or side effects.* Communicate with all providers involved in your patient’s care including behavioral healthproviders* Review and discuss all medications with the patient on each visit.* Review and update a medication list to keep track of when medications are started, dosingis changed, and when they are discontinued.* For patients on chronic pain medication, use a pain management contract and access theOhio and WV Prescription Drug Reporting system prior to prescribing.ACUTE LOW BACK PAIN- offer patient education and self-care (resumption of light duty activities, ice/heat, antiinflammatorymedication, over-the- counter analgesics, and early return to work activities)- opioid analgesics-which are rarely indicated in the treatment of acute low back pain; ifused, should be for short-term intervention of less than two weeks,- X-rays-which are not useful in the acute phase of low back pain; however, x-rays may bewarranted if conservative treatment has failed,- MRI and CT scan are only recommended if severe or progressive neurological deficits arepresent. Physical therapy and neurology/ pain management referrals may also beindicated.- Complete a thorough Pain Assessment Sheet and a Prescription Agreement and NarcoticUse Contract if narcotics are prescribed.* Please call a QI Coordinator at 740-695-7659 if you have any questions regarding these issues.Section 8 / Page 61

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramHELPFUL HINTS FOR OFFICE STAFFFinding a Provider and a Provider Directory on The Health Plan websiteTo look for a provider online or to print a Provider directory, visitwww.healthplan.org | Providers | Find A Provider and click on Search.Managing Your Patient RosterA Primary Care Physician Patient Roster can be obtained through our Provider SecureWebsite atwww.healthplan.org/ProviderSecureWebsite/Member Rosters. The member information isupdated every 24 hours.- Check your Roster for patients who may be listed but have never been seen, and for patientswho are seen regularly, but do not appear on the Roster.- Cross-reference the name, member ID, and DOB with the information in the chart.- The Roster should be checked before patient appointments.- You will only have website access to patients who have you listed as their PCP.- Members may change their Primary Care Physician once per month by calling the CustomerService Department at:Ohio Valley and Mountaineer Region: (740) 695-7902 or (800) 624-6961HomeTown Region: (888) 830-4370 or (330) 830-4370- If you wish to remove a patient from your Roster, submit a request in writing to the CustomerService department stating the reason for the request. You may make such a request in thefollowing situations:1. Non-compliance concerning the physician's orders.2. The member has been seeing other Primary Care Physicians on a regular basis.3. The member has been referred by other Primary Care Physicians on a regular basis.4. When a distinct personality clash exists.The member will receive a letter from The Health Plan requesting that they choose anotherPrimary Care Physician, and you will receive a copy of that letter.Section 8 / Page 62

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramDischarging a Member from your PracticeHelpful Hints for Office StaffIt is important to follow Health Plan policy when discharging a member from your practice.1. Send the member a written notification of discharge from the practice.2. Retain a copy of the letter in the medical record as well as documentation of what ledto this decision.3. For Medicaid members, the provider is to send a copy of the letter to the MHTDepartment. The MHT Department educates the member about compliance and theimportance of establishing with a new PCP. They will also help the member choose anew PCP.4. For all other lines of business, forward a copy of the letter to The Health PlanCustomer Service Department so that the member can be removed from your roster.Medicaid (MHT)The Health PlanMHT Outreach Dept52160 National Rd ESt. Clairsville, OH 43950All other Lines of BusinessThe Health PlanCustomer Service Department52160 National Rd ESt. Clairsville, OH 43850Section 8 / Page 63

May a health care provider disclose protected health information to a health plan for the plan's Health Plan Employer Data and Information Set (HEDIS)?U.S. Department of Health & Human ServicesImproving the health, safety, and well-being of AmericaSearch:SearchHHS Home|HHS News|About HHSHealth Information PrivacySearch OCR All HHSFont Size Print Download ReaderOffice for Civil Rights Civil Rights Health Information PrivacyOCR Home > Health Information Privacy > Frequently Asked QuestionsHIPAAUnderstanding HIPPA HIPAA PrivacyHIPAA AdministrativeSimplification Statuteandand Rules RulesEnforcement Activities&& ResultsHow to File a ComplaintNews ArchiveFrequently Asked QuestionsPSQIAUnderstanding PSQIAConfidentialityPSQIA Statute & RuleEnforcement Activities&& ResultsMay a health care provider disclose protected health information to a healthplan for the plan's Health Plan Employer Data and Information Set (HEDIS)?Answer:Yes, the HIPAA Privacy Rule permits a provider to disclose protected health information to ahealth plan for the quality-related health care operations of the health plan, provided thatthe health plan has or had a relationship with the individual who is the subject of theinformation, and the protected health information requested pertains to the relationship. See45 CFR 164.506(c)(4). Thus, a provider may disclose protected health information to ahealth plan for the plan’s Health Plan Employer Data and Information Set (HEDIS) purposes,so long as the period for which information is needed overlaps with the period for which theindividual is or was enrolled in the health plan.Date Created: 12/19/2002Last Updated: 03/14/2006How to File a ComplaintHHS Home | Questions? | Contacting HHS | Accessibility | Privacy Policy | FOIA | Disclaimers | Inspector General | No FEAR Act/Whistleblower | Viewers & PlayersThe White House | USA.gov | HHS Archive | Pandemic FluU.S. Department of Health & Human Services · 200 Independence Avenue, S.W. · Washington, D.C. 20201http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures/265.html2/22/2013 10:54:14 AM

Immunization RegistryPROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramImmunizations have protected millions of children from potentially deadly diseases and havesaved thousands of lives. The Health Plan Preventive Health Guidelines includerecommendations for childhood immunizations that follow the guidelines set forth by theAmerican Academy of Pediatrics, the American Academy of Family Physicians, and theAdvisory Committee on Immunization Practices.The Health Plan would like to encourage our providers to register childhood immunizations onthe State Immunization Registry. The information below will help you in this process.https://wvsiis.wvdhhr.org/wvsiis/main.jsp1-800-642-3634https://odhgateway.odh.ohio.gov/impact/1-800-282-0546West VirginiaOhioSection 8 / Page 65

PHYSICIAN:THE HEALTH PLAN - MEDICAL RECORD AUDIT - 2014MEMBER:CATEGORY #1 - MEDICAL RECORD ORGANIZATION Points YES NO N/A1. Do all pages contain patient name and date of birth? 42. Is there biographical/personal data? 43. Is the member clearly identified as a Health Plan member? 44. Is there evidence that information regarding advance directives was provided? (18 yrs & over) 45. Is there a completed problem list noting significant illnesses and medical conditions? 46. Is there a completed medication list? 47. Are allergies and adverse reactions to medications/food prominently displayed?(If appropriate, NKA displayed)48. Is the provider identified on each entry? 49. Are all entries dated? 410. Is the record legible? 411. Do consultant summaries, lab, and imaging study results reflect primary care physician review?Include notation of abnormal test results.412. Does the record contain a history and physical? 413. Are lab and other studies ordered as appropriate? 414. Evidence of plan of action/treatment for presenting problem (s)? 415. Is there a notation for return visit or other follow-up plan for each encounter? 416. Are unresolved problems from previous visits addressed? 417. Is there evidence of use of consultants if indicated? 418. Is there evidence of continuity and coordination of care between PCP and specialists? 419. Is there evidence in the medical record of visits to the emergency room if applicable? 420. Is there evidence in the medical record of an admission to a hospital if applicable? 421. TOBACCO USE: Is there documentation of tobacco use, including smokeless tobacco?Is counseling documented with history of tobacco abuse? (11 years and over)Not Assessed0 pts.Assessed,Non-Smoker4 pts.Assessed, Smoker,but Not Counseled0 pts.22. ALCOHOL USE: Is there documentation of alcohol use?Is counseling documented with history of alcohol abuse? (11 years and over)Not Assessed0 pts.Assessed,Non-Smoker4 pts.Assessed, Smoker,but Not Counseled0 pts.23. DRUG USE: Is there documentation of substance abuse?Is counseling documented with history of substance abuse? (11 years and over)Assessed, Smoker,& CounseledAssessed, Smoker,& CounseledAssessed,Assessed, Smoker,Assessed, Smoker,Not Assessed 0 pts.4 pts.0 pts.4 pts.Non-Smoker but Not Counseled& Counseled24. Are preventive services offered per The Health Plan Preventive Health Guidelines? 425. Is there a completed immunization record specific to patient’s age per The Health Plan PreventiveHealth Guidelines?4TOTAL SCORE: %4 pts.4 pts.444Medical Record Audit ToolSection 8 / Page 66

NAME:DOB:PATIENT PHONE NUMBER:PHARMACY: PHARMACY PH #:ALLERGIES/REACTIONS:MEDICATIONSSTARTDATED/CDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEMedication ListThis sample form is provided as a tool and not a requirement.Feel free to use it or adapt it to the individual needs of your office.Section 8 / Page 67

St. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365Phone: 1.800.624.6961Hearing Impaired1.800.622.3925Fax: 740.695.5297www.healthplan.orgHomeTown Office100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816PH: 1.877.236.2289Hearing Impaired1.877.236.2291Fax: 330.837.6869www.healthplan.orgObesity Referral FormPlease complete the information below to refer your patient to The Health Plan for nutrition / weight management.Fax to (740) 695-5297Attn:Joy Gillispie, R.N., B.S.N., QI / Wellness DepartmentFrom:Date:Re:Obesity ReferralPatient InformationName:Age:HP ID#:Home Phone#:Height? Weight? BMI?Cholesterol? Blood Pressure? Food Allergies?Indicate Any Medical Conditions or Physical Limitations for This MemberAsthma Diabetes Heart Disease High Blood Pressure Other (please list below):The Health Plan provides nutritional guidance for members who wish to control their weight. The 5210 Program isoffered by The Health Plan on an ongoing basis and is free for Health Plan members.If your patient is ready for change and would like more information, they may also contact Joy Gillispie, R.N., B.S.N.,Medical Affairs & Education Liaison, at 1-800-624-6961, Ext. 7640 or (740) 695-7640.Obesity Referral FormSection 8 / Page 68

PROVIDER PROCEDURAL MANUAL 2014ONSITE OFFICE REVIEWSHEDIS® and MEDICAL RECORD AUDITS*HEDIS® is a registered trademark of the National Committee forQuality Assurance (NCQA).Nurses from the Quality Improvement Department visit Primary Care Physician (PCP),Pediatrician, and Obstetrician provider offices bi-annually, in the spring and fall, for medicalrecord reviews.** These nurse are Health Plan employees who have been specifically trained inmedical record abstraction and are very efficient in their process.To schedule these visits, Health Plan staff calls to speak with the office manager or thedesignated staff member. When a date for the onsite visit is determined, a follow-up fax with apatient list is sent as confirmation.We do understand that this process can place additional stress on individual office routines andwe greatly appreciate the office personnel who schedule and prepare the charts prior to ourarrival.In lieu of an on-site visit, the following options are available:● Mail the requested medical records● Fax the requested medical records● Send the medical records by secure e-mail● Upload the requested medical records to a CD to be mailed● Upload the requested medical records to a secure FTP site (requires advance notice).* However, choosing any of these options may result in the need to pull extra pieces of themedical record for completion of the audit.When visiting your office, our nurse(s) will need:● Access to a power source for laptop data entry● Sufficient space accommodations for a laptop and scanner(Due to compliance recommendations by NCQA, we will be scanning designateddocuments from the medical record during the HEDIS® review)The goal of the Quality Improvement Department is to improve quality of service to ourmembers. Thank you for cooperating in these Quality Improvement projects and for continuingto provide quality care to our members.* HEDIS® – See HEDIS® 2014 Coding Guide;* Medical Record Audit – See Medical Record Audit Tool and “Standards for PatientRecords” guideline** Participation in chart reviews is part of the contractual agreement with The Health Plan.Section 8 / Page 69

PAIN ASSESSMENT SHEETPatient Name:Date of Birth:Pain PresentNo PainDate of Onset:Chief Complaint:Location of pain:Pain pattern: Constant Intermittent Other:Pain intensity: Patient rates pain on a scale of 0-10Pain at this time: 0 1 2 3 4 5 6 7 8 9 10Pain at its worst: 0 1 2 3 4 5 6 7 8 9 10Pain at its best: 0 1 2 3 4 5 6 7 8 9 10How does patient describe pain:Shooting Prick Ache Throbbing BurningPulling Sharp Dull Stabbing OtherWhat relieves the pain? Medication:Eating Rest Sleep Massage RepositioningHeat Cold Exercise Relaxation Techniques OtherWhat causes pain to increase?Pain interferes with the following:Disturbed sleep Activity Elimination Self-ImageMood Appetite/Nutrition Social Interaction Sexual FunctionIs there anything else you want to tell me about the pain? (Use patient’s own words)Physician SignatureDateSection 8 / Page 70

Patient Name: _____________________________________ Health Plan ID #___________________ Date: ___________DOB:_________ Age: _______ Allergies/Adverse Reactions: ________________________________________________Living will (Circle One): Yes No Medical Power of Attorney (Circle One): Yes NoREASON FOR VISIT: New Pt. □ Established Pt. □ ___________________________________________________Form Updated □ _________Form Updated □ _________ Form Updated □ _________ Form Updated □ _________Social History: □ Smoker years ___ packs/day ___ □ Smokeless Tobacco □ Second hand smoke exposure□ Alcohol drinks/wk _____ □ Caffeine cups/day _____ □ Exercise times/wk _____□ Street Drugs □ Unprotected Sex □ HIV High RiskMarital Status (Circle One): Married Single Widowed Divorced # of children___________________PAST MEDICAL HX:□Abnormal Mammogram □Broken Bones □Heart Valve Disease □Pacemaker□Abnormal Pap Smear □Bronchitis □Hemorrhoids □Pneumonia□Acid Reflux □Chest pain □Hepatitis □Polio□AIDS or HIV □Chicken pox □Hernia □Prostate Issues/PSA□Anemia □Chronic Cough □High Blood Pressure □Psoriasis/Eczema□Anxiety Attacks □Colon Polyps □High Cholesterol □Rheumatic Fever□Asthma □Congestive Heart Failure □Hives or Eczema □Seizures□Back Trouble □COPD □Home Oxygen □Sleep Apnea□Black or Bloody Stools □Depression □ICU Stay □Stomach Ulcers□Blood Clots □Diabetes □Kidney Disease □Stroke□Blood in Urine □Diverticulosis/Crohn’s/Celiac Dis. □Measles/Mumps □Thyroid Disease□Blood Thinner/Coumadin □Glaucoma □Migraines/Headaches □Tuberculosis□Blood Transfusion □Heart Arrhythmia □Obesity □Weight Loss□Breast Lump □Heart Attack □Osteoporosis □Weight Disorders□Cancer (where?)___________________________________________________________________________□Other___________________________________________________________________________________Women Only: □ 1 st day of last menstrual period ___________________________________ # of pregnancies__________# of live births __________ # of miscarriages ___________Birth Control ___________ type ________________________Page 1 of 2

Immunization History – Indicate Date:□Tetanus Shot______________ □Flu Shot______________ □Pneumonia Shot____________Past Surgery/Procedures (Please indicate date)□Blood Transfusion________________ □Echocardiogram_______________ □Hysterectomy_______________□Breast Biopsy___________________ □Endoscopy___________________ □Liver Biopsy________________□Bronchoscopy___________________ □Exercise Stress Test___________ □Lung Biopsy________________□C-Section ______________________ □Gall Bladder__________________ □Open Heart Surgery__________□Chemotherapy___________________ □Heart Catheterization___________ □Pacemaker_________________□Colonoscopy____________________ □Hip/Knee Replacement_________ □Skin Biopsy ________________□Colostomy______________________□Abdominal Surgery (why) __________________________________________________________________□Others: _________________________________________________________________________________Family History:□Anemia □Diabetes □High Blood Pressure □Stroke□Asthma □Heart Attacks □Kidney Disease □Thyroid Disease□Blood Clots □Heart Disease □Lung Disease□Cancer (type) _____________________________________________________________________________□Other: __________________________________________________________________________________Medications:Name Dose How Often______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________To the best of my knowledge, I certify that all information listed above is correct.Patient Signature __________________________________ Date ____________Page 2 of 2

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramPhysician OversightWhile completing the 2011-2012 HEDIS® chart reviews, the QualityImprovement nurses found many charts where a member had notbeen seen by the Physician for over a year. However, in many ofthese instances, prescription refills were provided. We also notedmembers on home oxygen for extended periods without an officevisit or physician oversight.If you have a patient on medication or home oxygen, they shouldbe reevaluated at least once a year by a physician, and theseservices should not be reordered if oversight has not occurred.Section 8 / Page 73

PRESCRIPTION AGREEMENT & NARCOTIC USE CONTRACTPatient Name:DOB:I, agree to the following provisions to continue toreceive narcotic pain medications for my chronic pain. I have been informed of the potential dangers andrisks associated with narcotic pain medication use. I understand that compliance with the followingguidelines is important to the continuation of pain treatment by my physician.1. I will take the medications at the dose and frequency prescribed. I understand that thesemedications are for my personal use only. No other pain medications are to be taken unless firstdiscussed with my physician / prescriber.2. I will comply with my scheduled appointments.3. No pain medication will be refilled by phone. I understand that pain medication prescriptionswill only be refilled at the scheduled clinic appointments. I will only fill narcotic/controlled painmedication prescriptions atpharmacy.4. I will not request controlled-substances or any other pain medication from prescribers other thanthe physician / prescriber listed below nor will I request pain medication from an emergencyroom.5. I will consent to random drug testing. Failure to comply with testing may result in denial ofprescriptions.6. I will protect my medications. Lost or stolen medications will not be replaced.7. I will tell all of my physicians that I am receiving pain medication/treatment from the physician /prescriber listed below. In case of emergency, surgery, or hospitalization, I will inform the doctorin charge of my care that I am on a chronic narcotic pain management program. If they choose toprescribe additional or different medications, I will inform the physician/prescriber listed belowand I will request that a record of that be sent to my physician / prescriber.8. I agree to participate in psychiatric, neuropsychology, and substance abuse assessments ifrecommended by my physician.9. I understand this agreement will be placed in my medical record.10. I understand that failing to follow this agreement may result in discontinuation of all narcotic orcontrolled substance prescriptions being prescribed from this physician / prescriber and couldpotentially result in care being terminated by the physician / prescriber listed below.I have read and understand the above agreement.Patient:Physician:Date:Date:Section 8 / Page 74

Prescription Drug AbusePROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramPrescription drugs are less expensive, more readily available, and often abused. Drugs that areoften abused or sold are mood elevators, steroids, and narcotic pain medications. This type ofabuse poses a serious health threat as many of these drugs can destroy the liver and other internalorgans if not monitored and used appropriately for the prescribed purpose.It has been noted that many individuals with this type of addiction frequent doctor offices, urgentcare settings, and emergency rooms with a generalized complaint of pain. They often state thatthey are visiting a relative or place of interest and that they forgot their medication.The following suggestions will help decrease the risk of prescription drug abuse:1. Make your patients aware of the danger of taking medications prescribed forsomeone else and of the danger of prescription medication abuse.2. Discuss a pain treatment plan and that pain medications are prescribed to relievesevere pain and to allow the patient to function while their physician finds thecause of the pain and treats it. When used properly, an addiction should not occur.3. Complete a thorough pain assessment.4. Consider using a pain medication contract for patients on pain medication.5. Reevaluate the pain on a regular basis.6. Limit the number of pills that are prescribed for each episode of pain.7. Limit the number of refills that a patient can receive without reevaluation.8. Consider non-narcotic medication and treatment options.9. Patients who reside out-of-the-area and who are seeking pain medication shouldhave a more extensive pain and medication history evaluation.10. Encourage patients seen in urgent care and emergency settings to follow-up withtheir Primary Care Physician. It may be beneficial to contact their PCP prior toprescribing pain meds.11. Encourage your patient to keep track of how many pills are in each bottle,to keep medicine out-of-reach and locked up, and to return unused medication totheir pharmacist for disposal.12. The danger for addiction occurs when the medication continues to be used whenit is no longer needed. A patient is at risk for addiction if they have a family orpersonal history of substance abuse, a recent emotional or psychiatric problem,or recent stressors such as the loss of a job or loved one. A patient running outof the medication before it is time to have it refilled can be the first sign ofaddictive behavior. Breaking an addiction can be difficult for patients and mayrequire lifestyle changes, detoxification, and ongoing therapy. A case managerat The Health Plan is available 24 hours a day at 1-877-221-9295 if you or yourpatients have any questions in regards to this issue.Section 8 / Page 75

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramPrescription Reporting System(Prescription Drug Database)The Ohio Department of Health reports thatdrug (illegal and legal) overdoses now topcar crashes as the leading cause ofaccidental death in the state of Ohio.To help discourage patients from “doctorshopping” for drugs such as vicodin,percocet, mood elevators, steroids, andADHD meds, a prescription drug databaseis available.Clarification1. The system was developed by the Boardof Pharmacy for Pharmacists to inputnarcotic prescription information.2. A Physician Assistant or Nurse Practitionercan only access the system using aPhysician’s ID Number.3. The system should be utilized byPhysicians for review of a patient’snarcotic history prior to writing aprescription.To access this system in Ohio, go to www.pharmacy.ohio.gov and click on Ohio PMP – OARRS(Ohio Automated Rx Reporting System to register).To access this system in West Virginia, go to www.wvbop.com and click on the ControlledSubstances Monitoring Program for the new user request.If you have anyquestions about thissystem, or concernsabout a patient thatmay be abusingprescribed medication,please call apharmacist inThe Health PlanPharmacy Departmentat (740) 695-7845.Section 8 / Page 76

PREVENTIVE HEALTH FLOW SHEETADULTS (in general)Head-to-Toe Physical /Medical History UpdateDATE DATE DATE DATE DATE DATE DATE DATEBMI - Body Mass IndexCholesterol ScreeningGlucose ScreeningColonoscopyFecal Occult Blood TestSigmoidoscopyTobacco - AssessmentTobacco EducationAlcohol - AssessmentAlcohol EducationDrug Use AssessmentDrug EducationWOMENClinical Breast ExamMammogramChlamydia ScreeningPAP ScreeningOsteoporosis - DexaScanMENPSA - Prostate SpecificAntigenRectal / Prostate ExamIMMUNIZATIONSINFLUENZAPNEUMONIATETANUS / DIPTHERIABOOSTERHEPATITIS BHPVVARICELLANON IMMUNE ADULTSRUBELLAOTHERADVANCE DIRECTIVES* For correct coding of the above, see the HEDIS® Coding Guide *

NAME:DOB:PROBLEMSVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATESURGERIESVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEVISITDATEProblem ListThis sample form is provided as a tool and not a requirement.Feel free to use it or adapt it to the individual needs of your office.Section 8 / Page 78

Signature LogLegible Name( Print / Type )CredentialsLegal Signature withCredentialsUnacceptable Unless …1. The provider authenticated Typed Name.2. Non-Physician or Non Physician Extender co-signed by acceptable physician.3. Provider of Services’ Signature without Credentials Name linked to provider credentials or name on physicianstationary.4. Illegible Signature verified from a signature log.Section 8 / Page 79

St. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365Phone: 1.800.624.6961Hearing Impaired1.800.622.3925Fax: 740.695.5297www.healthplan.orgHomeTown Office100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816PH: 1.877.236.2289Hearing Impaired1.877.236.2291Fax: 330.837.6869www.healthplan.orgSmoking Cessation Referral FormPlease complete the information below to refer your patient to The Health Plan for smoking cessation.Fax to (740) 695-8103Attn:Joy Gillispie, R.N., B.S.N., QI / Wellness DepartmentFrom:Date:Re:Smoking Cessation ReferralPatient InformationName:HP ID#:How long has this patient smoked?Home Phone#:How much do they smoke?Have they ever tried to quit before? NO YES (When)Smoking cessation aids used in the past? NO YES (List)Indicate Any Medical Conditions or Physical Limitations for This MemberDiabetes Heart Disease High Blood Pressure Peripheral Vascular DiseaseCancer Stroke(s) Lung Disease / Asthma Other (please list below):The Health Plan provides help for members who wish to stop smoking or using any other tobacco products.The American Lung Association’s “Freedom From Smoking” clinic is offered by The Health Plan on an ongoing basis.Classes are free to Health Plan members as well as the community at large.If your patient is ready to quit, would like more information, or wants to register for a class, they may contactJoy Gillispie, R.N., B.S.N., Health Plan Medical Affairs and Education Liaison, at 1-800-624-6961, Ext. 7640 or(740) 695-7640.Smoking Cessation Referral FormSection 8 / Page 80

Vaccine Administration Recordfor Children and TeensPatient name:Birthdate:Chart number:(Page 1 of 2)Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child’s parent or legal representativeand make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient’s personal record card.Type of Date given FundingVaccine InformationVaccineVaccineStatement (VIS)Vaccinator 5Vaccine 1 (mo/day/yr) Source Site 3(signature or(F,S,P) 2Lot # Mfr. Date on VIS 4 Date given 4 initials & title)Hepatitis B 6(e.g., HepB, Hib-HepB,DTaP-HepB-IPV)Give IM. 7Diphtheria, Tetanus,Pertussis 6(e.g., DTaP, DTaP/Hib,DTaP-HepB-IPV, DT,DTaP-IPV/Hib, Tdap,DTaP-IPV, Td)Give IM. 7Haemophilus influenzaetype b 6(e.g., Hib, Hib-HepB,DTaP-IPV/Hib,DTaP/Hib) Give IM. 7Polio 6(e.g., IPV, DTaP-HepB-IPV,DTaP-IPV/Hib, DTaP-IPV)Give IPV SC or IM. 7Give all others IM. 7Pneumococcal(e.g., PCV7, PCV13, conjugate;PPSV23, polysaccharide)Give PCV IM. 7Give PPSV SC or IM. 7Rotavirus (RV1, RV5)Give orally (po).See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, and other vaccines (e.g., travel vaccines).How to Complete This Record1. Record the generic abbreviation (e.g., Tdap) or the trade name for eachvaccine (see table at right).2. Record the funding source of the vaccine given as either F (federal),S (state), or P (private).3. Record the site where vaccine was administered as either RA (right arm),LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal).4. Record the publication date of each VIS as well as the date the VIS isgiven to the patient.5. To meet the space constraints of this form and federal requirements fordocumentation, a healthcare setting may want to keep a reference list ofvaccinators that includes their initials and titles.6. For combination vaccines, fill in a row for each antigen in the combination.7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous.Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.Abbreviation Trade Name & ManufacturerDTaPDaptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur)DT (pediatric) Generic (sanofi pasteur)DTaP-HepB-IPV Pediarix (GSK)DTaP/HibTriHIBit (sanofi pasteur)DTaP-IPV/Hib Pentacel (sanofi pasteur)DTaP-IPVKinrix (GSK)HepBEngerix-B (GSK); Recombivax HB (Merck)HepA-HepB Twinrix (GSK); can be given to teens age 18 and olderHibActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck)Hib-HepBComvax (Merck)IPVIpol (sanofi pasteur)PCV13Prevnar 13 (Pfizer)PPSV23Pneumovax 23 (Merck)RV1Rotarix (GSK)RV5RotaTeq (Merck)TdapAdacel (sanofi pasteur); Boostrix (GSK)TdDecavac (sanofi pasteur), Generic (MA Biological Labs)For additional copies, visit www.immunize.org/catg.d/p2022.pdf • Item #P2022 (3/11)This form was created by the Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org

Vaccine Administration Recordfor Children and TeensPatient name:Birthdate:Chart number:(Page 2 of 2)Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child’s parent or legal representativeand make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient’s personal record card.VaccineType ofVaccine 1FundingDate givenSource(mo/day/yr) Site 3(F,S,P) 2VaccineVaccine InformationStatement (VIS)Lot # Mfr. Date on VIS 4 Date given 4Vaccinator 5(signature orinitials & title)Measles, Mumps,Rubella 6 (e.g., MMR,MMRV) Give SC. 7Varicella 6 (e.g., VAR,MMRV) Give SC. 7Hepatitis A (HepA)Give IM. 7Meningococcal (e.g.,MCV4; MPSV4) GiveMCV4 IM 7 and MPSV4SC. 7Human papillomavirus(e.g., HPV2, HPV4)Give IM. 7Influenza (e.g., TIV,inactivated; LAIV, liveattenuated) Give TIV IM. 7Give LAIV IN. 7OtherSee page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus vaccines.How to Complete this Record1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine(see table at right).2. Record the funding source of the vaccine given as either F (federal), S (state),or P (private).3. Record the site where vaccine was administered as either RA (right arm),LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal).4. Record the publication date of each VIS as well as the date the VIS is givento the patient.5. To meet the space constraints of this form and federal requirements fordocumentation, a healthcare setting may want to keep a reference list ofvaccinators that includes their initials and titles.6. For combination vaccines, fill in a row for each antigen in the combination.7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous;IN is the abbreviation for intranasal.AbbreviationMMRVARMMRVHepAHepA-HepBHPV2HPV4LAIV (Live attenuatedinfluenza vaccine]TIV (Trivalent inactivatedinfluenza vaccine)MCV4MPSV4Trade Name & ManufacturerMMRII (Merck)Varivax (Merck)ProQuad (Merck)Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck)Twinrix (GSK)Cervarix (GSK)Gardasil (Merck)FluMist (MedImmune)Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK);FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi)Menactra (sanofi pasteur); Menveo (Novartis)Menomune (sanofi pasteur)Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.This form was created by the Immunization Action Coalition • www.immunize.org • www.vaccineinformation.orgFor additional copies, visit www.immunize.org/catg.d/p2022.pdf • Item #P2022 (3/11)

PROVIDER PROCEDURAL MANUAL 2014The Health Plan Quality Management ProgramVA Ccs, Spec a sts, and Health FairsIf your patient is being followed by a VA Clinic, a Specialist, or has participated in a communityhealth fair, ask them to request a copy of their lab and x-ray results for your chart. This simplestep will improve quality as well as continuity and coordination of care.Section 8 / Page 83

WebsiteHelpful resources for your patients at www.healthplan.orgA partial listing of what can be found on our website:• Advance Directive Information• Baby Keepsake and “Together Everyone Lives a Healthier Lifestyle” Booklet• Behavioral Health Information on Substance Abuse and Depression• Disease Management Information on Asthma, Acute Low Back Pain, CHF, COPD,and Diabetes Mellitus• Emergency Medical Information Form• Health Risk Assessments• Health Screening Tools• HealthWise (Commercial), Secure Connection (SecureCare), and Healthy Sense(Medicaid) Member Newsletters• Provider Focus - The Health Plan Provider Newsletter• HEDIS® Overview and HEDIS® Coding Guide• Pamphlets on Alcohol Use, Behavioral Health, Bullying and Cyberbullying,Medication Safety, Preventive Health, and Stress Management• Wellness Resources and 2014 Calendar (also found in The Health Plan lobby)Section 8 / Page 84


PROVIDER PROCEDURAL MANUAL 2014Table of ContentsBEHAVIORAL HEALTH UNIT (BHU)INTRODUCTION ......................................................3PRE-AUTHORIZATION /PRE-NOTIFICATION REQUIREMENTS .......................4INPATIENT CARE ................................................... 4DIAGNOSTIC TESTING AND STUDIES ..................... 4PROCEDURES ........................................................ 4AMBULATORY SERVICES ....................................... 4ANCILLARY PROVIDERS AND SERVICES ................. 4BEHAVIORAL HEALTH SERVICES ............................ 4DENTAL SERVICES ................................................. 4SPECIALTY PHARMACY .......................................... 5NEW TECHNOLOGY ............................................... 5PRE-AUTHORIZATION OPTIONS ............................ 5ADMISSION / CONCURRENT REVIEW PROCESS .......6CRISIS ENCOUNTERS ...............................................6PRE-AUTHORIZATION / REFERRAL MANAGEMENT .... 7REVIEW CRITERIA ....................................................8INTERQUAL® REVIEW ..............................................9DISEASE MANAGEMENT &HEALTH PROMOTION PROGRAMS ....................... 13DEPRESSION DISEASE MANAGEMENT .................. 15ANNUAL PROGRAM EVALUATION ........................ 17ACCESS TO CARE ................................................... 17CONTINUITY & COORDINATION OF CARE ............. 18BEHAVIORAL HEALTH UNIT FORMS ...................... 19ADMISSION REVIEW INFORMATION FORM ........ 20BHU MEDICAL REVIEW FAX COVER SHEET.......... 23CONCURRENT AUTHORIZATION FORABA / BEHAVIORAL SERVICES ............................. 24CONCURRENT OR DISCHARGEREVIEW INFORMATION FORM ............................ 26CONTINUITY OF CARE CONSULTATION SHEET .... 28CRISIS ENCOUNTERS REPORT FORM ................... 29INITIAL AUTHORIZATION FORABA / BEHAVIORAL SERVICES ............................. 30PSYCHOLOGICAL TESTING FORM ........................ 33TREATMENT CONTINUATION REQUEST FORM ... 35CASE MANAGEMENT ............................................ 10CARE MANAGEMENT. ........................................... 11SOCIAL WORK SERVICES ....................................... 12Section 9 / Page 2

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health Unit (BHU)IntroductionThe goal of the BHU is to ensure the highest quality of care for our members. To that end,we will work with providers and members to coordinate care. Our staff will work directly withproviders and members to make known available resources within the provider network and thecommunity network. Our Care and Case Managers, Depression Disease ManagementCoordinator, and Referral Coordinators are available to assist providers and members inobtaining and locating needed services.The BHU will work directly with other departments at The Health Plan to address behavioralhealth related concerns. This will incorporate behavioral components with disease management,primary care, specialty care, and behavioral providers.In this section, you will find information that will guide you in achieving this goal. You will findinformation regarding the referral process, preauthorizations, medical management oversight,forms necessary for continuation of treatment, and reimbursement.Our 24-hour phone number is (877) 221-9295 for any patient needs. You may also reach theBehavioral Health Unit at (740) 695-7896, (800) 624-6961, (877) 236-2291, or (330) 834-2354with any questions.You may fax requests for treatment and report crisis encounters to (740) 699-6255. This is adedicated computer fax that is available only to BHU personnel.Remember, The Health Plan does not require a preauthorization for crisis encounters or aninitial evaluation visit. Preauthorization may be necessary for Employer Funded groups.Section 9 / Page 3

THE HEALTH PLANPRE-AUTHORIZATION / PRE-NOTIFICATION REQUIREMENTSPLEASE NOTE: There are additional procedures that require preauthorization for EMPLOYER-FUNDED PLANS (ASO).Please contact the Customer Service Departments at The Health Plan, St. Clairsville, OH, (888) 816-3096 or (740) 695-7910for assistance on handling of authorization for employer-funded product lines.Inpatient CareAll Elective, Urgent, and Emergent Inpatient CareSkilled Nursing and Rehabilitation Inpatient CareAll Tertiary Care / Out of Network / Out of Area CareDiagnostic Testing and StudiesAll requests for MRI of the shoulder, knee, hip, extremity,elbow, ankle, foot, wrist, and the spine(cervical, thoracic, lumbar) – no exemption status grantedCT / MRI (other than listed above) / MRA *CT Angiography for CADSPECT MPI (Myocardial Perfusion Imaging)*PET Scan / PET / CT Fusion ScanVirtual Colonoscopy – CT ColonographyProceduresAutomatic Implantable Cardiac Defibrillator / WearableCardioverter Defibrillator / CRT-DBariatric SurgeryBone Anchored Hearing Aid (BAHA) / Cochlear ImplantsBrachytherapy for Treatment of CancerCosmetic Procedures (reduction mammoplasty,rhinoplasty, blepharoplasty, sclerotherapy, otoplasty,scar revision, abdominoplasty, panniculectomy, etc.)HysterectomyKyphoplasty / VertebroplastyProphylactic MastectomyAll Sleep Apnea SurgeriesAmbulatory ServicesAmbulatory Blood Pressure MonitoringCardiac Outpatient Monitoring / Mobile Real-TimeCapsule Endoscopy – Esophageal pH monitoring (Bravo)Continuous Glucose MonitoringDialysis – Out-of-PlanAll Genetic, Pharmocogenetic, & Pharmacodynamic TestingInfertility TreatmentIntensive Cardiac Rehabilitation (Ornish / Pritikin)Low Vision RehabilitationMonitored Anesthesia Care (MAC) for GI EndoscopicsOncotype DX AssayPodiatric Services* after 2 visits / calendar yr.Skin Substitutes (e.g. Dermagraft, Apligraft)Sleep Studies* - All unattended Sleep StudiesSurgical / Invasive Varicose Vein TreatmentTMJ – Diagnostics and TreatmentAll Tertiary Care / Out of Network / Out of Area CareUrinary / Fecal Incontinence ClinicWound Care Clinic (after initial eval) / Hyperbaric OxygenAncillary Providers and ServicesAmbulance / Ambulette – Non-EmergentAudiologists (Independent Practices) All Evals & TestingChiropractic Care – Children (< age 18) and/or out ofnetwork care only; limitations per benefit plan & contractHome Health Services / HospiceInfusion TherapyInsulin Pumps and SuppliesSpeech Therapy – All visits; PT / OT after 20 visitsOrthotics or Prosthetics ≥ $500All Molded-to-Patient Model & Custom FabricatedProsthetics / OrthoticsWheelchairs and AccessoriesDurable Medical Equipment ≥ $500 (rental or purchase)and as required per Health Plan Fee Schedule go towww.healthplan.org for complete informationBehavioral Health ServicesCare coordinated through The Health Plan BehavioralHealth Unit – Contact Information on ReverseAddictionology Outpatient Mental HealthCounselor / Therapist PsychiatryInpatient Mental Health PsychologyPre-auth not required for initial evaluation or crisis visitPre-auth required for initial 6 visits, but no TreatmentPlan requiredTreatment Plan must be submitted to continue carebeyond 6 visitsCrisis Encounter Forms requested within 48 hrs. ofcrisis interventionPre-auth required for Neuro-Psych & Psych TestingPre-auth required for ECTPre-auth required for ABA & all services relatedto AutismHealth & Behavior Assessment(CPT 96150, 96151, 96152)Dental ServicesEmergency Extractions for Mountain Health Trust (MHT) /Mountain Health Choices (MHC) / West Virginia MedicaidMembers: Preauthorization is only required for extractionof 3 or more teeth and all wisdom teeth extractions. For 1or 2 extractions, the claim should document that theservices were urgent / emergent. Pre-authorization required except for those physicians / providers currently exempt from review; periodic retrospective review willbe completed to assure compliance with standards of care and medical appropriateness guidelines.Updated September 2013

Specialty PharmacyTo preauthorize Specialty Pharmacy,New TechnologyPreauthorization required – for complete information andPA Forms please go to link belowhttp://www.healthplan.org/Content.aspx/prior-authorization-formsColony Stimulating DrugsRheumatoid Arthritis Drugs (systemic)Crohn’s DiseaseGrowth HormonesMultiple Sclerosis DrugsPsoriasis Drugs (systemic)Oral Chemotherapy AgentsDrugs to treat Pulmonary Arterial HypertensionIron Replacement TherapyKalydeco for Cystic FibrosisFor a complete list, see Specialty Medications athttp://www.healthplan.org/pdf/SpecialtyPharmacy2013_10_14_13.pdfTraditional drugs requiring preauthorizaton:See list under 2012 Drug Formularies athttp://www.healthplan.org/Content.aspx/drug-coverageinformationor via Epocrates.Artificial Uninary SphincterAutologous Chondrocyte ImplantationBioimpendance / Biventricular Pacemaker / CRT-DBone Morphogenetic Protein (BMP)Botulinum Toxin InjectionsCarotid Artery StentingChemoembolizationCryosurgery for Renal MassesDSEK and DSAEK for Corneal Endothelial DegenerationEnhanced External Counterpulsation (EECP)HALO 360 Coagulation SystemIntensity Modulated Radiation Therapy (IMRT)Intrastromal Corneal Ring Inserts (Intacs)Implantable / Insertable Loop RecorderGamma Knife / Stereotactic RadiosurgeryGastric Electrical StimulationLeft Ventricular Assist Device (LVAD)ProstaScintProvenge Immunotherapy for Prostate CancerRadiofrequency Ablation for Chronic Back PainSelective Internal Radiation TherapySacral Nerve Stimulation / Spinal Cord StimulatorTransperineal Template Guided Saturation Biopsy of theProstate (CPT 55706)X STOP Interspinous Process Decompression SystemXiaflex InjectionsReferral Line:Admissions:Elective admissions, non-emergent referrals, diagnostics, imaging and procedure pre-authorizationsAvailable 8:00am to 5:00 pm • Monday through FridaySt. Clairsville, OhioMassillon, Ohio(800) 526-7511 (888) 830-4370(740) 695-7905 (330) 830-4370The Health Plan PPO Products Line: (855) 577-7123 or (740) 699-6273ASO / Employer - Funded Product Line: (888) 816-3096 or (740) 695-7910Notification of urgent and emergent admissions to participating facilities (In-Plan)Fax:St. Clairsville, OhioMassillon, Ohio(800) 304-9101 (888) 830-4370(740) 695-7918 (330) 830-4370To submit clinical information for review:St. Clairsville, OhioMassillon, Ohio(888) 329-8471 (888) 450-6024(740) 695-5297 (330) 830-4380Behavioral Health Unit: For referrals, care coordination, and continuing behavioral health services:Physician Access Line:Provider Websites:Toll – Free 24 hrs / day 7 days / week (877) 221-9295Secure Fax (866) 616-6255 or (740) 699-6255EMERGENT BEHAVIORAL HEALTH ISSUES and contacting the Medical Director after hours(866) NURSEHP (866) 687-7347. Available 24 hours a day / 7 days a week – Physician Access onlywww.healthplan.org - Open website; links to password secure Provider Website for eligibility,claims, reference materials and provider support informationADDITIONAL SERVICES MAY REQUIRE PREAUTHORIZATION.Due to changes in medical technology, the accessibility of diagnostic equipment and services in an office / outpatient setting, as well as updated methods of performingprocedures, there may be additional services that will require prior authorization. Please contact The Health Plan prior to performing services related to newtechnology. Periodic review of provider utilization data may eliminate or require the need for medical appropriateness review and preauthorization of additional services anddiagnostic studies.Updated September 2013

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitAdmission and Concurrent review are expected on all inpatient, partial hospitalizations, intensiveoutpatient and crisis stabilization services.Admission / Concurrent Review ProcessPre-authorization of elective admissions is performed to confirm eligibility, benefits, andmedical appropriateness of services to be rendered and level of care to be utilized. The processis initiated by the member’s Primary Care Physician or referring participating specialist with theBehavioral Health Unit nurses.Pre-authorization notification of urgent / emergent admissions, by the admitting physician orfacility, is required at the time of, or as soon as practically possible after admission. This activityis performed for early discussion of member’s needs as related to the admission or alternativehealth care services.All out-of-plan and tertiary requests require a referral and pre-authorization. Clinicalinformation is reviewed for availability of service within the in-plan network, urgent / emergentsituation or other extenuating circumstances and should be supplied by the Behavioral HealthPractitioner.Concurrent review is the process of continued reassessment of medical appropriateness forcontinuing inpatient care. Any member identified with potential discharge planning needs isreferred by the Behavioral Health Unit’s hospital review nurse to care/case management, diseasemanagement or the social worker as appropriate for early intervention. Concurrent review isperformed telephonically or by fax. For facility convenience, Admission and Concurrent orDischarge Review Information sheets are available on the Behavioral Health tab of the Providerweb page. These reviews involve communication with physicians, hospital UR and socialworkers, and family members as necessary. Anytime a quality of care issue is identified orsuspected, the case is referred to The Health Plan Quality Improvement Department for review.Please indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan.Crisis EncountersCrisis Encounters should be reported to The Health Plan Behavioral Health Unit within 48 hours ofthe visit. A crisis encounter is defined as an unscheduled, direct, face-to-face encounter with amember in need of psychiatric or psychological intervention to resolve an acute or severe situation.Reporting of the encounter will ensure that the visit is not counted against any existingpreauthorization of services or prevent denial of service if there is no preauthorization of services.Crisis Encounters can be reported telephonically or electronically. The Crisis Encounter Formis located in the Behavioral Health Unit Forms found in this section or on The Health Plan web site athttp://www.healthplan.org/index.php/provider-services/behavioral-health/additional-bhuresources/doc_download/78-crisis-encounter-reportSection 9 / Page 6

PROVIDER PROCEDURAL MANUAL 2014Pre-Authorization / Referral ManagementBehavioral Health UnitMembers are afforded direct access to Behavioral Health practitioners for initialevaluation and crisis encounters. Preauthorization is necessary for follow up visits.Remember that additional services may require prior authorization based on specific planrequirements of some groups, especially those that are Self-Funded or Employer-Funded.There may be additional service that will require medical review. Contact The Health Plan ifyou have concern regarding a particular procedure or test.All out-of-plan and tertiary requests require a referral and pre-authorization.Clinical information is reviewed for availability of service within the in-plan network, urgent /emergent situation or other extenuating circumstances and should be supplied by the BehavioralHealth Practitioner, Primary Care Physician or appropriate in-plan specialist (if referring withintheir specialty).Authorization is obtained via telephone or fax. Copies of all treatment request forms areincluded in the preauthorization section to assist you in pre-authorizing these services.Additional services that require prior authorization include procedures that may have limitedcoverage under the plan benefits. Also, high cost procedures and new technologies that havespecific coverage guidelines should be pre-authorized to assure medical appropriateness andcompliance with established standard of care guidelines. Please contact the Health PlanBehavioral Health Unit if you have any concern regarding coverage of any service.Any referral that does not meet medical appropriateness review by the nurse reviewer is referredto the Medical Director for review determination. The Medical Director may contact theBehavioral Health Practitioner for case discussion. Availability of services within the providernetwork and alternative levels of care for services may be offered as appropriate to themember’s needs. “Member driven” referrals that you cannot justify as medically necessaryshould not be initiated.Refer to Appeals, found in the Medical Management section of the Practitioner Manual,to assist you in the event of prospectively non-authorized services.Autism Services are a covered benefit for eligible West Virginia Groups.Please indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan.Section 9 / Page 7

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health Unit Please see Section 7, Medical Management Program for procedural informationaddressing the following subjects:The Behavioral Health Unit follows the same policies and procedures as put forth by theMedical Management Department.Review CriteriaNationally recognized clinical criteria are utilized to perform reviews for medicalappropriateness allowing for consideration of the needs of the individual member, theircircumstances, medical history, and availability of care and services within The Health Plannetwork. Input is sought annually or as needed in the review of criteria from physicians inthe community and those who serve as members and Associate Medical Directors of thePhysician Advisory Committee. In cases where specific clinical expertise is needed toperform a particularly specialized review, experts outside The Health Plan may be used.Section 9 / Page 8

InterQual® ReviewPROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitThe Health Plan utilizes McKesson InterQual Criteria as a screening guideline to assistthe reviewers with respect to medical appropriateness of health care services.Any participating provider upon request may review the specific criteria used in an activeclinical review process of a procedure requiring the use of InterQual . You may callThe Health Plan Behavioral Health Unit if you have a general InterQual® question or aquestion regarding a particular case. Also, a Health Plan nurse can visit your office or youmay come to The Health Plan to review the criteria. InterQual review worksheets areavailable upon request.InterQual® may be utilized to assist in the review of the following procedures:• Psychological Testing• Inpatient Admissions• Partial Hospitalization• Intensive Outpatient Treatment• Community Based Treatment• Outpatient Treatment• Crisis StabilizationPlease indicate if your request is emergent so that we may expedite the review.Simply scheduling the testing/procedure does not warrant an expedited review.Unless an emergency, scheduling should be done after being approved by The Health Plan. See Preauthorization Request Form for necessary preauthorization information.Section 9 / Page 9

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitCase Management – Manage individual patients, normally on a long-term basis, who areidentified to be at high risk due to high costs or catastrophic illness or injury.The case management program is an individualized, patient-specific process of coordinatingresources and creating flexible, quality, cost effective health care options. The process isdependent upon collaboration between treating physicians, members and their family,or significant others.Identification of members is primarily through inpatient admission, illnesses, high costutilization, health risk assessment, or the pre-authorization / referral, and concurrent reviewprocess. Referrals for case management may also come from other sources such as family,physician, behavioral health providers, hospital staff, and other departments within The HealthPlan via health screening and outreach programs.Registered nurses perform the case management function. They coordinate care and resources,provide alternatives to hospital care, facilitate care across the continuum, and prevent duplicationand fragmentation of health care services. They manage individual patients normally on a longtermbasis who are identified to be at high risk due to high costs or catastrophic illness or injury.They work with the 20% of the people who use 80% of health care resources.The processes of case management include the following: case identification and referral,case screening and assessment, case implementation, case monitoring and case closure.Please contact The Health Plan Behavioral Health Unit at (877) 221-9295, or enroll membersonline at www.healthplan.org.Behavioral Health Case Management1. Multiple Co-Morbidities or High RiskCo-Morbidity (Chronic Medical Conditionwith Behavioral Health Diagnosis),Identified by Depression Survey or Referral2. Dual Diagnosis / Schizophrenia3. Attempted Suicides or Homicides4. Stays Longer than 30 Days as Identified bythe LOS > 15 Day Report5. MDD, not qualifying forDisease Management6. Substance Abuse Diagnosis with MentalHealth Diagnosis7. Inpatient Admission, not qualifying forDepression Disease Management8. Outpatient Treatment of Opioid Addiction9. Psychosis10. High Cost Ongoing Complex Care needs asidentified on the Weekly Paid HospitalClaims Report Greater than $20,000.00Cases with diagnoses 2, 3, 5, and 9 are designated as Complex Cases on the BH Assessment Screen,as well as any others at the discretion of the Case Manager.Section 9 / Page 10

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitCare Management – Manage individual patients as designated, normally on a short termbasis, mainly episodic or situational, such as those SecureCare Members identified by HRAor members identified through discharge survey.The care management program is also individualized to the member and coordinates resourcesacross the continuum to minimize costs while improving quality of care. Care management is apro-active approach that focuses on promotion of health education, and member empowermentthrough self-maintenance.Members are identified through established care management criteria, referrals from other areasof medical management, member / family or physician, and other departments within The HealthPlan, health risk assessments, and discharge surveys. Both physicians and members may use thefollowing methods to contact the Behavioral Health Unit to see if a particular patient couldbenefit from Care Management Services:Telephone: (800) 624-6961, ext 7301 or (740) 695-7301Secure E-mail: BehavioralHealthUnit@healthplan.orgThe care managers can take elective, urgent, or emergent admission notifications, as well asother services, such as partial hospitalizations, crisis stabilization, intensive outpatient services,or outpatient services. They will coordinate and authorize services with ComprehensiveCommunity Centers and secure the assistance of the Licensed Social Worker. They will alsopartner with other community organizations to link members to necessary services.Behavioral Health Care Management1. Primary Substance Abuse, other thanOpiates2. Multiple Co-Morbidities or High RiskCo-Morbidity with Short Term, Non-Bio-Based Behavioral Health Diagnosis,Identified by Depression Survey or Referral,not Suitable for Case Management3. Enrollment in Clinical Trials4. Identification through Discharge Survey5. All Members Seeing Out ofNetwork Providers6. Redirection / Transition of Members forOON to IP Providers7. Crisis Encounter Follow-Up8. Antidepressant Medication ManagementFollow-UpSection 9 / Page 11

Social Work ServicesPROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitSocial Work Services are available to assist Health Plan members and their families withsocio-economic, psychosocial, personal, and environmental issues, which can predisposeillness or interfere with obtaining the maximum benefit from medical care.The Social Worker coordinates with health care providers, the Behavioral Health Unit,and The Health Plan Medical Department staff to identify community resources that will assistthe member to resume life in the community or learn to live within the limits of a disability in aneffort to restore the member to an optimal level of social and health adjustment.Services provided by The Health Plan Social Worker may include:• Financial Counseling• Assisting in Applying for Financial Aid Programs• Assessing Need and Qualifications for Pharmacy Assistance Programs• Home Visits to Evaluate and Assess the Needs of the Member• Educating Members on Resources Available to Them and Their Families• Coordinating Referrals to Ancillary Support, Personal Care, and Nursing Home Placement• Will Coordinate with Comprehensive Community Centers, Targeted Case Managers,and Other Community Based Organizations to Assist in Member Care.Providers identifying social-economic needs of a Health Plan member may contact the SocialWorker to discuss possible assistance programs and support services.Section 9 / Page 12

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitDisease Management & Health Promotion ProgramsThe Health Plan’s Disease Management and Health Promotion Programs are multi-disciplinaryand continuum-based systems developed to proactively identify populations with, or at risk for,chronic medical conditions. Populations currently being managed include members withasthma, diabetes, chronic heart failure, chronic obstructive pulmonary disease, and depression.The Health Plan’s pregnant members are also monitored with the intent to identify those athigh risk for premature delivery.Disease management programs support the practitioner-patient relationship and plan of care;emphasize the prevention of exacerbations and complications using evidence based practiceguidelines and patient empowerment strategies. The Health Plan programs continuouslyevaluate clinical, humanistic, and economic outcomes with the goal of improving overallhealth status. The essential elements of disease management include understanding thecourse, clinical implications, and trajectory of specific diseases; identifying and targetingpatients likely to benefit from intervention; focusing on prevention; and working towardresolution of resource-intense problems.Each management program includes condition monitoring that is ongoing and proactive.This allows the member, the practitioner, and the disease manager to assess how well thecondition is being managed. Monitoring is done with regular clinical assessments withsurveillance of pharmacological management, lifestyle management, and assessment of themember’s understanding of the condition itself as well as the related co morbid conditionslikely to affect overall health status.Member adherence to the program’s treatment plan is an integral part of disease management.Members are followed to determine their success with self-management, self-monitoringactivities, and medication compliance. High-risk members are called at periodic intervals.Detailed questions are asked about the member’s condition and information is gathered regardinghealth status, treatment plan adherence, functional status, and quality of life. A specific plan ofcare is developed based on the findings from a clinical assessment and functional inventory.Ongoing monitoring by the disease manager ensures timely intervention when a change in riskstatus is identified. The frequency of outbound calls to participants by the case manager isdetermined by the severity of symptoms. This may result in daily contact in times of high risk orconcern. When home care is needed in high risk-cases, the disease manager works with thepractitioner and a home care agency to coordinate necessary care and services.In all instances, disease management and health promotion programs must consider otherhealth conditions that directly affect the member’s overall health status. A multi-disciplinaryapproach to disease management enables the disease manager to develop a treatment planthat includes condition monitoring of co morbid conditions frequently associated withchronic medical conditions.Section 9 / Page 13

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitBecause lifestyle issues are strongly linked with chronic disease and high-risk pregnancy,strategies to address current lifestyle and the need to modify behavior is addressed in everyprogram. Whether members need interventions addressing issues such as smoking cessation orweight loss management, the disease manager is able to address readiness to change and toprovide additional resources to affect needed change.The Health Plan’s Disease Management and Health Promotion Program elements include:• Identification of evidence-based standards of care, best practices, evidence-based• Intervention strategies, and targeted outcomes• Identification of the member and assessment of health status• Proactive intervention to include the application of appropriate therapies and systematicsurveillance of appropriateness of medication, education and counseling about daily selfmanagement,and symptom management• Tracking of the member’s clinical and functional status over time• Assessment of effectiveness of treatment and sharing of knowledge gained to achieveoptimal member outcomesAttention to all program elements and improvements in all of these areas will likely lead toimproved outcomes for the many who are at risk or who suffer chronic diseases.Please contact the Health Plan Disease Management Department at (800) 624-6961. Ext 7620 or6110, or call the Behavioral Health Unit directly for the management of depression at(877) 221-9295. You may also enroll members online at www.healthplan.org.Section 9 / Page 14

PROVIDER PROCEDURAL MANUAL 2014Depression Disease ManagementBehavioral Health UnitThe Depression Disease Management Program is designed to reach out to members who havebeen diagnosed with depression. Depression is a leading cause of medical disability in the U.S.,costing $53 billion per year in direct treatment costs, mortality, and lost productivity.This program is dedicated to helping our members cope with the stresses of their conditions andto feel better, thereby improving their lives, both at home and at work. The Depression DiseaseManagement Program strives to integrate behavioral, medical, and pharmacological aspects ofhealthcare to support the member totally. This will be accomplished thru establishment of asecure relationship between the DM nurse and the member. The DM nurse will reinforce themember’s capacity for self-reliance, self-determination, self-education, as well as provideeducational materials, information on the condition, collaborative planning, and assist withproblem solving. The program goal is to enhance the member’s own capacities of self-worth andself-reliance to care for his/her own needs.Goals of the program include:• Decrease in depression screening score,thereby preventing recurrence• Reduction in frequency of hospitalizations• Increase in medication compliance• Reduction in ER visits for members witha depression diagnosis.• Enhancement of the patient/providerrelationship• Improvement of quality of life• Remission from depressionDepressed individuals are determined tobe in remission when they no longer reporta period of two weeks where they feel:1. Down, depressed or hopeless or2. Little interest in doing things.Remission is also defined as a PHQ scoreof less than 5.The target population is adult members with qualifying diagnosis / events. Memberidentification is conducted by using claims encounters, health risk screening, or direct referralfrom a member, primary care physician, or Behavioral Health provider. Member stratification isbased PHQ-9 scoring.The Depression DM program relies on population based measures of hospitalization utilization,ER utilization, and the HEDIS Antidepressant Medication Management measure utilizingCodes to Identify Major Depression. The same measures are also used at the individual memberlevel for those stratified as high risk and who participate in The Health Plan’s telephonicDepression DM program. Primary attention is given to evaluation of clinical symptoms,assessment of the severity of those symptoms, safety issues, medication compliance and memberneeds, education and counseling about self- management and self-direction.Section 9 / Page 15

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitAdditionally, depression screening will be utilized during the telephonic process or by mail.Referrals, linkage, and follow-ups to primary care or Behavioral health providers will beprovided as necessary.Population based disease management strategies include targeted educational mailingsthroughout the year, accompanied by depression screenings. High-risk members receivetelephonic disease management intervention from a Behavioral Health nurse specialist whoprovides individualized interventions that include a depression screening, evaluation of clinicalsymptoms, lifestyle and coping, safety issues, education and counseling about self-managementand self-direction. The member will be also be referred, as appropriate, to counseling services,group services, and/ or community services. Consideration of co-morbid conditions is includedin the management program and integrated with the medical department as necessary.Condition monitoring and surveillance are ongoing and proactive. Calls are scheduled atperiodic intervals. Detailed questions are asked about the member’s condition and information isgathered about member status, treatment plan adherence, functional status, and quality of life.Ongoing monitoring by the Depression DM nurse ensures timely intervention when a change inrisk status is identified. The frequency of outbound calls to participants by the nurse isdetermined by the member severity of symptoms. This may result in daily contact at timesof high risk or concern as well as consultation with the physician. If referral to an alternate levelof care is necessary, the nurse will work with the physician to coordinate the necessary services.A major component of the Depression Disease Management Program is the empowerment of themember and, if appropriate, the caregiver, through education. A variety of topics are addressedin both initial and reinforcement teaching. Patient education materials are provided to eachmember throughout the program and are used in the teaching process. A thorough education ofthe disease process and recognition of triggers are included in the teaching process. Warningsigns are reviewed each assessment call along with a review of medications and medicationcompliance. Education is aimed to increase member awareness, knowledge, and comfort levelregarding depression. Lifestyle issues are addresses thru education and include the importanceof exercise, physical activity, and nutrition as related to management of depression.A clinical pharmacist will participate in the program by reviewing cases for appropriateness ofmedications. The pharmacist will be a member of the Health Plan Depression Management teamworking with the nurse, physician, and the member to promote the appropriateness of thetreatment plan.A successful Depression DM program is dependent on the coordination of health care services.The role of the physician is vital and this program is intended to compliment the medical care themember is receiving from his/her physician. The goal of the Depression DM program is to fostera collegial relationship between the physician and the DM nurse in order to coordinate thenecessary and appropriate care for the member. Evidence based guidelines are available andrecommended for use by the physician to manage the patient with depression.Section 9 / Page 16

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitAnnual Program EvaluationThe Behavioral Health Unit Utilization Management Program and the Quality ManagementProgram are evaluated on an annual basis. A written summary is prepared from the evaluationprocess that includes utilization and quality management activities during the year,achievement of goals, and revisions for the upcoming year.The Annual Program evaluation is approved by the Executive Management Team (EMT) &Quality Improvement Committee.Access to CareTo comply with NCQA standards, The Health Plan holds to the following standards foraccess to care for Behavioral Health Cases:• Practitioners should provide care within 6 hours in an emergent,non-life threatening situation.• Practitioners should provide care within 48 hours of a request for servicewhen the need is urgent.• Practitioners should provide a follow-up appointment within 7 daysof discharge from an inpatient facility.• Practitioners should provide a routine office visit within 10 days of request.If the practitioner is not available, the member should be made aware of how to access care.This would apply to after hours and weekend coverage as well as other situations.Section 9 / Page 17

PROVIDER PROCEDURAL MANUAL 2014Behavioral Health UnitContinuity & Coordination of CareThe Health Plan Behavioral Health Unit advocates continuity and collaboration of care betweenBehavioral Health and Physical Health practitioners.It is the responsibility of the Behavioral Health practitioner to communicate with the PCP andthe PCP to communicate with the Behavioral Health practitioner.According to Federal and State Law, the following information can be shared, in regard toBehavioral Health information:• Diagnosis• Medications, along with any changes• Labs, if applicable• Treatment PlanThe Health Plan expects that this information be shared, and recognizes the right to keepprogress notes private. The Health Plan also understands that there are special situationswhere information cannot be shared. A Continuity of Care Consultation Sheet is available onthe Health Plan web site for use in facilitiating this communication.Section 9 / Page 18

PROVIDER PROCEDURAL MANUAL 2013Behavioral Health UnitFormsThe following forms are provided to assist practitioners in requesting services for patients andproviding information necessary for coordination, continuity, and continuation of care. For yourconvenience, these forms are also available on the Provider Web Site.The Behavioral Health Treatment Continuation Request Form is also available on the ProviderSecure Site and can be submitted electronically.Section 9 / Page 19

St. Clairsville Office | 52160 National Road East, St. Clairsville, OH 43950-9365 | Local PH: 1.740.695.7896HomeTown Office | 100 Lillian Gish Boulevard, P.O. Box 4816 | Massillon, OH 44648-4816 | Local PH: 1.330.834.2354www.healthplan.orgPlease fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255ADMISSION REVIEW INFORMATIONToday's Date:Patient Name:ID#:Date of Birth:Referring Physician:Admitting Physician:Utilization Review ContactName:Phone Number:Fax:Information submitted by:Date of Review:Facility Name:Admission Date:Type of AdmissionEmergency RoomElective AdmissionTime:Urgent AdmissionTransfer from another UnitOutpatient/OfficeRoom Number:DSM IV Multi-Axial Diagnosis: (Complete all 5 Axis)Axis 1Axis 2Axis 3Axis 4Axis 5Diagnosis Code:Diagnosis Code:Does the patient have a current medical condition linked to the Axis 1 or 2 diagnosis?Please describe below:Describe Axis 3:Please indicate the Severity of Current Psych Social Stressors:GAF Score: Highest Past Year: Current:YesNoNone Mild Moderate Severe

Admission Chief Complaint:Precipitating Factors:Active Psychiatric Symptoms:Risk Level:SIPlan:HIPlan:Pertinent Lab Results:Other Pertinent Diagnostic Results:Mental Status:Current Psychotropic Home Medications:

Current Behavioral Health Services & Providers:ADLs: (ex. ambulation, sleep, appetite)Substance Abuse Issues:Legal Issues:Requested Level of Care:ObservationInpatientDetoxCrisis StabilizationPartial HospitalizationIntensive OutpatientChemical Dependency Intensive OutpatientRehabPrint Form

The Health Plan of the Upper Ohio Valley, Inc.52160 National Road EastSt. Clairsville, OH 43950-9365www.healthplan.orgTelephone: (740) 695-7896Toll Free: (877) 221-9295Fax: (866) 616-6255BHU FAX COVER SHEET -- FOR MEDICAL REVIEW ONLYTODAY’S DATE:TO:PROVIDER’S NAME:YOUR NAME:PHONE NUMBER:COMPANY FAX:PAGES INCLUDING THIS COVER SHEET:PLEASE COMPLETE EACH SECTION TO ENSURE YOUR DOCUMENTWILL BE ROUTED CORRECTLYFOLDER SYSTEM: MEMBER ID#: - (2-digit suffix)DATE OF SERVICE:DOCUMENT TYPE (XX) MEDICAL RECORDSDOCUMENT DESCRIPTION (PLEASE INDICATE ONE OF THE FOLLOWING:)ER TREATMENTOFFICE/CLINICAL NOTESAdmission Clinical InformationDischarge Clinical InformationPROGRESS NOTELAB REPORTSConcurrent Clinical InformationOtherCONFIDENTIALITY NOTETHE INFORMATION CONTAINED IN THIS FACSIMILE MESSAGE IS CONFIDENTIAL INFORMATION INTENDED FOR THE USEROF THE INDIVIDUAL ENTITY NAMED ABOVE. IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT, YOUARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION IS STRICTLY PROHIBITED.BHU Medical Review Fax Cover SheetSection 9 / Page 23

St. Clairsville OfficeBehavioral Health Unit52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgHomeTown OfficeBehavioral Health Unit100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 330.834.2354Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgConcurrent Authorization for ABA/Behavioral ServicesPatient Name: ________________________________________________Member ID#: _______________________________________ Date of Birth: ___________________Provider Name: ________________________________________________________Phone Number: __________________________ NPI#: _________________________Address: ________________________________________________________________________DSM‐IV Multi‐Axis Diagnosis (Complete all 5 axis)Axis I: ________________________________________Axis II: _______________________________________Axis III: _______________________________________Axis IV: Please indicate level of current psychosocial Stressors: __None ___Mild __Moderate __SeverityAxis V: Current ______ Highest Past Year: _____Behaviors and Interventions** Please list the behaviors that were identified for treatment on the Initial authorization form and level ofimprovement made along with any comments (i.e. improvement as evidenced by, tampering of services,expected completion date, etc.). If no improvement was made, please indicate steps being taken to alter theplan.1) _____________________________________________________________________Level of Improvement to Date: __ None __Low __Moderate __MajorComments: ______________________________________________________________________________________________________________2) _____________________________________________________________________Level of Improvement to Date: __ None __Low __Moderate __MajorComments: ______________________________________________________________________________________________________________3) _____________________________________________________________________Level of Improvement to Date: __ None __Low __Moderate __MajorComments: ______________________________________________________________________________________________________________*Supporting chart documentation in the form of (1) grafts of rates of the behavior across baseline andintervention conditions; (2) a list of the current behavioral objectives and an indicator of whether currentbehavioral data shows progress, no progress, or met/achieved in relation to the objectives; (3) a descriptionof any significant events that have served to promote or block success in achieving the objectives and (4) aplan of action for overcoming any barriers to success must be available upon request.

St. Clairsville OfficeBehavioral Health Unit52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgHomeTown OfficeBehavioral Health Unit100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 330.834.2354Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgCurrent Risk of Harm to Self: None Low Moderate HighComments:Current Risk of Harm to Others: None Low Moderate HighComments:If potentially harmful behavior exists, please submit full risk assessment and crisis plan. If assessment andplan were previously submitted, updates should be submitted.Individualized Service Plan* Plan must be child‐centered, strength‐based, family focused, community‐based, multisystem, &culturally‐competent. Parental training must be involved so they can provide additional hours ofintervention.Goal 1) _____________________________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Goal 2) _____________________________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Goal 3) _____________________________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________

St. Clairsville Office | 52160 National Road East, St. Clairsville, OH 43950-9365 | Local PH: 1.740.695.7896HomeTown Office | 100 Lillian Gish Boulevard, P.O. Box 4816 | Massillon, OH 44648-4816 | Local PH: 1.330.834.2354www.healthplan.orgPlease fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255Today's Date:CONCURRENT OR DISCHARGE REVIEW INFORMATIONPatient Name:ID#:Date of Birth:Referring Physician:Admitting Physician:Utilization Review ContactName:Phone Number:Fax:Information submitted by:Date of Review:Facility Name:Admission Date:Room Number:DSM IV Multi-Axial Diagnosis: (if changed from last review)Axis 1Axis 2Axis 3Axis 4Axis 5Diagnosis Code:Diagnosis Code:Does the patient have a current medical condition linked to the Axis 1 or 2 diagnosis?Please describe below:Describe Axis 3:Please indicate the Severity of Current Psych Social Stressors:GAF Score: Highest Past Year: Current:YesNoNone Mild Moderate SevereChanges in Medication:

Current Treatment/Services:Risk Level:SI Plan:HI Plan:Mental Status:Symptoms/Behaviors:Adherence to Program:Anticipated Discharge Date:if applicableFollow-Up Appointment(s) Scheduled:Discharge AddressDischarge PhoneDischarge Goals:Barriers to Discharge:Other Information:Print Form

St. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896www.healthplan.orgMassillon Office100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 1.330.834.2354www.healthplan.orgContinuity of Care Consultation SheetThis form is provided to facilitate communication between behavioral health and primary carephysicians to enhance continuity and coordination of care.Please complete the information below and forward to the appropriate practitioner.MEMBER INFORMATION:Member Name:Member I.D. #:BEHAVIORAL HEALTH:Provider Name:Provider ID/NPI:Provider Phone Number:Date of Birth:PRIMARY CARE PROVIDER:Provider Name:Provider ID/NPI:Provider Phone Number:TREATMENT UPDATES:Date/Reason for Behavioral Health visit: (check one)Initial Evaluation Continuation of Treatment Re-evaluation Crisis TestingDate/Reason for PCP visit:Diagnosis:CURRENT MEDICATION LIST: (Please include long-term and newly prescribed medications)RECOMMENDATIONS FOR CONTINUED TREATMENT REGIMEN:Please feel free to contact the office with any questions and/or concerns. Do not forget to download and sign theAuthorization to Disclose Health Information to PCP Form form our website. Thank you.Name of Person Completing Form:Provider Name:Date:Print Form

St. Clairsville Office | 52160 National Road East, St. Clairsville, OH 43950-9365 | Local PH: 1.740.695.7896HomeTown Office | 100 Lillian Gish Boulevard, P.O. Box 4816 | Massillon, OH 44648-4816 | Local PH: 1.330.834.2354www.healthplan.orgPlease fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255CRISIS ENCOUNTERS REPORT FORMCall Date:Provider Name and Address:Member Name:Member I.D. #:Caller Name:Contact Phone #:Crisis Date:Crisis Time:Description and Outcome of Event:Recorder Name:Follow-Up Notes:Date:Print Form

St. Clairsville OfficeBehavioral Health Unit52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgHomeTown OfficeBehavioral Health Unit100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 330.834.2354Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgInitial Authorization for ABA/Behavioral ServicesPatient Name: _________________________________________________________________________Member ID#: ________________________________________ Date of Birth: _____________________Provider Name: ________________________________________________________________________Phone Number: ______________________________________ NPI #: ____________________________Address: _____________________________________________________________________________DSM‐IV Multi‐Axis Diagnosis (Complete all 5 axis)Axis I: _________________________________________________________Axis II: _________________________________________________________Axis III: ________________________________________________________Axis IV: Please indicate level of current psychosocial Stressors: __None ___Mild __Moderate __SeverityAxis V: Current ______ Highest Past Year: _____*All evidence‐based screening and scaling results used in determining the diagnosis must be submittedwith this request form.Behaviors and InterventionsDate Functional Behavioral Assessment was completed: ___________________________Is there a specific behavior that has been targeted for intervention: __No __YesIf yes, please briefly describe each behavior and its impact on functioning.1)_____________________________________________________________________2)_____________________________________________________________________3)_____________________________________________________________________Individualized Service Plan* Plan must be child‐centered, strength‐based, family focused, community‐based, multisystem, &culturally‐competent. Parental training must be involved so they can provide additional hours ofintervention.Goal 1) _____________________________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________

St. Clairsville OfficeBehavioral Health Unit52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgHomeTown OfficeBehavioral Health Unit100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 330.834.2354Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgGoal 2) _____________________________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Goal 3) _____________________________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Objective: _______________________________________________________________As evidenced by:_______________________________________________________Risk Assessment*:Past Attempts to Harm Self or Others: None Self OthersComments: _____________________________________________________________________Current Risk of Harm to Self: None Low Moderate HighComments: _____________________________________________________________________Current Risk of Harm to Others: None Low Moderate HighComments: _____________________________________________________________________Functional Impairment (only indicate the impairments that are present)Social Interaction* If potentially harmful behaviors exist, please submit full risk assessment and crisis plan.Targeted Interventions aimed at specific behaviorsIntervention 1: a.) description of intervention: ______________________________________________b.) risk analysis: __________________________________________________________c.) possible impact on human rights: _________________________________________Intervention 2: a.) description of intervention: ______________________________________________b.) risk analysis: __________________________________________________________c.) possible impact on human rights: _________________________________________

St. Clairsville OfficeBehavioral Health Unit52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgHomeTown OfficeBehavioral Health Unit100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 330.834.2354Patient After Hours: 1.877.221.9295BHU FAX: 1.740.699.6255Toll Free FAX: 1.866.616.6255www.healthplan.orgIntervention 3: a.) description of intervention: ______________________________________________b.) risk analysis: __________________________________________________________c.) possible impact on human rights: _________________________________________Intervention 4: a.) description of intervention: ______________________________________________b.) risk analysis: __________________________________________________________c.) possible impact on human rights: _________________________________________Additional Interventions:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

St. Clairsville Office52160 National Road EastSt. Clairsville, OH 43950-9365Local PH: 1.740.695.7896www.healthplan.orgHomeTown Office100 Lillian Gish BoulevardP.O. Box 4816Massillon, OH 44648-4816Local PH: 1.330.834.2354www.healthplan.orgPlease fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255Psychological Testing Preauthorization REQUEST FORM*Behavioral Health Unit* All Sections must be completed for timely Preauthorization consideration.Today's Date: Member I.D. #:Member Name:Date of Birth:Referring Provider:Address:Phone Number:Testing Provider:Address:Phone Number:Has a diagnostic interview been conducted by the requesting practitioner?Date of InterviewYesNoWere rating scales and/or inventories completed?If so, please list:YesNoDSM IV DiagnosisCODE1)DESCRIPTION2)3)4)What is the question to be answered by testing that cannot be determined by diagnosticinterview, review of client's history?

INFORMATION CONTINUED for Member:What are the CURRENT symptoms the client is exhibiting?How will the results of the testing affect the treatment plan?What treatment(s) has/have already been rendered to the client?REQUESTED TESTING:TEST NAME/CPT CODE1)TEST TYPE2)3)4)Are there any factors that could affect the outcome of the test (i.e. substance abuse, illiterate)?Provider SignatureRequest Date

St. Clairsville Office | 52160 National Road East, St. Clairsville, OH 43950-9365 | Local PH: 1.740.695.7896HomeTown Office | 100 Lillian Gish Boulevard, P.O. Box 4816 | Massillon, OH 44648-4816 | Local PH: 1.330.834.2354www.healthplan.orgPlease fax to: Behavioral Health Unit: 740.699.6255 • Toll Free: 1.866.616.6255TREATMENT CONTINUATION REQUEST FORMBehavioral Health Unit* All Sections must be completed for timely approvalPatient Name:Member I.D. #:Date of Birth:Provider Name:Phone Number: NPI #:Address:Date of Evaluation Visit for current Episode of Care:DSM IV Multi-Axial Diagnosis (Complete all 5 Axis)Axis 1Axis 2Axis 3Axis 4Axis 5Diagnosis Code:Diagnosis Code:Does the patient have a current medical condition linked to the Axis 1 or 2 diagnosis?Please describe below:Describe Axis 3:Please indicate the Severity of Current Psych Social Stressors:GAF Score: Highest Past Year: Current:YesNoNone Mild Moderate SevereCurrent Medications:Anti-PyschoticHypnoticPsycho-StimulantAnti-AnxietyMood StabilizerOther/Commets:Anti-DepressantMedicalNoneRisk Assessment: Ideation Plan IntentSuicidal IdeationHomicidal IdeationNoneSymptoms: (if present, check degree)Mild Moderate Severe Mild Moderate SevereDepressed MoodAnhedoniaLow EnergyAnxietyPanic AttacksInattentionHopelessnessImpulsiveSomatoform/Bingeing/PurgingFictitious ProblemsRestricting Food IntakeSocial IsolationSelf MutilationSleep DisturbanceMood SwingsHyperactiveHallucinationDelusionsOther Psychotic SymptomsObsessions/CompulsionsNo Symptoms

Substance Abuse/Addictions:Active Drug UseCravingsDrug Seeking BehaviorGuilt/Remorse/ShamePreoccupation with getting highPreoccupation with GamblingAbuse in RemissionNoneIs this patient on mental health or chemical dependency disability?Have you contacted the patient's PCP?Have you contacted any other health care provider? If yes, list who.Other Provider:YesYesYesNoNoNoGoals expected:1.2.3.Time Frame to Complete:1 month 3 month 6 month Other1 month 3 month 6 month Other1 month 3 month 6 month OtherSpecific Services Requestedand Number of Services Requested:CODE Number of Services (1-12)90804908059080690807908479085390862Other Code:Number of Services:Frequency of Appointments Schedule:Weekly2 x a monthMonthlyOther:Level of Improvement to Date:None Minor Moderate MajorAdditional Symptoms, Functioning Level and Comments:Provider SignatureDate** Please Note **Only evaluation sessions and crisis encounters will be reimbursed prior to authorization requests.

PROVIDER PROCEDURAL MANUAL 2014Please click on the following link to access important pharmacy benefit information.www.healthplan.org/Content.aspx/provider-pharmacy-informationThe Health Plan Pharmacy Services Department wants to help you support your patients and customers. On our siteyou will find information on our Drug Formularies, Prior Authorization Forms, Specialty Drug List, MedicarePart D Billing and more. You can also directly access Epocrates and Express Scripts .If you have questions or concerns, you can call 1.800.624.6961, ext. 7914 or email us at pharmacy@healthplan.org.Beginning April 1, 2013, The Health Plan will begin administering Medicaid's Pharmacy Benefit. If you are lookingfor assistance or have any questions about the Medicaid Pharmacy Benefits, please call 1.888.571.8182, option 4.If you need pharmacy assistance with processing claims, please call 1.800.922.1557.Section 10 / Page 1


PROVIDER PROCEDURAL MANUAL 2014BILLING PROCEDURES1. All claims should be submitted to:The Health Plan52160 National Road EastSt. Clairsville, Ohio 43950The Health Plan – Hometown Office100 Lillian Gish BlvdPO Box 4816Massillon, Ohio 446482. Claim forms must be completed in their entirety. The efficiency with which the claim formis completed directly affects the efficiency with which the claim is processed for payment.3. The Health Plan requires that all claims are submitted with accurate and current CPT-4,HCPC's, as well as, ICD-9 codes. For each procedure that is listed on the claim adiagnosis Code (ICD-9) must support the Services (listed in block 24D on the CMS 1500form) to ensure expeditious and accurate processing of the claim. You must relate thediagnosis listed in block 21 to the individual service lines. You need ONLY to relatediagnosis 1, 2, 3, or 4 NOT the ICD-9 code in block 24E.4. The Health Plan accepts the standard CMS 1500 (08-05) forms and the UB-04 hospitalbilling forms.5. When indicating the member ID number on the billing form, the entire number, includingthe nine digit Health Plan ID number and two digit suffixes should be indicated as shownon The Health Plan ID card.Patient ID number starts with a letter H, the remaining (8) digits are numeric. The suffixidentifies the family member.Example: John Doe H01234567-01 SubscriberJane Doe H01234567-02 SpouseMary Doe H01234567-03 Child (eldest)6. The Health Plan Provider Website offers a link to the National NPI Registry for referringproviders and facilities:https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do7. All services must be billed within 180 days from the date of service except in the case of aCoordination of Benefits claim.Section 11 / Page 2

PROVIDER PROCEDURAL MANUAL 2014BILLING PROCEDURES8. Coordination of Benefits (C.O.B.) claims (where another carrier has primary responsibilityfor making payment), must be submitted within twelve (12) months from the date ofservice or three (3) months from the date of the primary carrier’s EOB. If you do notreceive payment or rejection from the primary carrier and the twelve (12) month time limitis approaching, you must bill The Health Plan before the twelve-month deadline, whetheror not you have received the Explanation of Benefits from the primary carrier.(Refer to Section 11 of this manual for additional C.O.B. information).9. All claims are paid (30) days from the date of receipt by The Health Plan.10. Payment and payment vouchers are mailed weekly or bi-monthly, depending on the line ofbusiness. Please refer to Section 10 for information regarding electronic remittances.11. Questions concerning payment or denial must be submitted to The Health plan within onehundred eighty (180) days from the date of the payment voucher. Please refer to Section 14of this manual for additional information on claims resubmission procedures.12. When submitting a refund check to The Health Plan for overpayment (e.g., Coordination ofBenefits, Workers' Compensation, Subrogation, etc.), include a copy of the paymentvoucher underlining or circling the claim, and document the reason for the refund.If unsure of the voucher date for the paid claim, you may contact the C.O.B./FundsRecovery Representative. It is best to include detailed information such as patient name,ID number, date of service, and the reason for the refund.13. Required and applicable co-pays from members are due at the time of service.Co-payments may not be waived (with the exception of C.O.B.) as this is in direct violationof the physician contract with The Health Plan.14. Health Plan members are NOT to be billed directly or balance billed for covered services.15. Procedural Manuals will be supplied by The Health Plan to all participating providers,and upon request, to assist with The Health Plan Guidelines and Procedures.The Procedural Manual can be found on the Health Plan Provider Secured Website thatcan be accessed on the main website (www.healthplan.org). Procedural Manuals arealso available on CD.Section 11 / Page 3

PROVIDER PROCEDURAL MANUAL 2014BILLING PROCEDURES16. The Health Plan will NOT reimburse physicians, nor can the member be billed, for thefollowing services:Services not renderedPhone calls (including phone consults)Canceled/missed appointmentsMaking referralsNormal postoperative careCompletion of paperworkUnnecessary services not indicated by diagnosisMileageStat chargesEducational servicesPrescriptionsFalse information/fraudulent billing17. Changes in reimbursement/fee schedules issued by Federal and/or State entities willbecome effective by The Health Plan on the date of notification.18. The Health Plan will comply with Ohio, West Virginia, and Medicare prompt pay requirements.19. Self-Funded employers require submission of claims and formal appeals within 365 days(1) year in order to be honored.ELECTRONIC BILLING – DOCUMENTATION SUBMISSIONTo assist with the submission of required documentation for claims adjudication, The HealthPlan has a dedicated fax line to submit your documentation. The fax number is 1-740-695-7882.In order to assure the required documentation is routed correctly, you must accurately completethe “Health Plan Fax Cover Sheet” in its entirety. Failure to complete the fax cover sheet mayresult in claim denials. A separate fax cover sheet is required for each document faxed.Your electronic claim should be marked in the Claim Note or Claim Line area with notificationstating additional documentation has been faxed. Placing the work FAX in the Claim Note areawill alert our Claim Reviewers.You must fax all required documentation within 24 hours of your electronic claims transmission.Section 11 / Page 4

The Health Plan of the Upper Ohio Valley, Inc.52160 National Road EastSt. Clairsville, OH 43950-9365Telephone: (740) 695-3585 or Toll Free: 1-800-624-6961www.healthplan.org Fax: 1-740-695-7882FAX COVER SHEET (FOR MEDICAL REVIEW ONLY)TODAY’S DATE:TO:PROVIDER’S NAME:YOUR NAME:PHONE NUMBER:COMPANY FAX:PAGES INCLUDING THIS COVER SHEET:PLEASE COMPLETE EACH SECTION TO ENSURE YOURDOCUMENT WILL BE ROUTED CORRECTLYFOLDER SYSTEM: MEMBER ID# -(MUST INCLUDE MEMBER SUFFIX)DATE OF SERVICE:DOCUMENT TYPE (XX) MEDICAL RECORDSDOCUMENT DESCRIPTION (PLEASE INDICATE ONE OF THE FOLLOWING…)ER TREATMENTOFFICE/CLINCAL NOTESOPERATIVE REPORTPHYSICIAN ORDERSMANUFACTURES INVOICEHEARING AID DOCUMENTATIONIV HOME INFUSIONTHERAPY NOTES (PT, OT, ST)X-RAY INTERPRETATION REPORTLAB REPORTCONFIDENTIALITY NOTETHE INFORMATION CONTAINED IN THIS FACSIMILE MESSAGE IS CONFIDENTIAL INFORMATION INTENDED FORTHE USER OF THR INDIVIDUAL ENTITY NAMED ABOVE. IF THE READER OF THIS MESSAGE IS NOT THE INTENDEDRECIPIENT, YOU ARE HEARBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION IS STRICTLY PROHIBITED.Section 11 / Page 5

PROVIDER PROCEDURAL MANUAL 2014Electronic Data InterchangePlease click on the following link to access important electronic communication information.www.healthplan.org/Content.aspx/electronic-communicationsThe Health Plan makes available to their providers various methods of electronic communications.Public Website - The Health PlanProvider Secure WebsiteRequires User ID and password for participating healthcare providersElectronic Claims SubmissionsElectronic Payment Vouchers/835/ERADirect DepositEligibility HIPAA 270/271 FilingIf you cannot find what you are looking for on our website, please contact ourEDI Support CenterThe Health Plan52160 National Road ESt.Clairsville, OH 43950TF: 1.800.624.6961 or 740.695.7649Email: hpecs@healthplan.orgSection 12 / Page 1

PROVIDER PROCEDURAL MANUAL 2014COORDINATION OF BENEFITS COBSection 13 / Page 1

PROVIDER PROCEDURAL MANUAL 2014COORDINATION OF BENEFITS (COB)Coordination of Benefits (C.O.B.) is intended to avoid claims payment delays and duplication ofbenefits when a person is covered by two or more Plans providing benefits or services formedical treatment. Coordination of Benefits is designed to eliminate the opportunity for aperson to profit from an illness as a result of duplicate group health care coverage. By allowingtwo or more insurance carriers to work together, the insurance companies can ensure that claimsare divided fairly and can avoid paying the same medical bills twice.Each employer group contracting with The Health Plan has a Coordination of Benefits provisionin their contract. In accordance with your provider contract, claims for members with anotherinsurance should be submitted to the Primary Carrier first for payment. The Primary Plan(Plan that pays benefits first) always pays the same benefits it would pay in the absence of anyduplicate coverage. The Secondary Plan (Plan that pays benefits second) pays the difference oftheir allowable amount and whatever the Primary Plan paid. In accordance with your contract,when The Health Plan is the secondary payor, Health Plan will consider the balance of coveredservices not paid by the Primary Plan, so long as the total payment does not exceed 100% of therates agreed to in your contract. This may mean in some cases if the primary payment isgreater than the Health Plan’s allowable amount, you will receive no additional paymentfrom The Health Plan. Please remember: that the patient may not be billed for this balance.ORDER OF BENEFIT DETERMINATION RULESEmployee:Spouse:The Plan covering the person as an employee pays benefits first. (If the patient isour subscriber The Health Plan is primary).The Plan covering that person as a dependent pays benefits second. (If the patientis the spouse of our subscriber, The Health Plan is secondary to the spouse’sinsurance).Dependent Children: The Plan covering the parent whose birthday falls earlier in the year isdetermined before those of the Plan of the parent whose birthday falls later in that year. Theterm “birthday” refers only to the month and day of birth during the calendar year. (If bothparents have the same birthday, the benefits of the Plan that covered the parent the longest is thePrimary Plan).However, situations may occur when one Plan uses the gender rule and the other Plan coveringdependent children uses the birthday rule. When this occurs, the birthday rule overrides thegender rule and will determine which parent’s insurance is primary.Section 13 / Page 2

PROVIDER PROCEDURAL MANUAL 2014ORDER OF BENEFIT DETERMINATION RULESDependent children of separated or divorced parents. When parents are separated or divorced,neither the gender rule nor the birthday rule applies.Instead:a. The Plan of the parent (with custody) who is the residential parent and legalcustodian of the child pays first.b. The Plan of the spouse of the parent (with custody) who is the residentialparent and legal custodian of the child pays next.c. The Plan of the parent (without custody) who is not the residential parent andlegal custodian of the child pays next.d. The Plan of the spouse of the parent (without custody) who is not theresidential parent and legal custodian of the child pays last.However, if specific terms of a court decree state that one parent is responsible for thehealth care expenses of the child, the Plan of that parent is the Primary Plan.Active/Inactive Employee: The Primary Plan is the Plan that covers a person as an employeewho is neither laid off nor retired, or that employee’s dependent. The Secondary Plan is the Planthat covers that person as a laid-off or retired employee, or the employee’s dependent.Longer/Shorter Length of Coverage: If none of the above rules determines the order ofbenefits, the Plan covering a person longer pays first. The Plan covering that person for theshorter time pays second.HEALTH PLAN PROCEDURES REGARDING C.O.B.All C.O.B. claims must be billed within one year of the date of service.When a member has another insurance as their primary, please bill that insurance first even ifthere is a deductible to be met so that the service can be applied to the deductible.Billing the primary insurance first and attaching the Explanation Of Benefits (E.O.B.) willexpedite payment from The Health Plan. All payments indicated on claim must be supportedby an E.O.B. or claim will be denied. If billing electronically, COB information must beincluded in the electronic submission.Each C.O.B. claim is reviewed to determine whether The Health Plan is primary. In cases wherewe are incorrectly billed as the primary payor, the claim will be denied “C”, indicating otherinsurance primary. The claim will show on your voucher as denied “C” – OTHERINSURANCE PRIMARY. Please bill the primary insurance carrier, then resubmit C.O.B. bysending a new claim with the E.O.B. attached to The Health Plan for processing.Section 13 / Page 3

PROVIDER PROCEDURAL MANUAL 2014Please remember, claims must be submitted to The Health Plan with E.O.B. within one yearfrom the date of service or 3 months from the date of the primary carrier’s E.O.B. Any claimsbilled to The Health Plan after this time frame will be denied “F” – “TIMELY FILING” and theamount you have billed to The Health Plan must be written off. The member cannot be billedfor the balance due. Claims that are submitted after the timely filing limit must have systemdocumentation explaining the reason for delay in submission. This will be reviewed.Co-payments are not to be taken if the primary insurance pays more than The Health Planco-pay. The collection of the co-pay is the responsibility of the individual office. If The HealthPlan is primary, the co-pay may be billed to the member’s secondary coverage if applicable.If co-pay is collected at the time of the visit, the provider’s office should refund the co-pay to themember if the payment voucher shows no co-pay is due.If there are two Health Plan coverage’s for a member, the co-pay, deductible, and/or coinsuranceshown on the payment voucher for the primary ID# should be billed to The HealthPlan using the secondary ID#. To submit this charge, a HCFA 1500 must be submitted showingthe Secondary ID#, and indicating clearly “Billing for Co-Payment.” Also, attach a copy of yourvoucher showing our payment under the Primary Health Plan ID number. This amount will beentered on your claim, by The Health Plan’s COB department, in the COB amount field, and wewill process your claim for the co-pay, coinsurance or deductible due.There is often confusion concerning billing procedures for HMO members on Medicare.Therefore, in order to clarify billing procedures for Part B charges for the three types of HMOMedicare Members, the billing process to follow when Medicare Members present their HealthPlan I.D. cards listed below.1. REGULAR MEDICARE (Red, Blue or Purple Card)The Health Plan evaluates Primary and Secondary coverage with Medicare inaccordance with the Tax Equity and Fiscal Responsibility Act of1982, (TEFRA).Please call the C.O.B./Funds Recovery Department at The Health Plan forclarification of primary responsibility for Medicare members with thisI.D. card.2. SECURECARE /SECURECHOICE / SECUREFREEDOM (Green Card)Bill The Health Plan directly for all charges. We are the Medicare carrier forPart A and Part B services.3. MEDICARE SELECT (Yellow Card)Bill Medicare first and then bill The Health Plan for any coinsuranceor deductibles.Section 13 / Page 4

PROVIDER PROCEDURAL MANUAL 2014MEDICARE PRIMARYAny physician who has submitted an assigned claim to Medicare has agreed to acceptMedicare’s reasonable charge as payment in full for his services. Per Medicare Carriers Manual,Section 3045.1, the physician is in violation of his signed agreement if he bills or collects fromthe enrollee and/or the private insurer an amount which, when added to the Medicare benefitreceived, exceeds the reasonable charge. The Health Plan, as a supplemental insurer, isfunctioning as a private insurer. Therefore, we will be reimbursing the physician the coinsurancedue on any Health Plan covered service, provided such coinsurance amount does not exceedThe Health Plan’s normal fee.The Health Plan will pay Deductibles, Co-payments, Coinsurances, and other MemberResponsibility amounts not paid by the Primary Carrier so long as the total payment does notexceed the amount The Health Plan would pay as the Primary Carrier. This process is applied toeach individual service.Section 13 / Page 5

CPT BILLED ALLOWED DISALLOWED COPAY CO-INSPROVIDER PROCEDURAL MANUAL 2014CommercialCredit Adjustment – ExampleOriginal Claim Paid As PrimaryDEDUCTIBLEMEMB RESP COB PAID99244 225.00 133.67 91.33 15.00 .00 .00 .00 112.74 5.93 .00 .00 .00 LREFW/HNONREFW/HADMINFEEDSCNTTOTAL 225.00 133.67 91.33 15.00 .00 .00 .00 112.74 5.93 .00 .00 .00ADJCDCredit Adjustment99244 225.00- 133.67- 91.33- 15.00- .00 .00 .00 112.74- 5.93- .00 .00 .00TOTAL 225.00- 133.67- 91.33- 15.00- .00 .00 .00 112.74- 5.93- .00 .00 .00 12Claim Paid With COB Amount Applied99244 225.00 133.67 91.33 15.00 .00 .00 62.62 112.74 5.93 .00 .00 .00 LCOB 62.62- .00 62.62- 15.00- .00 .00 .00 41.69- 5.93- .00 .00 .00TOTAL 225.00 133.67 91.33 .00 .00 .00 62.62 71.05 .00 .00 .00 .00Section 13 / Page 6

PROVIDER PROCEDURAL MANUAL 2014MEDICARE PRIMARY PAYMENT – EXAMPLE(HEALTH PLAN EMPLOYER GROUP COVERAGE SECONDARY)1. BILLED AMOUNT $140.00MEDICARE ALLOWABLE 81.90MEDICARE PAYMENT 65.52MEDICARE CO-INSURANCE 16.38HEALTH PLAN PAYMENT 16.38THE ABOVE EXAMPLES AS THEY WILL APPEAR ON YOUR PAYMENT VOUCHER.MEDICARE PRIMARY PAYMENT AS DISPLAYED ON VOUCHERCPT BILLED ALLOWED DISALLOWED COPAYCO-INSCOBAMTPAIDREFW/HNONREFW/H99205 81.90 81.90 .00 .00 .00 65.52 16.38 .00 .00 .00(ReducedTo Medicare’sAllowable)ADJCDSection 13 / Page 7

PROVIDER PROCEDURAL MANUAL 2014HELPFUL HINTSWe have listed a few helpful hints that will not only help us better serve you, but will assist inpromoting faster response and payments.1. If billing on paper, please send a separate Explanation of Benefits (E.O.B.) for “EACH”claim submitted to The Health Plan. (Do not attach several claims to one E.O.B.).2. When your claim has been denied “C” OTHER INSURANCE PRIMARY, bill the primarypayor for payment/denial. After you have received a response from the primary payor, senda “NEW CLAIM” to The Health Plan with E.O.B. attached for processing. Following thisstep will expedite your payment.3. Refer to your voucher for claim status prior to calling The Health Plan. If you still havequestions, please have the member’s identification number and date-of-service ready.4. When sending a refund to The Health Plan, include the member’s name, identificationnumber, date-of-service, claim number, and reason for refund, with documentation in theform of another carrier E.O.B. or voucher. This should be sent to the attention of “FundsRecovery”.5. C.O.B. filing limitations are calculated from the actual date-of-service, not from the date aclaim is received by The Health Plan or from the primary carrier’s E.O.B. date.6. When a provider receives their payment voucher, direct only those calls that pertain toclaims denied for C.O.B. reasons to The Health Plan C.O.B. Department. All other callsregarding your voucher are to be directed to the “Customer Service Department”.7. When sending documentation to the attention of the C.O.B. Department, pleaseindicate what you are questioning – even if you previously spoke to us about this situationover the phone.8. When The Health Plan is the secondary payor, all Health Plan guidelines for referrals andpre-authorizations apply.9. REMINDER: Health Plan and other health insurance carriers are always primary overMedicaid (Welfare) / Mountain Health Trust.10. When sending any claim or inquiry to The Health Plan, do not HIGHLIGHT. Circle, star,or bracket any information you want us to review.Section 13 / Page 8

PROVIDER PROCEDURAL MANUAL 2014COB DENIAL CODESTypeCCBCDCJCFCGUUCIOther insurance primary.DescriptionExplanation of benefits required for paid amount shown.Improper primary carrier denial code – primary carrier requesting additional informationfrom Provider.This code / change did not appear on EOB. Resubmit with EOB that corresponds.Incorrect EOB attached (e.g., pt name does not appear on EOB or DOS / Charges on EOBdisagree with claim).Require explanation / definition of primary carrier’s denial remarks / reason code.Worker’s Compensation Primary.FOR MOUNTAIN HEALTH TRUST MEMBERS ONLYMember did not follow primary carrier guidelines; therefore, service non -covered byMountain Health Trust.Section 13 / Page 9

PROVIDER PROCEDURAL MANUAL 2014The following is an example of the payment voucher used by The Health Plan when remitting toPhysician and Ancillary Providers. These payment vouchers are mailed weekly.IN ACCORDANCE WITH THE HEALTH PLAN RESUBMISSIONPOLICY, A COPY OF THE PAYMENT VOUCHER MUSTACCOMPANY ALL RESUBMITTED CLAIMS.Section 14 / Page 1

PROVIDER PROCEDURAL MANUAL 2014PAGE: 1 Health Plan Upper Ohio Valley11/19/2008PROVIDER REIMBURSEMENT VOUCHER1. Payment date of voucher. This is considered the paid/denied date. Any claims denied on the“11/19/2008” voucher must be resubmitted by “5/8//09” to avoid timely resubmission denials.PROVIDER NAME PROVIDER NO: 12345C TAX ID: 0000000002. Provider Number. An internal Provider Numberis assigned to all Providers and is used to3. Tax I.D.CLAIMS PAID *** COMMERCIAL *** identify and maintain Provider Information. CHECK NUMBER: 1000015. Disallowed Amount. 6. Actual Amount paid to Provider.4. Adjustment Code.CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJDATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT PRECERT COB PAID W/H FEE DSCNT CD200829621234 ABCD119 H12345678 02 LASTNAME, BETTY L 75326 1184674814 EXTENDER NAME10/20/2008 99213 1 80.00 79.38 .62 10.00 .00 .00 .00 .00 56.13 .00 1.35 11.90 L7. CPT Code. ___________________________________________________________________________________________________________________________________________TOTAL 1 80.00 79.38 .62 10.00 .00 .00 .00 .00 56.13 .00 1.35 11.908. Billed Amount as appears on claim. 10. Allowed Amount. This is the actual allowed amount per Provider Contract.9. Discounted payment applies toCLAIMS DENIED *** COMMERCIAL ***extenders (NP /PA/CNM).11. Claim Number. This is the 12-digit number, which contains a Julian Date. This number identifies the date and year for which the claim was received.CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJDATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT PRECERT COB PAID W/H FEE DSCNT CD200831721235 ABCD125 H23456789 01 LASTNAME, JOHN J 12345C 1376537191 PROVIDER NAME10/30/2008 99396 1 141.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 T**LINE DENIAL** SERVICE AFTER TERMINATION10/30/2008 81000 1 10.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 T**LINE DENIAL** SERVICE AFTER TERMINATION10/30/2008 82270 1 10.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 T**LINE DENIAL** SERVICE AFTER TERMINATION10/30/2008 90658 1 20.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 T**LINE DENIAL** SERVICE AFTER TERMINATION10/30/2008 G0008 1 30.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 T**LINE DENIAL** SERVICE AFTER TERMINATION___________________________________________________________________________________________________________________________________________TOTAL 1 211.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 T12. Account Number. Patient identifier with practice, if applies.200829721236 ABCD121 H34567890 01 LASTNAME, WILLIAM L 12663C 1376537191 PROVIDER NAME03/31/2008 99214 1 125.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00___________________________________________________________________________________________________________________________________________TOTAL 1 125.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 FCLAIMS IN PROCESS *** COMMERCIAL ***CLAIM NO DATE PATIENT ACCOUNT HID NO MEMBER NAME BILLED PROVIDER NPI NO PROVIDER NAME200831009999 09/22/2008 ABCD123 H45678901 02 LASTNAME, PATTY E 91.33 12345C 1234537890 PROVIDER NAME200832225555 10/30/2008 ABCD125 H23456789 01 LASTNAME, JOHN J 211.00 12345C 1357913579 PROVIDER NAME200832227777 11/12/2008 ABCD127 H67890123 01 LASTNAME, RICHARD A 38.00 12345C 1357913579 PROVIDER NAME200830323333 10/27/2008 ABCD129 H78901234 01 LASTNAME, SHERYL A 50.00 12345C 1357913579 PROVIDER NAMEADJUSTMENT CODE DESCRIPTION13 = SECOND REVIEW/SUPPORTING DOCUMENTATION4 = CLAIM PAID TWICEF = SERVICES DENIED, NOT SUBMITTED TO PLAN WITH IN ESTABLISHED TIME FRAME (TIMELY FILING)L = BILLED AMOUNT EXCEEDS THE MAXIMUM ALLOWABLERN = THIS ITEM OR SERVICE CANNOT BE PAID AS BILLEDRZ = THE PAYMENT OF THIS SERVICE IS INCLUDED IN ANOTHER SERVICE RECEIVED - MEMBER NOT RESPONSIBLET = SERVICE AFTER TERMINATION PATIENT RESPONSIBLESection 14 / Page 2(111111)

PROVIDER PROCEDURAL MANUAL 2014CLAIM NUMBERS2010 296 212341. The first four (4) digits represent the year: 20102. The fifth, sixth, and seventh digits represent the Julian Date or the Numeric Day of theYear. In the example above, Julian Day 296 = October 22, 2010.3. The last five digits are for Health Plan’s In-House record keeping, please disregardthese numbers.AGE OF CLAIMBy reviewing the “Claims In Process” section of your payment voucher, you can determine theage of your claims.Because all claims submitted to and received by Health Plan are paid within 30 days, you can alsodetermine the approximate date your claims will pay or deny.EXAMPLE #1: ESTABLISHING YOUR PAYMENT/DENIAL DATECLAIM DATE: 2010010 (JANUARY 10, 2010)ADD “30” TO THE CLAIM DATE = 10 + 30 = 40PAYMENT/DENIAL DATE = 40 TH DAY OF THE YEAR OR FEBRUARY 9, 2010EXAMPLE #2: ESTABLISHING THE AGE OF YOUR CLAIMTODAY’S DATE: AUGUST 26, 2010 OR JULIAN DATE 2010238DATE OF YOUR CLAIM: JUNE 9, 2010, OR JULIAN DATE 2010160SUBTRACT 2010160 FROM 2010238 = 78YOUR CLAIM IS 78 DAYS OLDBy following the examples above, you are able to track your claims from the time they enterHealth Plan’s System to the time you receive your payment or denial.Section 14 / Page 3

PROVIDER PROCEDURAL MANUAL 2014DENIALSAs shown on the “payment voucher” example, claim denials are listed separately on the voucherunder the “CLAIMS DENIED” heading. The adjustment codes for each denied claim willcorrespond with the “reason code” listed on the last page of the voucher.Members listed as “INVALID SUBSCRIBER” are members we cannot identify by the memberidentification number provided on the claim form. All invalid subscriber denials will be deniedwith the adjustment code “I”. The account number you assign to the member will appear belowthe claim number on the payment voucher to help you identify the member.CLAIMS IN PROCESSClaims that have been received by The Health Plan, but have not been adjudicated, will be listedunder the “CLAIMS IN PROCESS” heading of your payment voucher. The Health Planrecommends Providers check their aging reports at 45 days against the most recent “claims inprocess” report. This will enable you to track all claims submitted to The Health Plan. If youhave an outstanding claim on your aging report that does not appear on your most recent “claimsin process”, you should contact The Health Plan’s Customer Service Department to verify thestatus of the claim.IT IS THE RESPONSIBILITY OF THE INDIVIDUAL PROVIDERS TO REVIEWTHE VOUCHERS TO ASSURE ALL CLAIMS ARE RECEIVED.Section 14 / Page 4

8/4/2008Provider Name123 Wellness LaneSt. Clairsville, OH 43950Example of a Voucher CreditPROVIDER PROCEDURAL MANUAL 2014*** EXAMPLE FORM ***The Health PlanProvider Reimbursement VoucherProv. Num: 0000Page 52Tax ID: 00-000000Check Number 55555The voucher example below shows how a credit will appear on your payment voucher. If a claim is paid incorrectly, it can be corrected by creditingand then repaying the claim. If a claim is paid in error to an incorrect Provider, then only the credit will appear on the voucher. The Health Plandoes not do partial adjustments. The entire claim will be credited and resubmitted.CLAIMS PAID *** COMMERCIAL *** CHECK NUMBER: 100002CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJDATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT PRECERT COB PAID W/H FEE DSCNT CD200810600095 9014-4027.0-19 H03063364 02 LASTNAME, AMY M09/17/2008 99214 1 142.00- 119.54- 22.46- 10.00- .00 .00 .00 .00 107.15- .00 2.39- .00_________________________________________________________________________________________________________________________________TOTAL 1 142.00- 119.54- 22.46- 10.00- .00 .00 .00 .00 107.15- .00 2.39- .00 6In this example, The Health Plan paid the claim under the incorrect Member ID Number. The claim was credited, and then resubmitted to pay underthe correct Member ID.Section 14 / Page 5

PROVIDER PROCEDURAL MANUAL 2014BENEFIT LIMITATIONMember responsibility will be indicated in the MEMBER DEDUCT column on the payment voucher. The example below demonstrates how anamount is applied to the Member Deductible. The BILLED amount in the example is $888.00, however the “ALLOWED amount” is $440.92,therefore $125.00 is applied to the Member Deductible. The Member MAY NOT be balanced billed for the disallowed amount.CLAIMS PAID CHECK NUMBER: 100005CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJDATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD200805712013 G564255.2 H07015364 05 LASTNAME, JACK02/18/2008 10014 1 456.00 78.83 377.17 .00 .00 78.83 .00 .00 .00 .00 .00 .00 LCLAIM CODES: 1 4502/18/2008 63496 50 1 432.00 362.09 69.91 .00 63.18 46.17 .00 .00 252.74 .00 .00 .00 LCLAIM CODES: 1 45_________________________________________________________________________________________________________________________________TOTAL 1 888.00 440.92 447.08 .00 63.18 125.00 .00 .00 252.74 .00 .00 .00Section 14 / Page 6

PROVIDER PROCEDURAL MANUAL 2014*** EXAMPLE FORM ***Provider Reimbursement VoucherClaims Summary Page8/25/2008 Page 12Provider Reimbursement VoucherProvider Name Prov Num: 123456A Tax ID: 00-0000000NUMBER OF CLAIMS 18TOTAL BILLED $7,016.12TOTAL PAID $2,058.55CO-PAYMENTS $221.27ACCOUNT STATUSBILLED CHARGES # CLAIMSCLAIMS PAID/DENIED $7,016.12 18CLAIMS IN PROCESS $34,533.73 73TOTAL ALL CLAIMS $41,549.85 89ADJUSTMENT CODE DESCRIPTIONPROVIDER HAS THE RIGHT TO APPEALDECISION. REFER TO THE APPEAL PROCESSIN THE PROVIDER BILLING MANUAL.L = BILLED AMOUNT EXCEEDS THE MAXIMUM ALLOWABLEU = ROUTINE FOLLOW UP CARE IS INCLUDED IN THE GLOBAL SURGICAL FEEA = NOT ALLOWEDBE = BILLING ERRORT = SERVICE AFTER TERMINATIONN = NOT A COVERED BENEFIT12 = HEALTH PLAN PROCESSING ERRORCLAIMS SUMMARY PAGEThe above is an example of the last page of your payment voucher, or your “claims summarypage”. The claims summary includes the totals for each section of your payment voucher;“claims paid”, “claims denied” and “claims in process”. The totals on the summary pageshould equal the totals found on the individual voucher pages. The totals should be verifiedto ensure the accuracy of your payment.Section 14 / Page 7

PROVIDER PROCEDURAL MANUAL 2014PROVIDER ADJUSTMENT CODESBelow is a list of the most common adjustment codes (credit codes) used for claims:1 Paid wrong Provider 9 Miscellaneous Credit2 Member Terminated 10 Physician Billing error/change3 Other insurance primary 11 Pay and educate4 Duplicate Payment 12 HP processing error5 Concurrent Care 13 Second review/support documentation7 Per diem – Contract adjustment 14 Administrative Adjustment8 Physician SanctionPlease refer to the follow links below for current HIPAA Codes:Claim Adjustment Reason Codeshttp://www.wpc-edi.com/content/view/695/1Health Care Provider Taxonomy Code Sethttp://www.wpc-edi.com/content/view/793/1Remittance Advice Remark Codeshttp://www.wpc-edi.com/content/view/739/1WORKER’S COMPENSATION DENIAL CODESTypeU7U8U5U3U4U6D6MRSVNSEGPACED2DescriptionThe Health Plan is not the MCO for this employerProcedure/Treatment has no valid pre-authorization or referralPayment denied as a required field invalid/omittedThis worker’s comp claim has been determined to be disallowed by the BWCBilling for pharmacy changes is required on a C-17 formThe listed procedure code/DME/orthotic was not pre-authorizedState of Ohio employee-behavior health services need to be billed to United States BehaviorHealthMedical records for pre-existing condition required and NOT received (member responsibility)No student verification on file-services denied (member responsibility)Services provided or ordered by a Provider speciality not covered under your contractClaim denied, eligibility information pending from your group employerServices denied due to failure to pre-auth - participant’s responsibilityChiropractic benefits exhaustedPT/OT claim-submit original Physician claimSection 14 / Page 8

PROVIDER PROCEDURAL MANUAL 2014RESUBMISSION OF CLAIMSThe Health Plan’s Resubmit Policy was developed to expedite the processing and review of the claimsthat are resubmitted, these resubmit claims appear on your payment voucher as claims in process. When resubmitting a claim that may have denied for additional documentation, operativereport, or any change or adjustment to a previous submitted claim, the Provider will forward anew HCFA 1500 form with a copy of the payment voucher along with an explanation and/oradditional documentation as to why the claim is being resubmitted or indicate “correctedclaim” or “resubmitted claim” on the HCFA 1500 form. These claims are to be directed tothe Claims Department via fax (330) 830-5634, 180 days from the date of original denial. The explanation for the resubmitted claim should be clear and concise in order to address theissues of the resubmit and/or appeal. You may also resubmit your claims through the ProviderSecure Web Site by printing and indicating on the claim what you would like us to review. A description of services provided when submitting miscellaneous codes needs to be on theclaim in order to address or make any payment decision or reconsideration of payment. If notclearly identified, it will result in our inability to adjust the claim. As you are aware, we have enhanced your payment voucher to provide you with a moredescriptive message to assist you. If you are unsure as to why the claim was denied or you havequestions regarding the appropriate documentation to send with your resubmitted claim, pleasecall the Customer Service Provider Relations Department who will assist you on how to resubmityour claim. Those offices who submit their claims electronically can resubmit their claim by using theClaims Frequency Type Code also known as Claims Resubmission Reason Code. Place theReason Code “7” in the claim information 2300 Loop Segment CLM05. Claims receivedelectronically with the Code “7” will be processed as a replacement or resubmitted claim.If any other number is placed in the CLM05 Segment, the claim will be processed as “new”and could result in a duplicate denial. All requested documentation must be attached to the “new” 1500 form. When submitting documentation to support a complex or comprehensive level of service orwhen using modifier 22, you must have a written explanation and/or documentation attachedto reflect why the service (s) to be considered are “unusual” or more complex in nature. In order to be reimbursed for Critical Care and Prolonged Physician services the Providermust clearly document time spent with direct face-to-face encounter. We suggest that theProvider record the time services were initiated and the time services completed in themedical chart/record.Failure to follow the above guidelines or designate a resubmitted claim as a “corrected” or“resubmitted claim” may result in your claim remaining denied or being denied as a duplicate.Enclosed is a Claim Resubmission Form that is optional and may be used in lieu of the paymentvoucher. Please attach this form to the CMS 1500 (08/05) form.Section 14 / Page 9

PROVIDER PROCEDURAL MANUAL 2014RESUBMISSION OF CLAIMS DENIED FOR DOCUMENTATIONIn order to expedite the processing of claimsthat are denied for additional documentationwhen the diagnosis does not support thelevel of service the following procedureshave been implemented.Initially the claim will be reviewed and if itis determined that the diagnosis does notsupport the level of service, the claim will bedenied with the more descriptive denialcodes. The Providers at this time will needto resubmit the claim with the appropriatelevel of service or submit appropriatedocumentation such as, office notes,progress notes etc. to support the level forservice (180) days from the date of thepayment voucher.Level I: Once The Health Plan receives theadditional documentation to support thelevel of services it will be sent to the claimsdepartment for review by a different claimsreviewer. If the documentation supports thelevel of services the claim will bereprocessed and, depending on the reviewdate, will show on your next voucher aseither paid or denied. If the documentationdoes not support the level of service, theclaim will continue to deny. At this time,the Provider can correct the claim with theappropriate level of service.Level II: If the Provider feels that the levelof service is appropriate, the Provider maysubmit a written request for a third reviewwith additional documentation sent to aMedical Director for review. Uponcompletion of the Medical Director, theclaim will be paid or denied. If the MedicalDirector agrees with the initial adjudicationof the claim, the claim will deny. Thisrequest needs sent to:PROVIDER RELATIONS52160 NATIONAL RD ESAINT CLAIRSVILLE OH 43950-9306Level III: If the Provider does not agree withthe Medical Directors decision, the Providermay submit a written request for an outsideindependent review of the claim with theappropriate documentation to support thelevel of service. Send request to:PROVIDER RELATIONS52160 NATIONAL RD ESAINT CLAIRSVILLE OH 43950-9306The results of this review will be sentback within (30) days from date of thepayment voucher reflecting the MedicalDirectors determination.Once the decision has been received fromthe Independent Reviewer, the Practitioner /Provider will receive written notice oftheir decision. If it is determined that thedocumentation supports the claim assubmitted the claim will be reprocessed atthe level of service. If the reviewerdetermines that the documentation doesNOT support the claim as submitted,the Provider may resubmit the claimwith the appropriate level of service.If the Independent Outside Reviewer agreeswith The Health Plan’s adjudication of theclaim, the Provider will be responsible forthe charges of the Independent Reviewerwhich may vary depending on the hourlyrate and the number of claims reviewed.An invoice will be sent to the Provider alongwith the outside reviewer’s decision. If theIndependent Reviewer rules in favor of theProvider, the charges for the review will be aHealth Plan expense. The decision of theIndependent Reviewer is final and theProvider will have (30) days from the dateof the determination letter to resubmit acorrect claim.Section 14 / Page 10

CLAIM RESUBMISSION FORMPlease read and complete form in its entirety to ensure proper processing of yourresubmission.Provider Name:Provider Address:Date:Submitted by:Check one of the following reasons for resubmitting the attached claim:Referral Authorization ProvidedReferral number:Code Omitted From Original Claim ICD: CPT:Code Changed From Original Claim ICD: CPT:Modifier Omitted From Original Claim CPT: Modifier:Modifier Changed From Original Claim CPT: Modifier:Payment ErrorBilled Amount Changed From Original ClaimDocumentation Omitted From Original ClaimOther (explain)Brief explanation to support your resubmission:Please attach your CMS1500 form.The Health Plan cannot resubmit your claim without a new claimform.Contact PersonPhone NumberBilling service name (If applicable)Section 14 / Page 11

St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT1 2 3 41 2 3 4551212191926266613132020272777141421212828January88151522222929991616232330301010171724243131111118182525SUN MON TUE WED THU FRI SAT1 2 3 4 591 92 93 94 95696131032011027117797141042111128118898151052211229119April999161062311330120101001710724114111011810825115121021910926116SUN MON TUE WED THU FRI SAT1 2 3 4 5182 183 184 185 186618713194202012720871881419521202282098189151962220329210July919016197232043021110191171982420531212111921819925206121931920026207SUN MON TUE WED THU FRI SAT1 2 3 4274 275 276 277527812285192922629962791328620293273007280142872129428301October8281152882229529302928216289232963030310283172902429731304112841829125298SUN MON TUE WED THU FRI SAT13223394016472354334104117482455February43511421849255653612431950265763713442051275873814452152285983915462253SUN MON TUE WED THU FRI SAT1 2 3121 122 123412411131181382514551251213219139261466126131332014027147May71271413421141281488128151352214229149912916136231433015010130171372414431151SUN MON TUE WED THU FRI SAT1 2213 21432151022217229242363124342161122318230252375217122241923126238August6218132252023227239721914226212332824082201522722234292419221162282323530242SUN MON TUE WED THU FRI SAT13052306931316320233273033433071031417321243282014November43081131518322253295309123161932326330631013317203242733173111431821325283328312153192232629333SUN MON TUE WED THU FRI SAT1602619681675238230893621069177624833190463117018772584March564127119782685665137220792786766147321802887867157422812988SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7152 153 154 155 156 157 15881591516622173291809160161672317430181101611716824175June111621816925176121631917026177131642017127178141652117228179SUN MON TUE WED THU FRI SAT1 2 3 4 5 6244 245 246 247 248 24972501425721264282718251152582226529272September9252162592326630273102531726024267112541826125268122551926226269132562026327270SUN MON TUE WED THU FRI SAT1 2 3 4 5 6335 336 337 338 339 34073411434821355283628342153492235629363Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December934316350233573036410344173512435831365113451835225359123461935326360133472035427361

St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT1 2 3 4 51 2 3 4 5661313202027277714142121282888151522222929January991616232330301010171724243131111118182525121219192626SUN MON TUE WED THU FRI SAT1 2 3 4 5 691 92 93 94 95 96797141042111128118898151052211229119999161062311330120April101001710724114111011810825115121021910926116131032011027117SUN MON TUE WED THU FRI SAT1 2 3 4 5 6182 183 184 185 186 187718814195212022820981891519622203292109190161972320430211July10191171982420531212111921819925206121931920026207131942020127208SUN MON TUE WED THU FRI SAT1 2 3 4 5274 275 276 277 278627913286202932730072801428721294283018281152882229529302October928216289232963030310283172902429731304112841829125298122851929226299SUN MON TUE WED THU FRI SAT1 232 33334104117482455435114218492556February5361243195026576371344205127587381445215228598391546225394016472354SUN MON TUE WED THU FRI SAT1 2 3 4121 122 123 124512512132191392614661261313320140271477127141342114128148May8128151352214229149912916136231433015010130171372414431151111311813825145SUN MON TUE WED THU FRI SAT1 2 3213 214 215421611223182302523752171222419231262386218132252023227239August72191422621233282408220152272223429241922116228232353024210222172292423631243SUN MON TUE WED THU FRI SAT1 2305 306330710314173212432843081131518322253292013November53091231619323263306310133172032427331731114318213252833283121531922326293339313163202332730334SUN MON TUE WED THU FRI SAT1 260 613621069177624833190463117018772584564127119782685March665137220792786766147321802887867157422812988968167523823089SUN MON TUE WED THU FRI SAT11522153916016167231743018131541016117168241754155111621816925176June5156121631917026177615713164201712717871581416521172281798159151662217329180SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7244 245 246 247 248 249 25082511525822265292729252162592326630273September102531726024267112541826125268122551926226269132562026327270142572126428271SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7335 336 337 338 339 340 34183421534922356293639343163502335730364Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December10344173512435831365113451835225359123461935326360133472035427361143482135528362

St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 71 2 3 4 5 6 788151522222929991616232330301010171724243131January111118182525121219192626131320202727141421212828SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 792 93 94 95 96 97 988991510622113291209100161072311430121101011710824115April111021810925116121031911026117131042011127118141052111228119SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7183 184 185 186 187 188 1898190151972220429211919116198232053021210192171992420631213July111931820025207121941920126208131952020227209141962120328210SUN MON TUE WED THU FRI SAT1 2 3 4 5 6275 276 277 278 279 280728114288212952830282821528922296293039283162902329730304October10284172912429831305112851829225299122861929326300132872029427301SUN MON TUE WED THU FRI SAT1 2 3 432 33 34 35536124319502657637134420512758February73814452152285983915462253296094016472354104117482455114218492556SUN MON TUE WED THU FRI SAT1 2 3 4 5122 123 124 125 126612713134201412714871281413521142281498129151362214329150May913016137231443015110131171382414531152111321813925146121331914026147SUN MON TUE WED THU FRI SAT1 2 3 4214 215 216 217521812225192322623962191322620233272407220142272123428241August8221152282223529242922216229232363024310223172302423731244112241823125238SUN MON TUE WED THU FRI SAT1 2 3306 307 308430911316183232533020125310123171932426331November6311133182032527332731214319213262833383131532022327293349314163212332830335103151732224329SUN MON TUE WED THU FRI SAT1 2 361 62 63464117118782585565127219792686666137320802787March7671474218128888681575228229899691676238330901070177724843191SUN MON TUE WED THU FRI SAT1 2153 154315510162171692417641561116318170251775157121641917126178June6158131652017227179715914166211732818081601516722174291819161161682317530182SUN MON TUE WED THU FRI SAT1245224692531626023267302743247102541726124268September42481125518262252695249122561926326270625013257202642727172511425821265282728252152592226629273SUN MON TUE WED THU FRI SAT133623379344163512335830365333810345173522435931366Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December43391134618353253605340123471935426361634113348203552736273421434921356283638343153502235729364

St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT11229916162323303033101017172424313144111118182525January55121219192626661313202027277714142121282888151522222929SUN MON TUE WED THU FRI SAT1 291 92393101001710724114494111011810825115595121021910926116April696131032011027117797141042111128118898151052211229119999161062311330120SUN MON TUE WED THU FRI SAT1 2182 18331841019117198242053121241851119218199252065186121931920026207July6187131942020127208718814195212022820981891519622203292109190161972320430211SUN MON TUE WED THU FRI SAT1274227592821628923296303033276102831729024297313044277112841829125298October5278122851929226299627913286202932730072801428721294283018281152882229529302SUN MON TUE WED THU FRI SAT1 2 3 4 532 33 34 35 36637134420512758738144521522859February8391546225394016472354104117482455114218492556124319502657SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7121 122 123 124 125 126 1278128151352214229149912916136231433015010130171372414431151May111311813825145121321913926146131332014027147141342114128148SUN MON TUE WED THU FRI SAT1 2 3 4 5 6213 214 215 216 217 218721914226212332824082201522722234292419221162282323530242August10222172292423631243112231823025237122241923126238132252023227239SUN MON TUE WED THU FRI SAT1 2 3 4 5305 306 307 308 309631013317203242733120117311143182132528332November83121531922326293339313163202332730334103141732124328113151832225329123161932326330SUN MON TUE WED THU FRI SAT1 2 3 4 560 61 62 63 64665137220792786766147321802887867157422812988March9681675238230891069177624833190117018772584127119782685SUN MON TUE WED THU FRI SAT1 2 3 4152 153 154 155515612163191702617761571316420171271787158141652117228179June81591516622173291809160161672317430181101611716824175111621816925176SUN MON TUE WED THU FRI SAT1 2 3244 245 24642471125418261252685248122551926226269September6249132562026327270725014257212642827182511525822265292729252162592326630273102531726024267SUN MON TUE WED THU FRI SAT1 2 3335 336 33743381134518352253595339123461935326360Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December634013347203542736173411434821355283628342153492235629363934316350233573036410344173512435831365

St. Clairsville Office52160 National Rd. EastSt. Clairsville, OH 43950Phone: 740.695.3585Toll Free: 800.624.6961SUN MON TUE WED THU FRI SAT1 21 23310101717242431314411111818252555121219192626January66131320202727771414212128288815152222292999161623233030SUN MON TUE WED THU FRI SAT1 2 391 92 93494111011810825115595121021910926116696131032011027117April797141042111128118898151052211229119999161062311330120101001710724114SUN MON TUE WED THU FRI SAT1 2 3182 183 184418511192181992520651861219319200262076187131942020127208July71881419521202282098189151962220329210919016197232043021110191171982420531212SUN MON TUE WED THU FRI SAT1 2274 27532761028317290242973130442771128418291252985278122851929226299October6279132862029327300728014287212942830182811528822295293029282162892329630303SUN MON TUE WED THU FRI SAT1 2 3 4 5 632 33 34 35 36 3773814452152285983915462253February94016472354104117482455114218492556124319502657134420512758SUN MON TUE WED THU FRI SAT1121212291291613623143301503123101301713724144311514124111311813825145May5125121321913926146612613133201402714771271413421141281488128151352214229149SUN MON TUE WED THU FRI SAT1 2 3 4 5 6 7213 214 215 216 217 218 2198220152272223429241922116228232353024210222172292423631243August112231823025237122241923126238132252023227239142262123328240SUN MON TUE WED THU FRI SAT1 2 3 4 5 6305 306 307 308 309 310731114318213252833220108312153192232629333November9313163202332730334103141732124328113151832225329123161932326330133172032427331SUN MON TUE WED THU FRI SAT1 2 3 4 5 660 61 62 63 64 65766147321802887867157422812988968167523823089March1069177624833190117018772584127119782685137220792786SUN MON TUE WED THU FRI SAT1 2 3 4 5152 153 154 155 156615713164201712717871581416521172281798159151662217329180June9160161672317430181101611716824175111621816925176121631917026177SUN MON TUE WED THU FRI SAT1 2 3 4244 245 246 24752481225519262262696249132562026327270September725014257212642827182511525822265292729252162592326630273102531726024267112541826125268SUN MON TUE WED THU FRI SAT1 2 3 4335 336 337 33853391234619353263606340133472035427361Massillon Office100 Lillian Gish Blvd.PO Box 4816Massillon, OH 44648Phone: 330.830.4370Toll Free: 888.830.4370December73411434821355283628342153492235629363934316350233573036410344173512435831365113451835225359

JanuarySUN MON TUE WED THU FRI SAT1122334455667788991010111112121313141415151616171718181919202021212222232324242525262627272828292930303131FebruarySUN MON TUE WED THU FRI SAT1322333344355366377388399401041114212431344144515461647174818491950205121522253235424552556265727582859MarchSUN MON TUE WED THU FRI SAT1602613624635646657668679681069117012711372147315741675177618771978207921802281238224832584268527862887298830893190AprilSUN MON TUE WED THU FRI SAT191292393494595696797898999101001110112102131031410415105161061710718108191092011021111221122311324114251152611627117281182911930120MaySUN MON TUE WED THU FRI SAT11212122312341245125612671278128912910130111311213213133141341513516136171371813819139201402114122142231432414425145261462714728148291493015031151JuneSUN MON TUE WED THU FRI SAT115221533154415551566157715881599160101611116212163131641416515166161671716818169191702017121172221732317424175251762617727178281792918030181JulySUN MON TUE WED THU FRI SAT11822183318441855186618771888189919010191111921219313194141951519616197171981819919200202012120222203232042420525206262072720828209292103021131212AugustSUN MON TUE WED THU FRI SAT12132214321542165217621872198220922110222112231222413225142261522716228172291823019231202322123322234232352423625237262382723928240292413024231243SeptemberSUN MON TUE WED THU FRI SAT124422453246424752486249725082519252102531125412255132561425715258162591726018261192622026321264222652326624267252682626927270282712927230273OctoberSUN MON TUE WED THU FRI SAT12742275327642775278627972808281928210283112841228513286142871528816289172901829119292202932129422295232962429725298262992730028301293023030331304NovemberSUN MON TUE WED THU FRI SAT130523063307430853096310731183129313103141131512316133171431815319163201732118322193232032421325223262332724328253292633027331283322933330334DecemberSUN MON TUE WED THU FRI SAT133523363337433853396340734183429343103441134512346133471434815349163501735118352193532035421355223562335724358253592636027361283622936330364313652009


PROVIDER PROCEDURAL MANUAL 2014CREDENTIALINGBecause The Health Plan is a state and federally qualified HMO, it is required to comply withQuality Assurance Standards on credentialing in addition to complying with the State ofWest Virginia, Ohio, CMS, and Ohio HB125 Credentialing Guidelines.The Initial Credentialing Process Includes:• On-site survey• Medical record review• Physician ApplicationCopies and Verification of:• Licensure(s)• Clinical Privileges• DEA Registration• Complete Malpractice History• Board CertificationsAs any of these areas expire, a letter will be generated requesting a copy of the renewal.It is imperative that we receive this information as quickly as possible.Practitioner has the right to review all information submitted to The Health Plan in support ofthe credentialing / recredentialing application.RECREDENTIALINGThe Health Plan of the Upper Ohio Valley, Inc. recredentials all practitioners every three years.This Recredentialing Process Includes Primary Verification of:• Licensure(s)• Clinical Privileges• Valid DEA• Board Certification• Adequate Malpractice Insurance• Professional Liability Claims History• Reappointment Application• Verifying the Information Contained onthe Reappointment ApplicationSection 15 / Page 2

PROVIDER PROCEDURAL MANUAL 2014PRACTITIONER'S CREDENTIALING / RECREDENTIALING RIGHTS• Practitioner has the right to correct erroneous information• Practitioner has the right, upon request, to be informed of the status of their credentialing orrecredentialing application.• Practitioner has the right to review all information submitted to The Health Plan in support ofthe credentialing/recredentialing application.WV Practitioners: The Mandatory State of WV Credentialing & Recredentialing applicationsare available through West Virginia Offices of the Insurance Commissioner Website athttp://www.wvinsurance.gov/Default.aspx?tabid=352.OH Practitioners: As of September 2008, The Health Care Simplication Act, HB125, requiresall Ohio Physicians to submit the CAQH Form. The Health Plan does not subscribe to CAQH;therefore, the Practitioner must print out their completed form from http://www.caqh.org/. If thePractitioner has not yet completed their initial application through CAQH, they may access theapplication electronically through the CAQH at http://www.caqh.org/.OH Ancillary Providers: https://secured.insurance.ohio.gov/forms/INS5036.docIf the Practitioner is unable to obtain these forms electronically, please contact Provider Relationsat (800) 624-6961 and these forms will be provided to you via secure fax, e-mail, or certified mail.STANDARDS FOR PARTICIPATIONTo become a Health Plan Provider, a physician must be credentialed and meet the standards ofparticipation, as developed by Health Plan in association with participating physicians. Aphysician must have the following credentials:• Drug Enforcement Administration registration number if the scope ofpractice would warrant the physician to have a DEA.• Professional Liability - Minimum amount of $1 million, any amount belowminimum will be reviewed by the Credentials Committee.• Admitting privileges at a participating hospital.• Clear report from the National Data Bank.• Board Certified or Board Eligible. If not Board Certified or Board Eligible,the physician must demonstrate appropriate training for specialty listed.• Signed and dated agreement.• Site Survey conducted on all initial applicants offices.• Proof of current medical license(s).• Sufficient information concerning any malpractice actions.• NPI Number and UPIN Number.• Completed ApplicationSection 15 / Page 3

PROVIDER PROCEDURAL MANUAL 2014STANDARDS FOR PARTICIPATIONThe agreement will not be executed on behalf of The Health Plan until the Credentialing processhas been completed and the practitioner has been approved for participation.Notification of acceptance and/or rejection will be completed within 60 days of the decision.The Health Plan will complete the credentialing process 90 days of receipt of the application or180 days from the date of signature on the attestation statement of the application.In addition to the above credentials The Health Plan Quality Improvement Committee haveidentified the following behaviors and expectations for Health Plan physicians, who should:• Have 24-hour availability, seven days a week, with backup coverage.• Accept members of any or all Health Plan products, as required by Health Plan.• Admit Health Plan patients to participating hospitals.• Accept and support Health Plan Policies.• Allow medical records and office to be reviewed as part of collaborativequality program.• Have records and office meet criteria established by Health Plan andparticipating physician.• May not discriminate against Health Plan patients or “demarket” Health Plan.• Admit under own service to participating hospitals if patient’s condition iswithin physician’s range of expertise and scope of privileges.• Meet the CME requirement that is required for state licensure.The following guidelines are for PCP’s only:A PCP shall be required to provide a minimum of twenty (20) hours per week of patient careavailability in a county to be considered as a PCP in that county. The only exception shall bepractitioners who provide services at multiple sites.In the instance of multiple sites, these shall be acceptable providing the alternate location iswithin thirty (30) miles or forty five (45) minutes driving time of the primary location and thealternate location meets all the necessary requirements as determined appropriate by theCredentials Committee and/or the Executive Management Team. The PCP must also providecoverage 24 hours a day seven (7) days per week and have privileges at a provider facility or havemade arrangements with a contracting provider to handle all inpatient care for his/her patients.Maintain at least 50 percent primary care practice.Section 15 / Page 4

PROVIDER PROCEDURAL MANUAL 2014STANDARDS FOR PARTICIPATIONThe following guidelines are for Specialty Providers (Specialist and Secondary Care Physicians)Specialist practitioners who provide patient care access fewer than twenty (20) hours per week ina Health Plan county shall be considered as a provider practitioner in that region, only if thespecialty service of the physician is not otherwise available through sufficient plan providersresiding in that region. Furthermore, the ability of the specialist to provide the necessary servicelocally including inpatient care, surgery and back-up support shall be considered by theCredentials Committee and/or Executive Management Team in making the determination of theacceptance of the practitioner as a plan provider.The committee shall consider the specific needs of the specialty and how the physician willaccommodate his/her patient needs. Practitioners who provide only limited services locallyshall not be permitted to be accepted as a plan provider. In addition, if it is determined that thephysician specialty require the physician to be available locally, the practitioner shall not beaccepted as a plan provider.INITIAL CERTIFICATIONDuring the credentialing procedure, information that the physician submits to Health Plan as partof the application process is verified. This information includes, but is not limited to, medicallicensure, board certification, plus the credentials listed on the previous page. In addition, eachphysician must take part in an office site survey. Applicants and their practices are reviewedusing certification standards developed by Health Plan and approved by physician committee.PRACTITIONER’S RIGHTSPractitioner has the right to review all information submitted to The Health Plan in support ofthe Credentialing / Recredentialing application.Practitioner has the right to correct erroneous information.Practitioner has the right, upon request, to be informed of the status of their credentialing orrecredentialing application.Section 15 / Page 5

Provider Name:Revised: 05/99, 02/00, 03/02, 10/03, 08/04, 07/08, 12/08, 08/09, 10/22/2013Reviewed: 04/10, 04/11, 04/12(Please Print)Specialty:Provider Street Address:Provider Number:City: State: ZIP Code: Date:STDNBRSTANDARDDOESNOTAPPLYMETNOTMET1 All offices will be clearly marked.2 All office complexes will have wheelchair & handicapped access - single offices would notneed to provide handicapped access.3 All exits, if different from the main office entrance, will be marked and plainly visible.4 All offices shall have adequate parking with handicapped spaces marked.Street Lot5 All waiting rooms shall have adequate clean comfortable seating.6 All examination rooms will be private and clean.7 All instruments will be sterilized, individually wrapped, labeled, and dated.8 All pharmaceutical will reflect the following:A. Stored in a locked cupboard or accessible only to appropriate personnel.B. Controlled substances shall be stored in a double locked cupboard and logged.C. Drugs requiring refrigeration will be kept on a shelf separately.D. All needles/syringes will be disposed in a "sharps" container & incinerated or collectedby a special medical waste refuse company.E. All pharmaceutical, stock, meds, vaccines, anesthetic agents, ointments, and sampleswill be checked routinely for expiration dates. The office will have specific timeintervals to check dates.F. Syringes not accessible to patients.G. Prescription pads not accessible to patients.9 All rural and/or offices located at least 10 minutes from a hospital will have the followingemergency equipment:A. AdrenalinB. Oxygen10 All offices performing surgical or diagnostic procedures and located at least 10 minutesfrom a participating hospital, shall have the following emergency equipment in addition tostandard 9:A. IV’sB. Crash cart or case11 All offices performing cardiac stress tests shall have the following in addition to standard9 and 10:A. Endo/tube and ambu bagB. DefibrillatorC. Cardiac monitorT:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 1 of 8

12 Patients Rights.A. Patient greeted promptly, courteously, professionally. Yes NoB. Complaint/concerns handled by whom?C. Privacy is maintained. Yes NoD. Patient education. Video Written Brochures13 Emergency/After hour coverage:A. Answering service or device to instruct patients after hours.B. 24 hour life threatening emergency coverage.14 Provider AccessibilityA. Preventative Care within 30 daysB. Routine non-urgent, symptomatic care within 72 hoursC. Urgent care within 24 hrs Same Day OtherD. Emergency services immediately.E. Average waiting time within 45 minutesNumber of patients scheduled per hour15 All office with x-ray and lab facilities will:A. Have trained & qualified personnelB. Submit the qualification of personnel performing testing.C. Have all equipment inspected on a regularly scheduled basis.16 All offices will have a fire extinguisher that is inspected and reviewed regularly.17 All offices having more than one story or more than one suite of offices shall have awritten fire exit plan.18 Confidentiality:A. There should be written policy assuring confidentiality of personal health information(PHI) in accordance with the HIPAA guidelines.B. Office policy regarding release of information and records.19 A signature log is maintained (example in Provider Manual). Identifying 1st initial, lastname, and credentials (MD, DO, DC, DMD, DPM, PA, C-NP, OD, PO, LSW, LPPC, etc).T:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 2 of 8

STDNBRSTANDARDDOESNOTAPPLYMETNOTMET20 All offices will maintain records in a current, detailed, organized, and comprehensivemanner in accordance with the following Health Plan Standards for Patient Records.The medical record should be organized with the various types of information placedin a consistent location to enable easy access for reviewing the chart.(A minimum of 3 records reviewed)A. PATIENT ID — Each and every page in the record contains the patient's name or IDnumber and birthdate.B. BIOGRAPHICAL / PERSONAL DATA — Personal/biographical data includes address,employer, home and work telephone numbers, marital status, tobacco use, anddrug/alcohol use.C. PROVIDER IDENTIFICATION — All entries in the medical record contain authoridentification. Initials may be used only if there is a signature log identifying 1stinitial, last name & credentials. Electronic signatures are acceptable.D. DATED ENTRIES — All entries are dated.E. LEGIBILITY — The record is legible to someone other than the writer. Any recordjudged illegible by one physician reviewer should be evaluated by a second reviewer.F. PROBLEM AND MEDICATION LISTG. ALLERGIES — Medication allergies and adverse reactions are prominently noted in therecord. Absence of allergies should be recorded as NKA. The documentation forallergies should be in a consistent location in all charts.H. RETURN VISIT/FOLLOW-UP — Encounter forms or notes have a notation, whenindicated, regarding follow-up care, calls or visits. The specific time of return is notedin weeks, months or PRN.I. REVIEW SIGNIFICATION — Consultation, lab and x-ray reports filed in chart areinitialed by the ordering physician to signify review.J. IMMUNIZATION RECORD — For pediatric (ages 10 and under) records, there is acompleted immunization record or a notation that “immunizations are up to date”.K. PREVENTIVE SERVICES — There is evidence that preventive screening and servicesare offered.L. HEALTH PLAN ID — It is recommended that patients should be identified as HealthPlan patients. This evidence will assist in obtaining authorization and referrals whennecessary.M. ADVANCE DIRECTIVE — There is evidence that information regarding advancedirectives was provided to Health Plan member age 18 and over.T:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 3 of 8

STDNBRSTANDARDDOESNOTAPPLYMETNOTMETAdditional Surveyor's CommentsSurvey Performed By:Date:T:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 4 of 8

(Please Print)Provider Name:Specialty:Provider Street Address:Provider Number:City: State: ZIP Code: Date:I. EKGs performed in office. Yes NoHolter Monitor performed in office. Yes NoRequires:A. Type of Equipment:B. Names of technical personnel:C. Who does interp? and/or complete?II. Echocardiograms performed in office. Yes NoCardiac Stress Test Yes NoCarotid Studies Yes NoPeripheral Vascular Studies Yes NoRequires:A. Type of Equipment:B. Type of Protocol:C. Names of technical personnel:D. Qualifications of technical personnel (attach copies of certification)III. Laboratory Work performed in office. Yes NoRequires:A. Copy of CLIAB. Complete the following checklist of labwork performed in your officeCHEMISTRYAlbuminAlbumin/Globulin RatioBilirubin, totalBUNCalciumCarbon Dioxide ContentChloridesCholesterolCPKCreatinineGlobulinGlucoseLDLOsmolalityPhosphatase, alkalinePhosphorus inorganic phosphatePotassiumProtein, totalSGGTSGOTSGPTSodiumUric AcidT:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 5 of 8

III. Laboratory Work performed in office — continuedCHEMISTRY / TOXICOLOGYLipid ProfileUrinalysisGlucose Tolerance TestHemoccult, FecesPregnancy TestTheophylline LevelTriglyceridesUrobilinogenT3T4TSH & Thyroid ProfileHEMATOLOGYCBCDifferentialHematocritHemoglobinProtimePlatelet CountRBCSed RateWBCIMMUNOLOGYMono TestStrep ScreenANATOMIC PATHOLOGYPap SmearMICROBIOLOGYBacterial Culture(Including gonococcal)Occult blood, any source except fecesChlamydia culture/sensitivityThroat cultureMISCELLANEOUSUrine cultureUrine culture with colony countADDITIONAL LABORATORY TESTS Please list additional laboratory tests not already checked (If more space is needed, please use back of form) Are any of the laboratory tests done by automated analysis? Yes No If yes, list name and/or type of equipment: Please indicate from the following list the members of your staff who perform the laboratory tests and their credentials:PERSONNELCREDENTIALSMDRN/LPNRECEPTIONIST/SECRETARYMED. TECH.LAB. TECH.OTHER (specify)C. Equipment used:T:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 6 of 8

III. Laboratory Work performed in office — continuedD. Names of technical personnel:E. Qualifications of technical personnel (attach copies of certification)IV. X-Rays performed in office. Yes NoRequires:A. Certificate of inspection from state agency/or, certificate from health physicist.B. Names of technical personnel:C. Qualifications of technical personnel (attach copies of certification)D. Name of interpreting physician:E. Qualifications of interpreting physician:Billing: Identify who bills the technical and professional parts of the claim.TECHNICAL:PROFESSIONAL:V. OtherAny other test/procedure performed in the office should be listed here.The requirements for any test/procedure include:A. Type of Equipment:B. Names of technical personnel:C. Qualifications of technical personnel (attach copies of certification)D. Interpretation by:E. Other pertinent information:T:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 7 of 8

Additional Surveyor's CommentsCompleted By:Date:T:\SITESURV\New Site Survey Score\SITE SURVEY MEDICAL 499A.doc Page 8 of 8

BEHAVIORAL HEALTHProvider Name:Revised: 05/99, 02/00, 03/02, 10/03, 08/04, 07/08, 12/08, 08/09, 10/22/2013Reviewed: 04/10, 04/11, 04/12(Please Print)Specialty:Provider Street Address:Provider Number:City: State: ZIP Code: Date:STDNBRSTANDARDDOESNOTAPPLYMETNOTMET1 All offices will be clearly marked.2 All office complexes will have wheelchair & handicapped access - single offices would notneed to provide handicapped access.3 All exits, if different from the main office entrance, will be marked and plainly visible.4 All offices shall have adequate parking with handicapped spaces marked.Street Lot5 All waiting rooms shall have adequate clean comfortable seating.6 All examination rooms will be private and clean.7 All instruments will be sterilized, individually wrapped, labeled, and dated.8 All pharmaceutical will reflect the following:A. Stored in a locked cupboard or accessible only to appropriate personnel.B. Controlled substances shall be stored in a double locked cupboard and logged.C. Drugs requiring refrigeration will be kept on a shelf separately.D. All needles/syringes will be disposed in a "sharps" container & incinerated or collectedby a special medical waste refuse company.E. All pharmaceutical, stock, meds, vaccines, anesthetic agents, ointments, and sampleswill be checked routinely for expiration dates. The office will have specific timeintervals to check dates.F. Syringes not accessible to patients.G. Prescription pads not accessible to patients.9 All rural and/or offices located at least 10 minutes from a hospital will have the followingemergency equipment:A. AdrenalinB. Oxygen10 All offices performing surgical or diagnostic procedures and located at least 10 minutesfrom a participating hospital, shall have the following emergency equipment in addition tostandard 9:A. IV’sB. Crash cart or case11 All offices performing cardiac stress tests shall have the following in addition to standard9 and 10:A. Endo/tube and ambu bagB. DefibrillatorC. Cardiac monitorT:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 1 of 8

BEHAVIORAL HEALTH12 Patients Rights.A. Patient greeted promptly, courteously, professionally. Yes NoB. Complaint/concerns handled by whom?C. Privacy is maintained. Yes NoD. Patient education. Video Written Brochures13 Emergency/After hour coverage:A. Answering service or device to instruct patients after hours.B. 24 hour life threatening emergency coverage.14 Provider AccessibilityA. Routine office within 10 working days as clinically indicatedOtherB. Urgent care within 48 hrs Same Day OtherC. Non-life-threatening emergency within 6 hrs Same DayD. Emergency services immediately.E. Average waiting time within 45 minutesNumber of patients scheduled per hour15 All office with x-ray and lab facilities will:A. Have trained & qualified personnelB. Submit the qualification of personnel performing testing.C. Have all equipment inspected on a regularly scheduled basis.16 All offices will have a fire extinguisher that is inspected and reviewed regularly.17 All offices having more than one story or more than one suite of offices shall have awritten fire exit plan.18 Confidentiality:A. There should be written policy assuring confidentiality of personal health information(PHI) in accordance with the HIPAA guidelines.B. Office policy regarding release of information and records.19 A signature log is maintained (example in Provider Manual). Identifying 1st initial, lastname, and credentials (MD, DO, DC, DMD, DPM, PA, C-NP, OD, PO, LSW, LPPC, etc).T:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 2 of 8

BEHAVIORAL HEALTHSTDNBRSTANDARDDOESNOTAPPLYMETNOTMET20 All offices will maintain records in a current, detailed, organized, and comprehensivemanner in accordance with the following Health Plan Standards for Patient Records.The medical record should be organized with the various types of information placedin a consistent location to enable easy access for reviewing the chart.(A minimum of 3 records reviewed)A. PATIENT ID — Each and every page in the record contains the patient's name or IDnumber and birthdate.B. BIOGRAPHICAL / PERSONAL DATA — Personal/biographical data includes address,employer, home and work telephone numbers, marital status, tobacco use, anddrug/alcohol use.C. PROVIDER IDENTIFICATION — All entries in the medical record contain authoridentification. Initials may be used only if there is a signature log identifying 1stinitial, last name & credentials. Electronic signatures are acceptable.D. DATED ENTRIES — All entries are dated.E. LEGIBILITY — The record is legible to someone other than the writer. Any recordjudged illegible by one physician reviewer should be evaluated by a second reviewer.F. PROBLEM AND MEDICATION LISTG. ALLERGIES — Medication allergies and adverse reactions are prominently noted in therecord. Absence of allergies should be recorded as NKA. The documentation forallergies should be in a consistent location in all charts.H. RETURN VISIT/FOLLOW-UP — Encounter forms or notes have a notation, whenindicated, regarding follow-up care, calls or visits. The specific time of return is notedin weeks, months or PRN.I. REVIEW SIGNIFICATION — Consultation, lab and x-ray reports filed in chart areinitialed by the ordering physician to signify review.J. IMMUNIZATION RECORD — For pediatric (ages 10 and under) records, there is acompleted immunization record or a notation that “immunizations are up to date”.K. PREVENTIVE SERVICES — There is evidence that preventive screening and servicesare offered.L. HEALTH PLAN ID — It is recommended that patients should be identified as HealthPlan patients. This evidence will assist in obtaining authorization and referrals whennecessary.M. ADVANCE DIRECTIVE — There is evidence that information regarding advancedirectives was provided to Health Plan member age 18 and over.T:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 3 of 8

BEHAVIORAL HEALTHSTDNBRSTANDARDDOESNOTAPPLYMETNOTMETAdditional Surveyor's CommentsSurvey Performed By:Date:T:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 4 of 8

BEHAVIORAL HEALTHProvider Name:(Please Print)Specialty:Provider Street Address:Provider Number:City: State: ZIP Code: Date:I. EKGs performed in office. Yes NoHolter Monitor performed in office. Yes NoRequires:A. Type of Equipment:B. Names of technical personnel:C. Who does interp? and/or complete?II. Echocardiograms performed in office. Yes NoCardiac Stress Test Yes NoCarotid Studies Yes NoPeripheral Vascular Studies Yes NoRequires:A. Type of Equipment:B. Type of Protocol:C. Names of technical personnel:D. Qualifications of technical personnel (attach copies of certification)III. Laboratory Work performed in office. Yes NoRequires:A. Copy of CLIAB. Complete the following checklist of labwork performed in your officeCHEMISTRYAlbuminAlbumin/Globulin RatioBilirubin, totalBUNCalciumCarbon Dioxide ContentChloridesCholesterolCPKCreatinineGlobulinGlucoseLDLOsmolalityPhosphatase, alkalinePhosphorus inorganic phosphatePotassiumProtein, totalSGGTSGOTSGPTSodiumUric AcidT:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 5 of 8

BEHAVIORAL HEALTHIII. Laboratory Work performed in office — continuedCHEMISTRY / TOXICOLOGYLipid ProfileUrinalysisGlucose Tolerance TestHemoccult, FecesPregnancy TestTheophylline LevelTriglyceridesUrobilinogenT3T4TSH & Thyroid ProfileHEMATOLOGYCBCDifferentialHematocritHemoglobinProtimePlatelet CountRBCSed RateWBCIMMUNOLOGYMono TestStrep ScreenANATOMIC PATHOLOGYPap SmearMICROBIOLOGYBacterial Culture(Including gonococcal)Occult blood, any source except fecesChlamydia culture/sensitivityThroat cultureMISCELLANEOUSUrine cultureUrine culture with colony countADDITIONAL LABORATORY TESTS Please list additional laboratory tests not already checked (If more space is needed, please use back of form) Are any of the laboratory tests done by automated analysis? Yes No If yes, list name and/or type of equipment: Please indicate from the following list the members of your staff who perform the laboratory tests and their credentials:PERSONNELCREDENTIALSMDRN/LPNRECEPTIONIST/SECRETARYMED. TECH.LAB. TECH.OTHER (specify)C. Equipment used:T:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 6 of 8

BEHAVIORAL HEALTHIII. Laboratory Work performed in office — continuedD. Names of technical personnel:E. Qualifications of technical personnel (attach copies of certification)IV. X-Rays performed in office. Yes NoRequires:A. Certificate of inspection from state agency/or, certificate from health physicist.B. Names of technical personnel:C. Qualifications of technical personnel (attach copies of certification)D. Name of interpreting physician:E. Qualifications of interpreting physician:Billing: Identify who bills the technical and professional parts of the claim.TECHNICAL:PROFESSIONAL:V. OtherAny other test/procedure performed in the office should be listed here.The requirements for any test/procedure include:A. Type of Equipment:B. Names of technical personnel:C. Qualifications of technical personnel (attach copies of certification)D. Interpretation by:E. Other pertinent information:T:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 7 of 8

BEHAVIORAL HEALTHAdditional Surveyor's CommentsCompleted By:Date:T:\SITESURV\New Site Survey Score\SITE SURVEY BEHAVIORAL 499B.doc Page 8 of 8

The Health Plan Office OrientationOrientation Service Call Recruitment Site Visit( Please Print )Group Name:Date:Address:City: State: Zip:Physicians :Contact:Phone:Email Address:EducationReferrals/Pre-CertificationsNetwork OR Out of NetworkPrompt PayBalance Billing (Advance Beneficiary Notice)Co-payments, Deductibles, Co-insurance24/7 Availability – Covering Physician(s)Laboratory usage (Contracted Labs, Hospitals)Medicare Fraud, Waste, & Abuse Awareness TrainingDisease ManagementMember Identification CardsOverview of Health Plan ProductsHealth Plan Billing & EDI GuidelinesSubmission of ClaimsRed and White Claim Forms Only – No FaxingNo Handwriting on ClaimsSubmission of Additional lnformation by FaxResubmissions of ClaimsPaper – Red and White FormsElectronic – Use HlPAA (Frequency Flag of 7)Electronic ClaimsHealth Plan Public WebsiteHealth Plan Provider Practitioner ManualHealth Plan Provider Educational MaterialsHealth Plan Provider DirectoriesReimbursementCodingHealth Plan Policy and ProcedureOther:Health Plan Secure Provider WebsitePrimary Contact RequiredClaim StatusEligibility lnformation for MembersReferral StatusSubmission of Electronic Professional ClaimsVouchers – Download to ObtainRelease Website Access to Billing ServiceClearinghouse or Submitters:Electronic Remittance:Direct Deposit FormBilling Service:Billing Service Contact:Resubmissions of ClaimsPaper – Red and White FormsElectronic – Use HlPAA (Frequency Flag of 7)T:\SITESURV\Office Orientation Form\Office Orientation Form 2013-02-18.docCOB Claims Accepted Electronically1

The Health Plan Office OrientationGroup Name:Date:Physician Site VisitNew PractitionerEducational VisitQuality / Member Complaint VisitQuality ImprovementPractice Standards and GuidelinesOrientationNew Practitioner / GroupRe-OrientationOther:DeliverDirectoriesPractitioner Manual (Website)Provider FocusChart StickersProduct MatrixBehavioral HealthCrisis Encounter Form Request for Continuation of Treatment Other:CommentsOffice Representative Signature:Network Representative:Date:Date:2T:\SITESURV\Office Orientation Form\Office Orientation Form 2013-02-18.doc

Section 15 / Page 24

THE HEALTH PLANSTANDARDS FOR PATIENT RECORDSThe medical record should be organized with the various types of information placed in a consistentlocation to enable easy access for reviewing the chart. Practitioners are responsible for medicalrecords that were created in their office only.1. PATIENT IDENTIFICATIONEach page in the record contains the patient’s name and date of birth. A page is defined as asingle sheet of paper. If front and back or tri-fold, the name and date of birth is expected toappear at least once.2. BIOGRAPHICAL/PERSONAL DATAPersonal/biographical data includes address, home and work telephone numbers.3. HEALTH PLAN IDThe member is clearly identified as a Health Plan member.4. ADVANCE DIRECTIVESThere is evidence that information regarding advance directives was provided to Health Planmembers age 18 and over.5. COMPLETED PROBLEM LISTA problem list noting significant and/or chronic medical conditions is in the medical record.A problem list is a separate document from the physician’s clinical notes. The problem listand the medication list may be on the same page.6. COMPLETED MEDICATION LISTMedication list includes name of medication, dosage, frequency, start date and stop date.Medication lists should be reviewed and updated with each visit. Any change to medicationsrequires either dating and initialing the change or entering a stop date for the initial entry andre-entering the medication with the change. The medication list and problem list may be onthe same page.7. ALLERGIES & ADVERSE REACTIONSMedication/food allergies and adverse reactions are prominently noted in the record.Absence of allergies should be recorded as NKA. The documentation for allergies should bein a consistent location in all charts. Compliance can be met with the use of allergy stickersand/or documentation in the chart.8. PROVIDER IDENTIFICATIONAll entries in the medical record contain author identification. Initials may be used only ifthere is a signature log identifying 1 st initial, last name, and credentials. Electronic signaturesfor computerized records are acceptable. This standard excludes ancillary documents such asproblem list, medication list, flow sheets e.g., Health Plan Diabetic Flow Sheet.Section 15 / Page 25

THE HEALTH PLANSTANDARDS FOR PATIENT RECORDS9. DATED ENTRIESAll entries are dated. Ancillary documents such as problem list, medication list, flow sheetse.g., Health Plan Diabetic Flow Sheet may or may not be dated as long as each entry is dated.10. LEGIBILITYThe record is legible to someone other than the writer. Any record judged illegible by onephysician reviewer should be evaluated by a second reviewer. A second reviewer can beoffice staff. Non-compliance occurs when a second reviewer cannot read the entry.11. EVIDENCE OF REVIEW - DIAGNOSTICS/CONSULTATIONSConsultations, lab, and x-ray reports filed in chart are initialed by the primary/secondary carephysician to signify review. Consultation and abnormal lab and imaging study results havean explicit notation in the record of follow-up plans.12. HISTORY AND PHYSICAL (H&P)The History and Physical documents contain subjective and objective information. H&Psperformed by other medical professionals participating in a member’s care meetscompliance. Patient-completed questionnaires count as evidence of compliance for historycomponent.13. LAB/OTHER STUDIESAll lab and other studies are ordered as appropriate for member age, gender and symptoms,as well as chronic conditions per The Health Plan guidelines.14. PLAN OF ACTION/TREATMENTThere must be evidence of a plan of action/treatment for presenting problem(s). Preventiveor health maintenance exams do not require an action plan.15. RETURN VISIT/FOLLOW-UPEncounter forms or notes have a notation, when indicated, regarding follow-up care, calls, orvisits. The specific time of return is noted in weeks, months, or PRN.16. PROBLEMS FROM PREVIOUS VISITSUnresolved problems from previous office visits are addressed in subsequent visits.Unresolved is defined as an illness or symptoms not responding to treatment.17. CONSULTATIONThere is evidence of use of consultants if condition does not improve or is outsidethe expertise of the primary care physician.18. CONTINUITY AND COORDINATION OF CAREIf a consultation is requested, there should be a note from the consultant in the record. Therecord should indicate communication and feedback between the primary care physician andspecialists.Section 15 / Page 26

THE HEALTH PLANSTANDARDS FOR PATIENT RECORDS19. EMERGENCY ROOM VISITSThere is evidence in the medical record of visits to emergency rooms, when applicable.20. HOSPITAL ADMISSIONSThere is evidence in the medical record of admissions to hospitals, when applicable.21. TOBACCO USEFor patients age 11 and over, assessment of the use of tobacco and smokeless tobacco mustbe documented. Counseling must occur with identification of tobacco use.22. ALCOHOL USEFor patients age 11 and over, assessment of the use of alcoholic beverages must bedocumented. Counseling must occur with identification of alcohol use.For patients age 21 and over, assessment of the use of alcoholic beverages must bedocumented. Moderate drinking is defined as no more than one drink a day for women andno more than two drinks a day for men. Twelve ounces of beer; 5 ounces of wine; or 1.5ounces of distilled spirits (80 proof) counts as one drink. Counseling must occur if alcoholabuse is identified.23. SUBSTANCE ABUSEFor patients age 11 and over, assessment of substance abuse must be documented.Counseling must occur with identification of substance abuse.24. PREVENTIVE SERVICESThere is evidence that preventive screening and services are offered in accordance with TheHealth Plan Preventive Health Guidelines.25. IMMUNIZATION RECORDAn immunization record for children and adults is up to date according to The Health PlanPreventive Health Guidelines. Practitioners not providing immunizations in their offices areresponsible for obtaining updated information from source providing the immunizations.-----------------------------------------------------------------------------------------------------------Resources used in standard development: The Health Plan Quality Improvement Committee The Health Plan Guidelines Delmarva Quality Improvement Standards CMS Quality Improvement Standards Centers for Disease Control US Department of Health and Human ServicesSection 15 / Page 27

PHYSICIAN:THE HEALTH PLAN - MEDICAL RECORD AUDIT - 2014T:\PHYSBILL\2014 Billing Manual\Section 8 QI\Medical Record Audit Tool - 2014.docMEMBER:CATEGORY #1 - MEDICAL RECORD ORGANIZATION Points YES NO N/A1. Do all pages contain patient name and date of birth? 42. Is there biographical/personal data? 43. Is the member clearly identified as a Health Plan member? 44. Is there evidence that information regarding advance directives was provided? (18 yrs & over) 45. Is there a completed problem list noting significant illnesses and medical conditions? 46. Is there a completed medication list? 47. Are allergies and adverse reactions to medications/food prominently displayed?(If appropriate, NKA displayed)48. Is the provider identified on each entry? 49. Are all entries dated? 410. Is the record legible? 411. Do consultant summaries, lab, and imaging study results reflect primary care physician review?Include notation of abnormal test results.412. Does the record contain a history and physical? 413. Are lab and other studies ordered as appropriate? 414. Evidence of plan of action/treatment for presenting problem (s)? 415. Is there a notation for return visit or other follow-up plan for each encounter? 416. Are unresolved problems from previous visits addressed? 417. Is there evidence of use of consultants if indicated? 418. Is there evidence of continuity and coordination of care between PCP and specialists? 419. Is there evidence in the medical record of visits to the emergency room if applicable? 420. Is there evidence in the medical record of an admission to a hospital if applicable? 421. TOBACCO USE: Is there documentation of tobacco use, including smokeless tobacco?Is counseling documented with history of tobacco abuse? (11 years and over)Not Assessed0 pts.Assessed,Non-Smoker4 pts.Assessed, Smoker,but Not Counseled0 pts.22. ALCOHOL USE: Is there documentation of alcohol use?Is counseling documented with history of alcohol abuse? (11 years and over)Not Assessed0 pts.Assessed,Non-Smoker4 pts.Assessed, Smoker,but Not Counseled0 pts.Assessed, Smoker,& CounseledAssessed, Smoker,& Counseled23. DRUG USE: Is there documentation of substance abuse?Is counseling documented with history of substance abuse? (11 years and over)4Assessed,Assessed, Smoker,Assessed, Smoker,Not Assessed 0 pts.4 pts.0 pts.4 pts.Non-Smoker but Not Counseled& Counseled24. Are preventive services offered per The Health Plan Preventive Health Guidelines? 425. 4Health Guidelines?TOTAL SCORE: %Section 15 / Page 284 pts.4 pts.44

PROVIDER PROCEDURAL MANUAL 2014MEDICAL RECORDS AND CONFIDENTIALITY STATEMENTTo ensure that a separate comprehensive medical record is created and maintained in aconfidential manner for each member as well as to provide easy access to all biographical andmedical information and to promote quality care.All participating physicians and providers shall maintain a separate on-site and up-to-datemember medical record in accordance with The Health Plan Standards for Patient Recordsas well as compliance with all Federal and State laws and regulations, which are consistent withall Federal and State laws and regulations, which are consistent with good medical andprofessional practice.All physicians shall preserve all records related to members for a period of not less than ten(10) years and retain longer if the records are under review or audit.The medical records shall be made available, as needed, to each physician treating the member.These records will be made available upon request of an authorized representative of The HealthPlan for medical audit, utilization review, fiscal audit, and other periodic monitoring.All medical records and discussion of details regarding patient information shall be confined tothat which is necessary to complete normal job duties. Such discussion outside regular workingduties and home is strictly prohibited.Members shall have the opportunity to approve or deny the release of identifiable personalinformation by the physician or the provider except when the release is required by law. Memberinformation shall not be released without signed authorization.Copying of member medical records and other data containing patient information shall be kept tothe minimum that is needed to accomplish work. Member information, whether personal ormedical, shall be released only when necessary.All member’s medical record information shall be kept confidential. All files have limited access and not left open wheresomeone could casually read them. Computer system files require special password capabilityfor access. All computer terminals accessing themainframe shall be logged off at the close of each day toprevent unauthorized access to system data.All member medical records requiring disposal shall be placed inappropriate receptacles for shredding. Burning may be used in lieuof shredding.All physicians shall require the review of this policy with any new employee, and with allemployees on an annual basis.Section 15 / Page 29

PROVIDER PROCEDURAL MANUAL 2014SIGNATURE LOGPhysician offices should sign all entries in patient’s charts either by a signature or initials(full name & title). When initials are used, a record of the initials along with the person’sname should be kept on file in each office.For your convenience, we have devised a “Signature Log” for your use. The formcontains the following sections:Legible Name — Print the employee’s name.Credentials — MD, DO, DPM, DDS, CNP, NP, PA, & etc.Legal Signature with Credentials — Have the employee signtheir name with credentials.Any Signature Variations — Employee signature if differentfrom their legal signature.A copy of the form is shown on the next page and may be reproduced.On-site visits of physician offices will be conducted spontaneously to review charts, officeprocedures, hazardous waste disposal, and Pharmaceutical and narcotic storage.The Provider Relations Department attempts to educate offices regarding these areas as wereceive additional information. It is the office’s responsibility to implement these procedures.Section 15 / Page 30

Signature LogLegible Name( Print / Type )CredentialsLegal Signature with CredentialsUnacceptable Unless …1. The provider authenticated Typed Name.2. Non-Physician or Non Physician Extender co-signed by acceptable physician.3. Provider of Services’ Signature without Credentials Name linked to provider credentials or name on physicianstationary.4. Illegible Signature verified from a signature log.Section 15 / Page 31

PROVIDER PROCEDURAL MANUAL 2014TELEPHONE MESSAGE FORMAt the request of many offices, we have devised a “Telephone Message Form” on the next pagefor your use. This form contains the necessary information needed to document phone callsreceived from patients. It provides space for recording times and intervention that may beimportant. By using this form, you may reduce the number of messages contained in your charts.In today’s legal climate, it is increasingly important to document accurately and in acomprehensive manner. One office had indicated that a form such as this afforded them theprotection and documentation necessary to defend their office against a liability claim.Use of this form is recommended but not mandatory.Section 15 / Page 32

Today’s Date:Time:PATIE NT INFORMA TIO NLast Name: First Name: Middle Name: Birth Date:Street Address: Social Security No.: Home Phone No.:( )P.O. Box: City: State: ZIP Code:Person Calling:Reason Calling:Phone Number Where Patient Can Be Reached: ( )( )Doctor’s Name:Time Message Reviewed:INTERVENTIONSchedule appointment for: Date: Time:Doctor will call patient on: Date: Time:Nurse will call patient on: Date: Time:List Instructions Given to Patient:Instructions given to:Patient:Family Member (Name):Section 15 / Page 33


PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN TELEPHONE DIRECTORYOhio Valley and Mountaineer RegionsHomeTown Region800-624-6961 877-236-2289740-695-3585 330-834-2200HEALTH PLAN TITLE ST. CLAIRSVILLE MASSILLONIN-PLANElective Admissions, Non-Emergent Referrals,Diagnostics and Imaging Pre-AuthorizationNotification of Urgent/Emergent Admissions toparticipating in-plan facilitiesAUTHORIZATIONSReferral Intake RepresentativeReferral Intake ASO RepresentativeReferral Intake PPO Representative790579107123282479107123Hospital Review Nurse 7918 2237OUT-OF-PLAN (TERTIARY)All ServicesReferral Intake RepresentativeReferral Intake ASO RepresentativeReferral Intake PPO Representative790579107123282479107123INQUIRIES; CLAIMS, REFERRALS & AUTHORIZATIONS, ELIGIBILITY, PROVIDER STATUS, & COMPLAINTSMembers Customer Service Representative 740-695-7902 or888-847-7902330-837-6880 or800-426-9013ASO Members ASO Customer Service Representative 740-695-7910 or888-816-3096740-695-7910 or888-816-3096PPO Members PPO Customer Service Representative 740-695-7123 or855-577-7123740-695-7123 or855-577-7123Quality Complaints Quality Improvement Coordinator 7664 7664Section 16 / Page 2

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN TELEPHONE DIRECTORYHEALTH PLAN TITLE ST. CLAIRSVILLE MASSILLONCOORDINATION OF BENEFITS (COB)Claims Pending/In Process/Denied for COB Reasons COB/Funds Recovery Representative 740-695-7903 or800-624-6961Ext 7903SUBROGATION COB/Funds Recovery Rep. 740-695-7903 or800-624-6961Ext 7903330-837-6880 or800-426-9013330-837-6880 or800-426-9013MEMBER INQUIRIESASO Groups’ BenefitsClaim Payments/DenialsCustomer Service Representative740-695-7910 or888-816-3096740-695-7910 or888-816-3096Groups’ BenefitsClaim Payments/DenialsCustomer Service Representative740-695-7902 or888-847-7902330-837-6880 or800-426-9013PPO Groups’ BenefitsClaim Payments/DenialsCustomer Service Representative740-695-7123 or855-577-7123740-695-7123 or855-577-7123Mountain Heath Trust BenefitsClaim Payments/DenialsCustomer Service Representative740-695-7904 or888-613-8385SecureCare (Medicare) BenefitsClaim Payments/DenialsCustomer Service Representative740-695-7907 or877-847-7907330-834-2301 or877-236-2290Section 16 / Page 3

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN TELEPHONE DIRECTORYHEALTH PLAN TITLE ST. CLAIRSVILLE MASSILLONPHARMACY Pharmacy Services /Prescription Prior Authorization740-695-7914 or888-847-7914740-695-7914 or888-847-7914PHYSICIAN / ANCILLARY INQUIRIESClaim Payments/Denials, Voucher Questions, Claims inProcess, Payment Level ConcernsCustomer Service Representative(Provider Line)740-695-7901 or877-847-7901330-830-4370 or888-830-4370ASO - Claim Payments/Denials, Voucher Questions,Claims in Process, Payment Level ConcernsASO Customer Service Representative(Provider Line)740-695-7910 or888-816-3096740-695-7910 or888-816-3096PPO - Claim Payments/Denials, Voucher Questions,Claims in Process, Payment Level ConcernsPPO Customer Service Representative(Provider Line)740-695-7123 or855-577-7123740-695-7123 or855-577-7123PHYSICIAN OFFICE CALLS REGARDINGVariances Medical Secretary 7644Current In-Patients Utilization Management Support 7639 or 7641Section 16 / Page 4

PROVIDER PROCEDURAL MANUAL 2014HEALTH PLAN TELEPHONE DIRECTORYHEALTH PLAN TITLE ST. CLAIRSVILLE MASSILLONMEMBER CHANGING PHYSICIAN SELECTIONASO Groups’ Member Changing/Selecting Primary orSecondary Care PhysicianCustomer Service Representative740-695-7910 or888-816-3096740-695-7910 or888-816-3096Commercial Groups’ Member Changing/SelectingPrimary or Secondary Care PhysicianCustomer Service Representative740-695-7902 or888-847-7902330-837-6880 or800-426-9013Mountain Heath Trust Member Changing/SelectingPrimary or Secondary Care PhysicianCustomer Service Representative740-695-7904 or888-613-8385PPO Groups’ Member Changing/Selecting Primary orSecondary Care PhysicianCustomer Service Representative740-695-7123 or855-577-7123740-695-7123 or855-577-7123SecureCare (Medicare) Member Changing/SelectingPrimary or Secondary Care PhysicianCustomer Service Representative740-695-7907 or877-847-7907330-834-2301 or877-236-2290HEALTH PLAN ST. CLAIRSVILLE MASSILLON MORGANTOWNPHYSICIAN CHANGES IN PHONE, ADDRESS, TAX I.D., BACKUPAny Changes to Your Practice 740-699-6248 or 800-624-6961Ext 6248877-236-2289 304-598-3911 or 800-598-3911Ext 6500Section 16 / Page 5

Provider Procedural Manual - The Health Plan

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