Sierra Optima by Sierra Health and Life

Plan Payment GuideSierra Optima by Sierra Health and LifeProviders should submit claims for services directly to Sierra Optima as indicated in SierraOptima’s Terms and Conditions. Completed HCFA 1500 and UB-92 forms should be submitteddirectly to:Sierra Health and Life Insurance CompanyP.O. Box 15645Las Vegas, NV 89114-5645Sierra Health and Life Insurance Company is able to receive HIPAA-compliant electronic claimsfrom the following clearinghouses:HCRnet WebMd Envoy ENS2310 Paseo Del Prado, #208 One Century Plaza 7899 Lexington Drive, #203Las Vegas, NV 89102 26 Century Blvd, #601 Colorado Springs, CO 80920(702) 735-5525 Nashville, TN 37214 (800) 341-6141(615) 885-3700For electronic claims submissions, please use Payor ID 76342.

Claims shall be submitted within ninety (90) calendar days of the date of service. If a claimis submitted more than 90 calendar days after the date of service, it will not be honored forpayment.Claims will be processed according to Medicare guidelines and will be subject to the eligibilityand benefit provisions of the member’s plan.Reimbursement will be made based upon Medicare allowable amounts, as outlined in thefollowing pages, and will be made directly to the provider of service. Reimbursement willnot be less than the amount the provider would have received directly from Medicare.If the provider believes there is a discrepancy between the amount reimbursed by Sierra Optimaand the amount they would have received from Medicare, the provider can submit a requestfor reconsideration of payment by following the “Appeals Process” detailed in Sierra Optima’sProvider Summary Guide.As outlined in the Terms and Conditions, participating providers agree to accept the Medicareallowable amount minus the member’s cost-share amount as payment in full for services,regardless of whether or not they accept Medicare assignment.For questions or concerns regarding Sierra Optima’s reimbursement, please contact MemberServices at 888-274-2207.

Sierra Optima by Sierra Health and LifePlan Payment GuideBenefit CategoryPlan ReimbursementAcute Care Hospital - Inpatient Services Services are reimbursed at 100% of the diagnosis related group (DRG) underthe Prospective Payment System (PPS). This includes disproportionateshare hospital (DSH) and/or capital indirect medical expense (IME)payments. Operating IME and Graduate Medical Education (GME)payments are fully carved out. Organ acquisitions and bad debt are to bepaid on a case by case basis.Acute Care Hospital - Inpatient OutliersHospital - Outpatient ServicesHospital - Outpatient OutliersAcute Care Hospitals - Transfer fromand to Acute Care HospitalsAmbulanceAmbulatory Surgery CentersAssistant Surgeon - PhysicianServices are reimbursed per Medicare guidelines.Services are reimbursed at 100% of Medicare Ambulatory PaymentClassifications (APCs). Services excluded from the Outpatient ProspectivePayment System will be reimbursed 100% of the corresponding MedicareFee Schedule.Services are reimbursed per Medicare guidelines.The transferring hospital is reimbursed a per diem rate that is calculatedusing the full DRG amount divided by the Geometric Mean Length of Stayfor the DRG. The first hospital will be reimbursed double the per diem forthe first day of hospitalization. Regular per diem will be reimbursed for theremaining days of the hospital stay. Total reimbursement will not exceed thefull DRG amount.The final discharging hospital is reimbursed the full DRG amount.A hospital that transfers a patient classified into DRG 385 or 456 isreimbursed the full DRG amount.Services are reimbursed at 100% of the Medicare Ambulance Fee Schedule.Services are reimbursed at 100% of the Medicare Ambulatory SurgeryCenter (ASC) Fee Schedule and, if appropriate, are wage adjusted.Services are reimbursed at 16% of Medicare Physician Fee Schedule.Assistant Surgeon - Physician Assistant Services are reimbursed at 85% times 16% of Medicare Physician Fee Schedule.BloodCancer HospitalsChildren’s HospitalsClinical TrialsCritical Access HospitalsDurable Medical EquipmentEnd Stage Renal Disease FacilitiesServices are reimbursed at 100% of Medicare APC.Services are reimbursed per Medicare guidelines and are applicable toMedicare approved facilities only.Services are reimbursed per Medicare guidelines.Services are reimbursed directly by Medicare.Services are reimbursed per Medicare guidelines.Services are reimbursed at 100% of the Medicare Durable MedicalEquipment, Prosthetic Orthotic and Supplies (DMEPOS) Fee Schedule.Services are reimbursed at 100% of the Medicare composite rate.Services not included in the composite rate are reimbursed at 100% of thecorresponding Medicare Fee Schedule.

Benefit CategoryFederally Qualified Health CentersHome HealthInpatient Rehabilitation HospitalsLaboratoryLow Volume HospitalsPlan Payment Guide, continuedPlan ReimbursementServices are reimbursed at the lesser of the Medicare “all-inclusive rate” orthe national per visit limit. Providers are reimbursed 80% of the allowedcharge plus 20% of the actual charge minus the member’s cost-share.Services are reimbursed at 100% of the Medicare Prospective PaymentSystem (PPS) using the home health resource group (HHRGs) paymentgroups.Services are reimbursed at 100% of the Medicare PPS using the case-mixgroup (CMG) methodology.Services are reimbursed at 100% of the Medicare Laboratory Fee Schedule.Services are reimbursed per Medicare guidelines.Acute Long Term Care Services are reimbursed at 100% of the Medicare PPS (effective 10/1/06).Acute Long Term Care - OutliersMedicare Dependent HospitalsNon-physician ServicesPart B DrugsPhysician ServicesPsychiatric HospitalsPsychiatric Hospitals - OutliersRural Health ClinicsSkilled Nursing FacilitiesSole Community HospitalsSwing BedsServices are reimbursed per Medicare guidelines.Services are reimbursed per Medicare guidelines.Services are reimbursed as follows:- Clinical Nurse Specialist, 85% of Medicare Fee Schedule- Clinical Psychologist, 100% of Medicare Fee Schedule- Clinical Social Worker, 75% of Medicare Fee Schedule- Nurse Practitioner, 85% of Medicare Fee Schedule- Physician Assistant, 85% of Medicare Fee Schedule- Registered Dietician, 85% of Medicare Fee ScheduleServices are reimbursed per Medicare guidelines.Services are reimbursed at 100% of Medicare Physician Fee Schedule except for:- Anesthesia services which are reimbursed at 100% of Medicare payment- Co-surgeons who are reimbursed at 62.5% of the Medicare Fee ScheduleServices are reimbursed per Medicare guidelines.Services are reimbursed per Medicare guidelines.Services are reimbursed at the lesser of the Medicare “all-inclusive rate” orthe national per visit limit. Providers are reimbursed 80% of the allowedcharge plus 20% of the actual charge minus the member’s cost-share.Services are reimbursed at 100% of the Medicare Resource UtilizationGroups (RUGs) rates.Services are reimbursed per Medicare guidelines.- Participating providers agree to the Terms and Conditions of Sierra Optima.- Payment will be reduced by the applicable member cost-share.Services are reimbursed at 100% of the Medicare Resource UtilizationGroups (RUGs) rates.Sierra Optima is a product of Sierra Health and Life Insurance Company, Inc. with a Medicare contract to offer MedicareAdvantage Private Fee-For-Service plans available to anyone enrolled in both Medicare Parts A and B through age or disability.Benefits and premiums vary by state and county.Last revision: 03/200841NVSHL06859