con NORTHERN & TENCON HEALTH PLAN

Transcription

NORTHERN &
TENCON HEALTH
PLAN
Provider Manual
North
e rn He
January 2012
alt
hP
la
n
con
Health Plan
Northern Health Plan/Tencon Health Plan
P.O. Box 1511
Flint, Michigan 48501-1511
(888) 327-0671
FAX: (877) 502-1567
Northern Health Plan
Table of Contents
Introduction................................................................................................................................ Page 1
Section 1 Member Eligibility and Enrollment .................................................................. Page 2
Section 2
Disenrollment.....................................................................................................Page 4
Section 3 Member Identification Cards ............................................................................ Page 6
Section 4 Primary Care Provider Assignments................................................................ Page 10
Section 5 Change in Primary Care Provider Assignment................................................ Page 11
Section 6 Covered Services............................................................................................. Page 12
Section 7 Benefit Determination for Covered Medical Services..................................... Page 16
Section 8 Benefit Determination Process........................................................................ Page 17
Section 9 Covered Services – mihealth card................................................................... Page 22
Section 10 Prescription Benefit – Northern & Tencon Health Plan.................................. Page 23
Section 11 Prescription Benefit – mihealth card............................................................... Page 27
Section 12 Medical Supplies............................................................................................. Page 29
Section 13 Services Not Covered...................................................................................... Page 30
Section 14 Member Appeal Process.................................................................................. Page 33
Section 15 Provider Responsibilities................................................................................. Page 35
Section 16 Information Services........................................................................................ Page 36
Section 17 Billing Information.......................................................................................... Page 37
General Information
Directory.................................................................................................................................. Page 54
Appendixes
Appendix A Family Planning & BCCCP Services.............................................................. Page 57
Appendix B Member Information Change Form................................................................. Page 58
Appendix C County Health Plans Copay Amounts............................................................. Page 60
Appendix D Eligibility Viewing System.............................................................................. Page 61
Appendix E
Michigan County Codes.................................................................................. Page 62
Appendix F
Provider Claim Status Fax Form..................................................................... Page 63
Appendix G Provider Claim Adjustment Form................................................................... Page 64
Appendix H Provider Request for Appeal Form.................................................................. Page 65
INTRODUCTION
Many communities in Michigan are using an innovative approach to providing health care
benefits to persons in need. Programs called County Health Plans are serving as a vehicle to
provide access to organized systems of health care for the indigent uninsured and lower income
persons without private or public health insurance.
This “coverage” model has been widely used throughout Michigan. Typically, a not-for-profit
organization is formed in each of the communities where plans exist. The plans contract with
providers and hospitals to provide care to enrollees. Each County Health Plan is unique and
therefore has its own budget and set of covered benefits.
Each County Health Plan is responsible for administering the State’s Adult Benefits Waiver
(ABW) program for the county or counties it services. The ABW program provides health care
for the State’s childless adult residents with income at or below 38 percent of the Federal Poverty
Level. Individuals who qualify for the ABW program are enrolled through the local Department
of Human Services (DHS), formerly known as the Family Independence Agency (FIA), and
automatically made eligible for the County Health Plan - Plan A.
Through hospital contributions, most County Health Plans have expanded their coverage
program to include low income uninsured residents with incomes between 39 and 200 percent of
the Federal Poverty Level. Residents of the county are determined eligible by a local
organization, such as the county health department, and enrolled in the County Health Plan - Plan B.
Northern and Tencon County Health Plans have a contractual arrangement with McLaren Health
Advantage to administer its plans.
This manual is an instruction handbook and reference guide. It is intended to offer additional
detail to areas covered in the contract between the County Health Plan and the participating
provider. It is also intended to provide instruction to staff when managing the care of County Health
Plan members.
Northern and Tencon Health Plans
Customer Service
(888) 327-0671
www.mclarenhealthadvantage.org
1
Section 1
MEMBER ELIGIBILITY AND ENROLLMENT
PLAN A
.01 Northern Health Plan (NHP) and Tencon Health Plan (THP) are responsible for
administering the ABW program.
.02
Childless adults, 19-64 years old and with countable income at or below 38% of the
Federal Poverty Level, may be eligible for the ABW program.
.03 All eligibility for the ABW program is determined by the DHS.
.04 Persons determined eligible for the ABW program by DHS are enrolled in NHP or THP Plan A.
.05 Eligibility begins the first day of the next available month after the person is determined
eligible by DHS.
.06 Applicants unable to meet the eligibility criteria for the ABW program are classified as
ineligible for NHP or THP - Plan A.
.07 The State of Michigan determines open enrollment periods for the ABW program.
PLAN B
.08 Subject to enrollment limitations, persons must meet the following criteria established by
NHP and THP to be eligible for Plan B:
a) NHP - Be a resident of Alpena, Antrim, Charlevoix, Cheboygan, Emmet, Montmorency,
Otesgo, or Presque Isle County
THP - Be a resident of Crawford, Kalkaska, Lake, Manistee, Mason, Mecosta,
Missaukee, Newaygo, Ocena, or Wexford County
b) Be ineligible for Medicaid, ABW program, Medicare, Healthy Kids, MIChild, or any
other health insurance or medical benefit, including employer-sponsored health
insurance
c) NHP - Have a yearly household income equal to or below 200 percent of the Federal
Poverty Level
THP - Have a yearly household income equal to or below 150 percent of the Federal Poverty Level
Customer Service
(888) 327-0671
2
.09 Eligibility Determination:
.10
Eligibility Limitations:
a) All eligibility determination for NHP and THP - Plan B is done by NHP/THP
b) Applicants unable to meet NHP or THP’s eligibility criteria are classified as ineligible
a) NHP/THP reserves the right to determine whether a person meets the eligibility criteria
established by Section 1.08 (a-c)
b) If funds are limited, NHP/THP may limit enrollment.
Customer Service
(888) 327-0671
3
Section 2
DISENROLLMENT
PLAN A
.01 The local Department of Human Services (DHS) is responsible for disenrolling members
from the ABW program (NHP/THP - Plan A). When a member is no longer
eligible, NHP/THP is notified by the local DHS of the member’s change in enrollment
status.
.02 Upon cancellation, coverage will end on the last day of the month the member’s ABW
program eligibility ended.
.03 If a member is disenrolled from NHP/THP due to incarceration, the effective date of the
disenrollment is the date on which the member was incarcerated, not the last day of the
month.
.04
If a member moves out of NHP or THP’s service area, NHP/THP retains responsibility for that
member until the member is disenrolled. The member will be disenrolled when the
member’s case is transferred to the DHS in the new county of residence. The enrollment
in the new County Health Plan will begin the first day of the next available month after
the case is transferred. If the member moves to a county where there is no County Health
Plan, the member is enrolled in the State’s fee-for-service ABW program.
.05 If a member is enrolled in NHP or THP - Plan A in error, and the State is notified within 15
days, the member will be disenrolled retroactively to the first day of enrollment. If the State
is notified after 15 days of the error, the disenrollment will be prospective.
.06 NHP/THP may not encourage a member to disenroll because of health care needs or a change
in health care status.
.07 NHP/THP may initiate special disenrollment requests, to the State of Michigan, based on
actions inconsistent with NHP or THP membership. Requests fall under the following
general categories:
a) Violent or Life Threatening Behavior
b) Fraud or Misrepresentation
c) Other Non-Compliant Behavior
.08 If the member is disenrolled, NHP/THP is responsible for the member until the date of
disenrollment.
PLAN B
.09 The member may cancel his/her membership at any time by contacting NHP/THP.
Customer Service
(888) 327-0671
4
.10 A member may be disenrolled by NHP/THP for any of the following reasons:
a) NHP/THP limits enrollment and must terminate memberships, or terminates its operation
for any reason
b) The member fails to meet the eligibility criteria established by Section 1.08 (a-c)
c) The member’s actions are inconsistent with NHP or THP membership:
i. Non-Compliance - Abusive or inappropriate behavior or language
ii. Non-Compliance - Failure to follow treatment plan or medical advice of
healthcare provider
iii. Non-Compliance - Failure to keep scheduled appointments
iv. Non-Compliance - Failure to pay required “co-pays”
v. Non-Compliance - Failure to cooperate in providing information requested by
the Health Plan or provider’s office
vi. Non-Compliance - Inappropriate use of non-plan providers
vii. Non-Compliance - Inappropriate urgent care or emergency room use
viii. Non-Compliance - Inappropriate prescription use
ix. Fraud - Altering prescriptions
x. Fraud - Forging prescriptions
xi. Fraud - Stealing prescriptions
xii. Fraud - Impersonating a provider to obtain prescriptions
xiii. Fraud - Allowing others to use one’s NHP/THP card to receive health care
xiv. Fraud - Using the health plan benefits in furtherance of a crime
xv. Violent or Life Threatening Behavior - Physical acts of violence
xvi. Violent or Life Threatening Behavior - Physical or verbal threats of violence
xvii. Violent or Life Threatening Behavior – Stalking
.11 In the event that a member is disenrolled for reasons in Section 2.10 (a), NHP/THP may
reenroll per guidelines established by NHP/THP.
.12 A member disenrolled for failure to meet eligibility guidelines, Section 2.10 (b), will be
eligible to reenroll at any time assuming he/she meets the eligibility criteria established
by NHP/THP, NHP/THP is in operation, and enrollment limitations have not been enforced.
.13
A participating provider may request a member be discharged from the practice for
reasons stated in Section 2.10 (c). The participating practice should inform the NHP/THP of
the request to discharge and provide supporting documentation upon request.
.14 A member disenrolled for reasons set forth under Section 2.10 (c) shall have the right to
appeal. (See Section 14 for more information.)
Customer Service
(888) 327-0671
5
Section 3
MEMBER IDENTIFICATION CARDS
PLAN A
.01 NHP and THP are responsible for administering the ABW program.
.02 NHP/THP members will receive a permanent plastic mihealth card from the State of Michigan
approximately ten (10) days after the member is determined eligible by DHS.
The beneficiary will use only the mihealth card until he/she is enrolled
in NHP/THP - Plan A. Once the beneficiary is enrolled in NHP/THP - Plan A, he/she will
use the mihealth card for a limited number of covered services. (See Section 6 for more
information)
.03 ABW program beneficiaries enrolled in NHP/THP - Plan A will also receive a NHP/THP
identification card. The member will use their NHP/THP card for each month he/she is
eligible for NHP/THP ABW program. (See Section 6 for more information)
Identification card - Adult Benefits Waiver program/mihealth card
Line 1
Line 2
.04 mihealth ID card information:
a) Line 1: This number represents the ABW program recipient’s ID number
assigned by DHS
b) Line 2: ABW program beneficiary’s full name - One family member per card.
Customer Service
(888) 327-0671
6
.05
Important information about the ABW program beneficiary’s ID card:
a) The mihealth card must be carried by the beneficiary at all times
b) The beneficiary should not throw his/her mihealth card away. The beneficiary will
use the mihealth card each month he/she is eligible for the NHP/THP ABW program
c) The beneficiary must contact the Beneficiary Help Line at (800) 642-3195 if he/she
does not receive a mihealth card, or if his/her card is lost, stolen or damaged. A
replacement card will be mailed.
d) Lost, stolen or damaged cards are replaced at no cost to the beneficiary.
.06 The beneficiary must report name and address changes to his/her DHS caseworker before
the Help Line will issue a replacement card.
Identification card - NHP/THP - Plan A
NORTHERN HEALTH PLAN
Line 1
Line 2
To verify eligibility, please call
Customer Service toll free (888) 327-0671
Member Name: «MemberName»
ID #:
«MemberID»
Assigned Office: «ClinicName»
Plan: A
COPAYMENTS: (may apply for each charge, procedure, or visit)
Office Visit
Xray
Lab
ER
Prescription
$3.00
$0.00
$0.00
$0.00
$1.00/$1.00
Pharmacy
Management
Systems Inc.
Line 3
Line 4
Tencon Health Plan
3766 W. 12 Mile Road #224
Pharmacy Provider Support
Berkley, MI 48072
Argus Health Systems
RxBin #: 600428 • RxPCN: 01990000
1-800-522-7487
This card is not proof of program eligibility. Please keep this card with you at all times.
Line 1
Line 2
ID #:
«MemberID»
COPAYMENTS:
Office Visit
$3.00
Pharmacy
Management
Systems Inc.
Plan: A
Line 3
(may apply for each charge, procedure, or visit)
Xray
$0.00
Lab
$0.00
ER
$0.00
Prescription
$1.00/$1.00
Line 4
3766 W. 12 Mile Road #224
Berkley, MI 48072
1-800-522-7487
RxBin #: 600428 • RxPCN: 01990000
.07 NHP/THP Plan A ID card information:
a) Line 1: Member’s full name - One family member per card
b) Line 2: Member’s identification number – The ID # is a 7 digit numeric ID number
c) Line 3: Assigned office – This is the primary care office/doctor the member has been
assigned to
d) Line 4: Copay amount - The member’s financial responsibility for each visit,
procedure or prescription (see Appendix C for a list NHP/THP - Plan A
copay amounts)
Customer Service
(888) 327-0671
7
.08 Important information about a member’s NHP/THP ID card:
a) A NHP/THP member will receive his/her ID card after he/she becomes
eligible for NHP/THP. Providers can verify coverage online through FACTSWeb at
www.mclarenhealthadvantage.org or by calling Customer Service at (888) 327-0671
b) A member’s NHP/THP ID card and member information are mailed to his/her mailing
address unless specified otherwise
c) The NHP/THP card must be carried by the member at all times
d) The member should notify NHP/THP Customer Service by calling (888) 327-0671
when a card is lost, stolen or damaged
e) Lost, stolen or damaged cards are replaced at no cost to the member
f) If a card is mailed to a member and is returned to NHP/THP for insufficient or incorrect
address, the card will be returned to Customer Service
g) The identification card is the property of NHP/THP. The member is responsible for
returning his/her card upon request.
PLAN B
.09 Plan B members will receive a NHP/THP identification card that will arrive
after the member has been determined eligible. The member will use their
NHP/THP ID card each month he/she is eligible. The Plan B member will not receive
a mihealth card.
Identification card - NHP/THP - Plan B
NORTHERN HEALTH PLAN
Line 1
Line 2
ID #:
«MemberID»
Plan: B
COPAYMENTS: (may apply for each charge, procedure, or visit)
Office Visit
Specialist Visit
Xray
Lab
Prescription
$5.00
$5.00
$0.00
$0.00
50%
Pharmacy
Management
Systems Inc.
Line 3
Line 4
3766 W. 12 Mile Road #224
Berkley, MI 48072
RxBin #: 600428 • RxPCN: 01990000
1-800-522-7487
Tencon Health Plan
Line 1
ID #:
«MemberID»
Line 2
COPAYMENTS:
Office Visit
$5.00
Pharmacy
Management
Systems Inc.
Line 3
Plan: B
(may apply for each charge, procedure, or visit)
Specialist Visit
$5.00
Xray
$0.00
Lab
$0.00
Prescription
$5 Generic
$10 Brand
Line 4
3766 W. 12 Mile Road #224
Berkley, MI 48072
1-800-522-7487
RxBin #: 600428 • RxPCN: 01990000
Customer Service
(888) 327-0671
8
.10 NHP/THP Plan B ID card information:
a) Line 1: Member’s full name - One family member per card
b) Line 2: Member’s identification number – The ID # is a 7 digit numeric ID number
c) d) .11 Line 3: Assigned office – This is the primary care office/doctor the member has been
assigned to
Line 4: Copay amount - The member’s financial responsibility for each visit,
procedure or prescription (see Appendix C for a list of NHP/THP - Plan B
copay amounts)
Important information about a member’s NHP/THP ID card:
a) After the person is determined eligible they will receive their NHP/THP ID card.
Providers
can
verify
coverage
online
through
FACTSWeb
at
www.mclarenhealthadvantage.org or by calling Customer Service at (888) 327-0671
b) A member’s NHP/THP ID card and member information are mailed to his/her mailing
address unless specified otherwise
c) The NHP/THP ID card must be carried by the member at all times
d) The member should not throw his/her card away. The member will use the NHP/THP card
each month he/she is eligible
e) The member should notify Customer Service by calling (888) 327-0671 when a
card is lost, stolen, or damaged
f) Lost, stolen, or damaged cards are replaced at no cost to the member
g) If a card is mailed to a member and is returned to NHP/THP due to an insufficient or
incorrect address, the card will be returned to Customer Service
h) The identification card is the property of NHP/THP. The member is responsible for
returning his/her card upon request.
Customer Service
(888) 327-0671
9
Section 4
PRIMARY CARE PROVIDER ASSIGNMENTS
PLAN A & PLAN B
.01 Members enrolled in NHP/THP must use participating providers.
.02 Members are assigned to a participating primary care practice according to the following
guidelines:
a) All placements are coordinated by NHP/THP
b) At the time of enrollment, the member is assigned to a participating primary care
practice
c) All reasonable attempts are made to assign a member to his/her present primary care
practice; however, due to capacity and contractual issues, this may not be possible
d) At the participating primary care provider’s request and with good cause, a member
enrolled in Plan A only may be placed with a non participating primary care practice. All
placements must be approved and coordinated by NHP/THP. For more information
contact Customer Service at (888) 327-0671
Customer Service
(888) 327-0671
10
Section 5
CHANGE IN PRIMARY CARE PROVIDER ASSIGNMENT
PLAN A & PLAN B
.01 A NHP/THP member may request, in writing or by telephone, a transfer or
reassignment to another participating primary care practice (if other
participating practices are accepting members). A member may request a transfer at any
time during the year. NHP/THP may limit the number of transfer requests.
.02 The member may make the request by calling Customer Service at (888) 327-0671. If
approved, the member is responsible for transferring his/her medical records.
.03 A primary care practice may call Customer Service at (888) 327-0671 or use the
Member Information Change Form (see Appendix B) to request that a member be
assigned to their location or reassigned to another primary care practice.
.04 If an office discharges a member due to the member’s behavior, a copy of the discharge
letter or other documentation should accompany the request for reassignment.
.05 To assist in the decision of reassignment or disenrollment from NHP/THP, additional
documentation may be requested such as:
a) Police report
c) Broken narcotic contract
d) Documentation of non-compliant behavior
e) Forged or altered prescriptions
f) Medical records documenting behavioral issues
g) Reports or notes on counseling regarding inappropriate emergency room use
h) Counseling or treatment attempts to correct behavior
i) Summary of MAPS report
For additional information contact Customer Service at (888) 327-0671
.06
NHP/THP may reassign a member at any time due to provider network issues.
b) Incident report
Customer Service
(888) 327-0671
11
Services provided by a
Specialist
Service
Office Visits at Assigned
Service
Primary Care Practices
.01 Office visits at
assigned primary
care practices
Plan B




Only professional services are covered
Medically necessary services provided by a
specialist in the office or outpatient hospital
setting are covered.
Daily inpatient hospital care services are covered
(inpatient rounding, admitting and discharge
services ONLY).
A limited number of eye care services are
12
Coverage
Notes
Plan A members needing
 Professional
service
and
facility
fees
covered
Coverage
Provisions
Covered By
contraceptives should be referred
 Service must be medically necessary
Members needing
contraceptives
PLAN A:
to the local
Family Planning Northern and
 Visits with a mild to moderate mental health
to the
Program,
butlocal
thereFamily
are two Tencon Health
code
(209-316)
are covered. should be referred
•
Professional diagnosis
service and
facility
fees covered.
Planning Program.
(See Appendix
A
contraceptives
that are covered
on
Plan
•
Service
must
be
medically
necessary.
Plan B
the Plan A Formulary.
 Only professional services are covered for more information.)
•
Visits with
a
mild
to
moderate
mental
health
 Service must be medically necessary
diagnosiscode
(290-316)
are covered.
Plan B members needing
Visits
with a mild
to moderate mental health
PLAN B ONLY:
Contraceptives
arereferred
should be
PLAN B:
diagnosis code (290-316) are covered. Limit
per contraceptives
not a 5covered
benefit.
to the local Family Planning
calendar
year.are covered.
• Only professional
services
Program. Contraceptives are not a
 Injectable medications, including
covered benefit for Plan B
• Service must be
medically necessary. are not covered. The
vaccines/immunizations
members.
• Visits with a mild
to moderate
health
administration
feemental
is covered.
(290-316) are
Limit 5covered
Plan Adiagnosis code
Procedures require prior
 Professional
andcovered.
facility services
authorization through benefit
per calendar
 year.
determination process.
specialist in
the office or outpatient hospital
• Injectable medications,
including
are not covered by
Daily
inpatient hospital
services are covered Office visits do not require prior
NHP/THP. The
administration
fee iscare
covered.
authorization/benefit
(inpatient rounding, admitting and discharge
determination.
services ONLY).
 A limited number of eye care services are covered
Allergy testing and treatment is
when provided by an ophthalmologist. Services
must be related to an acute medical condition or a covered for Plan A only.
chronic illness to be covered. Routine eye care or
Plan A and Plan B chiropractic
vision services are not covered.
care/services are not covered.
 A limited number of oral surgery services are
covered when provided by a licensed dentist
enrolled in Medicaid as a Type 10 provider (oral
surgeon).
Plan
Plan A
Section 6
Covered Services for Northern
and Tencon
Health Plans - 2011
COVERED
SERVICES
Section 6
COVERED SERVICES
Outpatient Hospital
Outpatient Radiology
Outpatient Laboratory
.02 Services provided
by a specialist
Service
13
Procedures must be prior authorized Northern and
PLAN A:
by - 2011
NHP/THP. (See Section 7 for Tencon Health
Covered
Services
for
Northern
and
Tencon
Health
Plans
•
Professional and facility services covered.
more
information.)
Plan
Plan
Coverage
Notes
•
covered when provided by an ophthalmologist.
specialist in the office or outpatient hospital
Services must be related to an acute medical
Office visits do not require prior
condition or a chronic illness to be covered.
authorization.
•
Daily inpatient
hospital
Routine
eyecare
care(inpatient
or vision services are not
rounding, admitting,
covered. and discharge services
ONLY) services
are covered.
 Injectable
medications and vaccinations are not
covered.
•
A limited number of eye care services are
Plan A covered when
Prior authorization/benefit
 Professional
and
services for medically
provided by
anfacility
ophthalmologist.
determination is not required.
necessary
laboratory
tests
are
covered
for
and treatment
purposes.
condition or diagnostic
a chronic illness
to be covered.
Plan A – lab services conducted in
Routine eye care or vision services are not
Plan B
conjunction with inpatient surgery

Professional
and
facility
services
for
medically
covered.
are not covered.
necessary laboratory tests are covered for
•
A limited number
of
oral
surgery
services
are
diagnostic and treatment purposes.
covered when provided by a licensed dentist
Plan B – lab services conducted in
enrolled in Medicaid as a Type 10 provider (oral
conjunction with inpatient surgery
surgeon).
or emergency room treatment are
not covered.
PLAN B:
Plan A
 Professional and facility services for medically
• Only professional
services
are
covered.
determination is not required.
necessary diagnostic imaging procedures are
• Medically necessary
provided
a
coveredservices
for diagnostic
andby
treatment
purposes.
specialist in the
office
or outpatient
hospital
This
includes
mammograms
(digital included) for Screening bone density testing
and CPT Codes 77001-77799 are
women over the age of 40.
not covered for Plan A B.
• Daily inpatient hospital care (inpatient rounding,
Plan B

Professional
and
facility
services
for
medically
admitting, and discharge services ONLY)
Plan A – radiology services
necessary diagnostic imaging procedures are
services are covered.
conducted in conjunction with
covered for diagnostic and treatment purposes.
• A limited number
eye care
services are(digital included) for inpatient surgery are not covered.
This of
includes
mammograms
covered whenwomen
provided
bythe
an age
ophthalmologist.
over
of 40.
Plan B – radiology services
condition
or a chronic
illness
to be
covered.
Outpatient
radiology
codes
covered
for Plan A and Plan B conducted in conjunction with
Routine
care or
services
are not and 78000-79999. inpatient surgery or emergency
areeye
defined
as vision
CPT codes
70010-76999
room treatment are not covered.
covered.
Mammogram codes covered for Plan A and Plan B are
77051-77059.
• Injectable
medications or vaccinations are not
Plan Acovered by
Prior authorization is required
 NHP/THP.
Facility charges for diagnostic and treatment
through the benefit determination
services are covered. There are exceptions –
process.
services not covered include: screening services
of any kind, cardiac rehabilitation, experimental
or investigation treatment, sleep apnea treatment






Plan B
Plan A
Plan A
Plan B
Plan A
Plan B
B
Plan
Ambulance
Ambulance
Medical Supplies/DME
Speech, Physical and
Occupational Therapy



Plan B
14
covered
service.
One
Prior
authorization
is required
Outpatient
radiology
codes
are defined
One time
time evaluation
evaluationisisathe
only covered
6service.
Physical Therapy Visits are covered.
through
the
benefit
as CPT codes 70010-76999 and
Professional and facility services for
speech or
determination process.
78000-79999.
occupational therapy are not covered.
Professional and facility services for speech,
Ground
to atherapy
hospitalare
emergency
physicaltransportation
or occupational
not
PLAN A ONLY: determination
Radiology services
is not required.
department for life-threatening medical
covered.
conducted
in conjunction with
emergencies and accidental injuries
are covered.
Prior
Ground transportation to a hospital
emergency
Services
may be provided outside
inpatient
surgery are
not covered.
determination
department
for
life-threatening
medical
of Michigan. is not required.
Ground transportation is not covered.
emergencies and accidental injuries are
Prescription is required for Plan
Limited coverage for medical supplies including
Services
mayservices
be provided
PLAN B ONLY:A.
Radiology
covered.
some dressing/wound care, ostomy, catheter and
of Michigan.
conducted in outside
conjunction
with
casting supplies.
inpatient surgery Free
or emergency
room meters
Ground transportation
is not
covered.
Ascensia glucose
Medical
equipment is not
covered.
treatment are not covered.
through Bayer for Plan A & B.
Professional charges for Plan A and Plan B are explained
 Services
Facilityprovider
charges by
foradiagnostic
treatment
under
Specialist. and
PLAN
B ONLY: Laboratory services
services
are
not
covered.
Plan A
 Professional and facility services for
emergency
conducted
in conjunction
with
determination
is not required.
room treatment of accidental injuries
or
inpatient surgery or emergency room
Professional
charges
for
Plan
A
and
Plan
B
are
conditions considered medical emergencies
treatment are
are not covered.
explained
under Services provider by a Specialist.
Emergency services for Plan A
covered.
age 40 and
over
should
be Northern
PLAN
Prior
PlanAA& PLAN B: Professional and facility servicesWomen
members
may
be provided
outside and
for emergency
referred
to
the
Breast
and
Cervical
Tencon
Medically
imaging
procedures
Plan B necessary diagnostic
of Michigan. is not required. Health
determination
room treatment
accidental
injuries
or
Professional
and of
facility
services
for emergency
Cancer Control
Program for their Plan
are covered for diagnostic
and
treatment
room
treatment
arepurposes.
not medical
covered.emergencies
conditions
considered
are
mammogram.
(See
Appendix
A forfor Plan A
Emergency
services
Plan A
Prior
covered.
 Professional
services only for urgent care
more
information.)
determination
required.
members mayisbenot
provided
center/after hours clinic are covered.
Plan B
outside
of
Michigan.
 Professional and facility services for emergency
Plan B
Facilitytesting
charges
 Professional
services
only
for urgent
care bone density
room treatment
are not
covered.
Screening
is for
notPlan
a A and
are not covered.
cliniconly
are for
covered.
Plan A
PriorBauthorization/benefit
covered
 center/after
Professionalhours
services
urgent
carebenefit. Plan
Prior
authorization
is required.
required
Plan A
is a are
covered
service.
 One
time evaluation
determination is not
center/after
hours clinic
covered.
through the benefit determination
 6 Physical Therapy Visits are covered.
Prior
authorization
is notcharges
requiredforbyPlan A and
process.
 Professional
facility
services
for speech
Plan B
Facility
Professionaland
services
only
for urgent
care or
NHP/THP.
occupational
therapy
are not
covered.
Plan B are not covered.
center/after hours
clinic
are covered.
Prior
authorization
is not required by
Northern and
PLAN A &Covered Services for Northern and Tencon Health Plans ‐ 2011 PLAN B:
Covered
Services for Northern and Tencon Health
Plans
- 2011
Plan A
 Facility charges for diagnostic and
treatment
NHP/THP.
Tencon Health
Plannecessary laboratory tests are
Coverage
Notes
Medically
covered for
through the benefit
services are covered. There are exceptions –
Plan
weight reduction services
diagnostic and treatmentorpurposes.
services not covered include: screening services determination process.
PLAN
A ONLY: Laboratory services
of any kind, cardiac rehabilitation,
experimental
Plan B
 Facility charges for diagnostic andconducted
treatment in conjunction with
or
investigation
treatment, sleep apnea
services
are not covered.
inpatient surgery are not covered.
treatment or weight reduction services
Plan B
Plan A
Urgent Care
Speech, Physical and
Occupational Therapy
UrgentProfessional
Care
and
facility services
.04 Outpatient
Emergency
Room
radiology
Emergency Room
Professional and
facility services
.03 Outpatient
Outpatient
Hospital
laboratory
Service
.08 Pharmacy Substance Abuse Services
ABW
Mental Health Services
Services provided by a
Specialist
Pharmacy
.07 Pharmacy Northern and
Tencon Health
Plan
Professional and
facility services
.06 Visits to the
Diabetic Education
emergency room
.05 Outpatient
Service
hospital
OfficeService
Visits at Assigned
Primary Care Practices
Facility
charges
15
Covered Services for Northern and Tencon Health Plans ‐ 2011 Hospital services provided should be Northern and
PLAN A ONLY:
Plan
Coverage
prior
authorized by NHP/THP. Notes
Covered
Services
for
Northern
and
Tencon
Health
Plans
- 2011
Tencon Health
Diagnostic and treatment services are covered.
Plan
A
members
needing
Plan
A

Professional
service
and
facility
fees
covered
Plan
Plan
Coverage
Notes
contraceptives should be referred
 Service
mustfor
be medical
medically
necessary
 Limited
coverage
supplies
including
See Section 13 for some
list
non-covered
services
in the catheter
to the local Family Planning
 of
Visits
with a mild
to moderate
mental and
health
dressing/wound
care,
ostomy,
outpatient hospitalcasting
setting.
Program, but there are two
supplies.code (209-316) are covered.
diagnosis
BCP’s that are covered on the
Medical equipment is not covered.
PLAN B: NOT COVERED
Plan A Formulary.
Plan B
Emergency services may be provided Northern and
PLAN A ONLY:  Only professional services are covered
Plan A
 Diabetes
education
services
are covered
in the
 Service
must be
medically
necessary
outside of Michigan.
Tencon Health
Emergency room outpatient
care
for
the
stabilization
and
PlantheB benefit
members
needing
determination
ordered
by a physician
 Visitssetting
with aifmild
to moderate
mentaland
health through
treatment of accidental
injuries
contraceptives should bePlan
referred
the program
is certified
byconditions
Community
PublicLimit 5process.
diagnosis
code or
(290-316)
are covered.
considered medicalHealth.
emergencies
is
covered.
to
the
local
Family
Planning
Prior authorization is not required by
per calendar year.
Program. Contraceptives are not
 Injectable medications, includingNHP/THP.
Plan B
a covered benefit for Plan B
 Diabetes
education
services
are
covered
in
the
are as
not covered. The
Routine care for minor
medical problems such
members.
outpatient setting if ordered by a physician and
administration
is covered.
colds, headaches, and backaches
is notfee
considered
an
the program is certified by Community Public
Plan A
Procedures require prior
emergency.
 Professional and facility services covered
Health.
authorization through benefit

Medically
necessary
services
provided
by
a
PLAN
Plan
A B: NOT COVERED
Medications included on the Plan A formulary are All prescriptions must be filled by
determination
process.
specialist in the office or outpatient hospital a participating
pharmacy.
covered.
All
prescriptions
must
be
filled
by a Northern and
PLAN A:
 Notesetting
for Planare
A:covered.
Psychotropic, HIV and
participating
pharmacy.
Tencon
Office
visits are
do available
not require
priorHealth
Products included on
NHP/THP
formulary
are
 the
Daily
inpatient
hospitalare
care
servicesunder
are
Diabetic
supplies
substance
abuse
medications
provided
Plan
covered.
covered
(inpatient
admittingThe
and through
the pharmacy benefit &
the Adult
Benefit
Waiverrounding,
(ABW) program.
determination.
discharge
services
ONLY).
require
a
prescription.
Limited to
Diabetic
supplies
are
available
through
Note: Psychotropic,
HIV,
and
substance
abuse
beneficiary should use the mihealth card at the
Ascensia
brand.
 A limited
number
eye care services
are
the pharmacy
benefit and require a
medications are provided
under the
Adult of
Benefits
pharmacy.
Allergy testing
and treatment is
covered
when provided
by use
an ophthalmologist.
prescription.
Limited
to Ascensia
Waiver (ABW) program.
The beneficiary
should
Plan A only.
Plan
B
A – priorfro
authorization
is
must beon
related
to an
acute
medical
 atMedications
included
the Plan
B formulary
are Plan covered
brand.
the mihealth
card
theServices
pharmacy.
required
for
drugs
not
listed
on
the
condition or a chronic illness to be covered.
covered.
PLAN B:
Plan A and Plan B chiropractic
Routine eye care or vision services are not formulary.
PLAN
A
ONLY:
Products
included
on
the
NHP/THP
formulary
are
care/services
are not covered.
Plan A
Services
must be provided
by
covered.
 Services
must be medically necessary. Services
covered.
local
Community
Mental
Health
Prior
authorization
is
required
for
are
covered
under
the
ABW
program.
The
 A limited number of oral surgery services are
Services
(CMHSPs).
beneficiary
should
the mihealth
card
for dentist
these
drugs
not listed
on thePrograms
NHP/THP
covered
whenuse
provided
by a licensed
services.
formulary.
enrolled in Medicaid as a Type 10
provider See Section 10 for
information
about prior authorization.
(oral surgeon).
Plan B
 Mental Health Services are not covered.
Prior authorization may be required by mihealth card
PLAN A ONLY:
Plan Plan
A B
must be provided by
 Services
be medically
necessary.
Services
 Onlymust
professional
services
are covered
First
Health atServices
(877) 864-9014.
The list of psychotropic,
HIV,
and
substance
abuse
local
Community
Mental Health
are
covered
under
the ABWservices
program.
The by a
 through
Medically
necessary
provided
drug classes covered
the
ABW
program
is
beneficiary
should use the mihealth card for these Services Programs (CMHSPs).
included in Sectionservices.
11. specialist in the office or outpatient hospital
PLAN B: NOT COVERED

Daily inpatient hospital care services are
Plan B
 Substance Abuse Services are not covered.
covered (inpatient rounding, admitting and
Section 7
BENEFIT DETERMINATION FOR COVERED MEDICAL SERVICES
The following describes how authorization is obtained through the benefit determination process to
assure that a service is a covered service by NHP/THP.
PLAN A & B
.01
A benefit determination provides information regarding what services are covered and not
covered by NHP/THP. Benefit determinations for covered services must be obtained prior to
the service being rendered. Retroactive determinations are not given.
.02
When a requested service is determined to be a covered benefit, an authorization number is
assigned. The authorization number does not always apply to both professional and
facility charges. Plan B does not cover facility charges. An authorization number issued for
a Plan B member applies to the professional charges only.
.03
Failure to follow the existing process may lead to non payment of services.
.04 Payment for a covered service is contingent on the member being eligible on the date of
service and the service being payable according to Medicaid guidelines.
.05 Medical services that require benefit determination by NHP/THP include:
a) Services rendered by a specialist, other than an office visit, in an outpatient or
office setting
b) Professional services for scheduled outpatient procedures (other than lab or
radiology services).
.06 Medical services that do not require an authorization by NHP/THP are:
a) Outpatient laboratory tests
b) Outpatient radiology
and 78000-79999)
procedures
(CPT
codes
70010-76999,
c) Usual and customary services provided by a primary care provider
d) Visits to an urgent care center/clinic or hospital emergency room
e) Ground transportation to a hospital emergency department
77051-77059
f) Visits to a specialists billed under the following procedure codes: 99201-99215,
99241-99245, and 9938 1-99397.
Customer Service
(888) 327-0671
16
Section 8
BENEFIT DETERMINATION PROCESS
PLAN A & B
Outpatient Professional Services:
.01 A primary care physician may refer NHP/THP members to any physician specialist, in the
State of Michigan, who will accept persons enrolled in NHP/THP. A benefit determination is
not necessary when making the referral. A provider must follow the benefit determination
process (as described in Section 7) to perform a procedure or testing in the office or
outpatient hospital setting.
.02 To determine if a service is a covered benefit:
a) Complete the Benefit Determination Form. See Pages 19-21 for an example of the
form and additional instructions
b) Fax the Benefit Determination Form to Customer Service at (877) 502-1567. A
response will be faxed back within two (2) business days
c) For same day or urgent situations, call Customer Service at (888) 327-0671
.03 If the Benefit Determination Form is incomplete or unclear, it will be faxed back with
comments
.04 Clinical documentation is not required for benefit determination unless requested by
NHP/THP
Outpatient Laboratory and Radiology Services:
.05 It is not necessary to receive an authorization number from NHP/THP or send a Benefit
Determination Form when ordering covered laboratory or radiology services (CPT codes
70010-76999 and 78000-79999)
.06 All reports should be sent to the ordering provider, not NHP/THP
Inpatient Professional Services:
.07
Inpatient services are not a covered benefit for Plan A or Plan B members.
Medical Review:
.08 NHP/THP may limit covered services to those that are medically necessary and appropriate,
and that conform to professionally accepted standards of care.
Customer Service
(888) 327-0671
17
.09 Medical review by a physician may be required for some services. For these requests, the
provider should send documentation to support medical necessity to:
ATTN: Medical Management
P.O. Box 1511
Flint, MI 48501-1511
.10 Medical review cases are reviewed using the following guidelines:
a) Non-urgent pre-service decisions within 14 calendar days of receipt of request
b) Urgent pre-service decisions within 72 hours of receipt of request
c) Urgent concurrent review within 24 hours of receipt of request
d) Post-service decisions within 30 calendar days of receipt of request.
.11 A “decision notice” is sent to the member and provider(s) informing them of the
following:
a) Decision
c) Right to appeal (if denied)
.12 The requesting provider has the right to discuss the decision with a person familiar with
the case
b) Reason for decision
Customer Service
(888) 327-0671
18
North
e rn He
alt
hP
la
Northern and Tencon Health Plan Benefit Determination Form FAX THIS FORM TO (877) 502‐1567 FOR AUTHORIZATION
n
The following services do NOT require authorization: con
Health Plan
Office Visits (CPT 99201‐99215, 99241‐99245, & 99381‐99397) Outpatient Diagnostic Laboratory (CPT 80047‐88399) Outpatient Diagnostic Radiology (CPT 70010‐76999 & 78000‐79999) OFFICE REQUESTING AUTHORIZATION MEMBER INFORMATION Provider Name Last Name Office/Entity Name Address First Name DOB (mm/dd/yy) Member ID # Assigned Office Phone # w/Area Code Fax # w/Area Code Office Contact: ________________________ Phone # & Ext. _________________ Date Submitted ___/___/___ SERVICES REQUESTED (Services NOT specified may not be covered) Authorization Begin Date Authorization End Date Date of Appointment Diagnosis Code Diagnosis/Comments SPECIALIST OFFICE TESTING AND PROCEDURES Specialist/Office Name Specialty Specialist Phone # Specialist Fax # Specialist Address CPT Code (Required) and Description of Test/Procedure: OUTPATIENT HOSPITAL TESTING AND PROCEDURES Please note that for Plan A members the facility and professional charges are covered for authorized procedures and for Plan B members the professional charges ONLY are covered for authorized procedures. Name of Hospital: CPT Code (REQUIRED): Description of Test/Procedure (REQUIRED): □ PT Evaluation Plan A ‐ Therapy (Evaluation only is a covered benefit) □ OT Evaluation □ ST Evaluation Benefit Determination (Staff Use Only) Reserved for FAX stamp □ Authorized Authorization #: ___________________ □ Non‐Covered Benefit □ Not Authorized MHA Staff ____________________ Date ______________ This electronic message, including any attachments, is confidential and intended solely for use of the intended recipient(s). This message may contain information that is privileged or otherwise protected from disclosure by applicable law, including Health Plan member protected health information (PHI), and is being sent under circumstances where member authorization is not required. Member PHI shall only be disclosed to permitted recipients for purposes of treatment, payment or health care operations for the member. The disclosure or request for PHI shall be limited to the PHI that is the minimum amount necessary to achieve the intended purpose of the use, disclosure, or request. Any unauthorized disclosure, dissemination, use or reproduction is strictly prohibited. If you have received this message in error, please destroy it and notify the sender immediately. Form # CHP10015 Contact Customer Service for benefit questions at (888) 327‐0671 www.mclarenhealthadvantage.org 19
How to Complete the Benefit Determination Form
Please print or type all information and complete all relevant fields in all sections.
Office Requesting Authorization Section
Provider: - Provider requesting the authorization
Office name, Address, Phone, Fax: - Information reflects where the response to benefit
determination is to be sent
Member Information Section
Last and first name: - Member’s complete name
DOB: - Member’s complete birthdate, MM/DD/YY
Health Plan ID #: - Identification number
Assigned Office: - Office listed on the member’s ID card which indicates the primary care group to which the member is assigned
Person Submitting Form, Phone Ext #, and Date Section
Office staff submitting the form, telephone extension number of office phone, and date the form is
submitted
Services Requested Section
Authorization Begin and End Date: - Estimate of time span in which services will be given
(maximum of one year); if not completed, default will be
date of authorization times one year
Service dates prior to the submission of Benefit
Determination Form will not be authorized.
Date of Appointment:
- Enter, if known
If appointment is rescheduled, it is not necessary to
complete another Benefit Determination Form.
Diagnosis Code: - ICD9 code
Diagnosis/Comments: - Primary diagnosis related to reason for procedure
Specialist/Office Name: - Name of office where procedure is to be performed
Specialty:
- Medical specialty of the specialist/office which is
performing the procedure.
Specialist Phone, Fax, and Address: - Complete all
If the information is the same as the “Office Requesting
Authorization”, it may be filled in as “see above”
CPT Code (required) and: Description of Test/Procedure:
- Specify the procedure that is requested with the
appropriate CPT code
Name of Hospital: - List hospital where outpatient hospital testing and
procedures will be performed
CPT Code:
- CPT code for the outpatient hospital testing or procedure
(REQUIRED)
Description of Test/Procedure:
-Description of the testing or procedure (REQUIRED)
Customer Service
(888) 327-0671
20
Special Notations
Plan A professional and facility charges are covered for outpatient hospital testing and procedures.
Plan B professional charges only are covered for outpatient hospital testing and procedures.
Services that are NOT specified may not be covered.
Office visits in the CPT ranges listed on the form do not require authorization. These include new
and established patient office visits, preventive medicine visits, and office consultations.
Scheduled outpatient radiology with CPT codes 70010-76999, 77051-77059 and 78000-79999 do
not require submission of a benefit determination.
Outpatient laboratory does not require authorization.
Specific procedure codes may be reviewed by calling Customer Service at (888) 327-0671.
Visit our website at: www.mclarenhealthadvantage.org for further health plan information.
Customer Service
(888) 327-0671
21
Section 9
COVERED SERVICES - mihealth Card
PLAN A ONLY
The following describes the authorization process for those services that are covered by the mihealth
card. See Section 7 for information about benefit determination for services covered by NHP/THP.
.01 Substance abuse and mental health services under the ABW program must
be provided through the local Community Health Services Programs (CMHSPs).
Services are limited to those that are medically necessary and that conform
to professionally acceptable standards of care consistent with the Michigan Mental
Health Code.
.02 Providers should direct their questions about substance abuse and mental health services
to Provider Inquiry, Department of Community Health at (800) 292-2550.
Customer Service
(888) 327-0671
22
Section 10
PRESCRIPTION BENEFIT - NHP/THP
PLAN A
NHP/THP’s prescription benefit is subject to a limited formulary. The formulary is available on our
website at www.mclarenhealthadvantage.org.
.01 Prescriptions or refills cannot be written for more than a 30-day supply
.02 Refills will not be dispensed after one (1) year from the original date of order
.03 Some medications have monthly quantity limits
.04 Only the medication form(s) and doses listed on the formulary are covered
.05
Diabetic supplies such as test strips, lancets, and insulin syringes are on the formulary as
a pharmacy benefit. Quantity limits and brand restrictions apply
.06 Members enrolled in NHP/THP are subject to a prescription copay. Copays are expected to be
paid at the time the prescription is dispensed
.07 Members are responsible for covering the cost of any medication dispensed at a
nonparticipating pharmacy
.08 Members are responsible to pay 100% of the cost of the medication if it is less than the
copay amount (when co-pays apply)
.09 On a case-by-case basis, NHP/THP may pay for a prescribed medication not on the formulary
for Plan A members only. The prior authorization request is processed by the Pharmacy
Benefit Manager
.10 The following process should be used by the prescriber when a non-formulary medication
is requested for a Plan A member:
a) Complete the Request for Prior Authorization form (see Page 25 (NHP) and Page 26
(THP) for a sample form)
b) c) Fax the Form to 4D (Pharmacy Benefit Manager) at (248) 540-9811
Inform the member that it will take one (1) business day for the prior authorization to
be processed if approved. Prescribers will not be notified if the prior authorization is
approved. They will be notified if the request is denied
d) Instruct the member to take his/her prescription and ID cards to a participating
pharmacy
e) Any prescriber or his/her designee may complete the Request for Prior Authorization
form
Customer Service
(888) 327-0671
23
.11 Certain medications are excluded and are not a covered benefit
.12 All prescription problems should be directed to the Pharmacy Benefit Manager, 4D,
at (888) 274-2031 Monday-Friday 9 am-6 pm. If these problems are not resolved call
NHP/THP Customer Service at (888) 327-0671
PLAN B
NHP/THP’s - Plan B prescription benefit is subject to a limited formulary
The formulary is available on our website at www.mclarenhealthadvantage.org
.13 Prescriptions or refills cannot be written for more than a 30-day supply
.14 Refills will not be dispensed after one (1) year from the original date of order
.15 Some medications have monthly quantity limits
.16 Only the medication form(s) and doses listed on the formulary are covered
.17 Diabetic supplies such as test strips, lancets, and insulin syringes are on the formulary as
a pharmacy benefit. Quantity limits and brand restrictions apply
.18 Members are subject to a prescription co-pay. Co-pays are expected to be paid at the time
the prescription is dispensed
.19 Members are responsible for covering the cost of any medication dispensed at a
nonparticipating pharmacy
.20 Members are responsible to pay 100% of the cost of the medication if it is less than the
co-pay amount (when co-pays apply)
.21 NHP/THP will not pay for off-formulary medications for Plan B members
.22 All prescription problems should be directed to the Pharmacy Benefit Manager, 4D, at
(888) 274-2031 Monday-Friday 9 am-6 pm. If these problems are not resolved call
NHP/THP Customer Service at (888) 327-0671
Customer Service
(888) 327-0671
24
4D
REQUEST FOR PRIOR AUTHORIZATION
Northern Health Plan - 5016
PRESCRIBING PHYSICIAN:
(ALL AUTHORIZATIONS ARE PENDING VALID ELIGIBILITY)
BENEFICIARY:
Name:___________________________
First
Last
Direct Phone #: (_ _ _) - _ _ _ - _ _ _ _
Name:________________________________
First
Last
Subscriber ID #: ___________________________
Fax #:
Date of Birth: _ _ - _ _- _ _ _ _
(_ _ _) - _ _ _ -
____
Physician specialty: _________________
Sex:
Female
Male
Name and title of person completing form (please print): _______________________________________
Drug name:
Strength:
Administration Schedule:
Length of Therapy: Quantity Requested:
a) ______________________________________________________________________________________
b) ______________________________________________________________________________________
c) ______________________________________________________________________________________
Patient’s diagnosis for use of this medication: ____________________________________________
1. Previous history of a medical condition, allergies or other pertinent medical information, that
necessitates the use of this medication:
______________________________________________________________________
Yes
2. Has the patient been seen by any other provider for this condition?
If so, what was the prescriber’s specialty? ________________________________________
No
3. Previous non-prior authorized and prior authorized medications tried and failed for this condition:
Name of medication
Reason for failure
Date:
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
4. Pertinent laboratory test or procedure: (if applicable)
Procedure:
Findings:
Date:
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
5. Other Information:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Submit Requests to:
4-D Pharmacy Management Systems
P.O. Box 721098
DT REC:______________TIME REC:___________
Berkley, Michigan 48072
GCN: a)_________ b)_________c)__________
Phone: (248) 540-6686 Fax: (248) 540-9811
EC: a)___________b)__________c)_________
4D PA COMMENTS:________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Qty:a)___________b)__________c)_________
Appd :a)_________b)__________c)_________
R.Ph:_________________ DATE:___________
Entrd by: ______________ DATE:__________
Auth # a)_______________________________
b)_______________________________
c)______________________________
25
4D
REQUEST FOR PRIOR AUTHORIZATION
Tencon Health Plan - 5017
PRESCRIBING PHYSICIAN:
(ALL AUTHORIZATIONS ARE PENDING VALID ELIGIBILITY)
BENEFICIARY:
Name:___________________________
First
Last
Direct Phone #: (_ _ _) - _ _ _ - _ _ _ _
Name:________________________________
First
Last
Subscriber ID #: ___________________________
Fax #:
Date of Birth: _ _ - _ _- _ _ _ _
(_ _ _) - _ _ _ -
____
Physician specialty: _________________
Sex:
Female
Male
Name and title of person completing form (please print): _______________________________________
Drug name:
Strength:
Administration Schedule:
Length of Therapy: Quantity Requested:
a) ______________________________________________________________________________________
b) ______________________________________________________________________________________
c) ______________________________________________________________________________________
Patient’s diagnosis for use of this medication: ____________________________________________
1. Previous history of a medical condition, allergies or other pertinent medical information, that
necessitates the use of this medication:
______________________________________________________________________
Yes
2. Has the patient been seen by any other provider for this condition?
If so, what was the prescriber’s specialty? ________________________________________
No
3. Previous non-prior authorized and prior authorized medications tried and failed for this condition:
Name of medication
Reason for failure
Date:
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
4. Pertinent laboratory test or procedure: (if applicable)
Procedure:
Findings:
Date:
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
___________________________ _____________________________________
__/__/____
5. Other Information:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Submit Requests to:
4-D Pharmacy Management Systems
P.O. Box 721098
DT REC:______________TIME REC:___________
Berkley, Michigan 48072
GCN: a)_________ b)_________c)__________
Phone: (248) 540-6686 Fax: (248) 540-9811
EC: a)___________b)__________c)_________
4D PA COMMENTS:________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Qty:a)___________b)__________c)_________
Appd :a)_________b)__________c)_________
R.Ph:_________________ DATE:___________
Entrd by: ______________ DATE:__________
Auth # a)_______________________________
b)_______________________________
c)______________________________
26
Section 11
PRESCRIPTION BENEFIT - mihealth card
PLAN A ONLY
.01 The following list of medication classes on Page 28 are covered by the State of
Michigan’s mihealth card
.02 Prescriptions for these medications should be billed to the Michigan Department of
Community Health’s (MDCH’s) Pharmacy Benefit Manager, First Health
.03 A member must present his/her mihealth card to obtain any of these medications. A
rejection will occur if the member tries to use his/her NHP/THP ID card
.04 A member is subject to a $1.00 copay for generic and preferred brand medications and a
$1.00 copay for brand name and non-preferred medications
.05 The list of medication classes and specific medications that should be billed through First
Health can be found at www.michigan.fhsc.com. To reach the list of drug classes click
on Providers/Drug Information/ABW County Plan Carveout. The drug classes are
marked with an asterisk
.06
Any prescriber or his/her designee may obtain necessary prior authorizations through the
MDCH Clinical Call Center at (877) 864-9014
Customer Service
(888) 327-0671
27
Psychotropic, HIV/AIDS, and Substance Abuse Medications Covered By the State of
Michigan’s mihealth Card – October 2007
Class Code
Class Name
Class Code
Class Name
H2A
Central Nervous Systems stimulants
H2D
Barbiturates
H2E
Sedative-hypnotic, non-barbiturate
H2F
Anti-anxiety
H2G
Anti-psychotic, phenothiazine
H2H
MAO inhibitors
H2I
Anti-psychotic, phenothiazine, con’t
H2J
Anti-depressants
H2K
Anti-depressant combinations
H2L
Anti-psychotic, non-phenothiazine
H2M
Anti-mania
H2N
Anti-depressants, con’t
H2O
Anti-psychotic, non-phenothiazine,
H2P
Anti-anxiety, con’t
con’t
H2Q
Sedative-hypnotics, non-barbiturates,
H2S
SSRIs
con’t
Tx for Attention Deficit-Hyperactivity
H2U
TCA & related non-selective RU
H2V
inhibitors
Disorder (ADHD)
H2W
TCA/phenothiazine combinations
H2X
TCA/benzodiazepine combinations
H2Y
TCA/non-phenothiazine
H4B
Anti-convulsants
combinations
H4C
Anti-convulsants, con’t
H6B
Antiparkinsonism drugs, anticholinergics
H7A
TCA/phenothiazine/benzodiazepine
H7B
Alpha-2 receptor antagonist anticombinations
depressants
H7C
SNRIs
H7D
NDRIs
H7E
SARIs
H7J
MAOIs - non-selective and irreversible
H7K
MAOIs - selective and reversible
H7L
MAOIs N-S and irreversible/phenothiazine
comb.
H7M
Anti-depressant/carbamate anxiolytic
H7O
Anti-psychotic, dopamine antag.,
comb.
butyrophenon
H7P
H7Q
thioxanthene
benzamides
H7R
H7S
diphenylbutylpiperdines
dihydroindolones
H7T
Anti-psychotic, atypical dopamine &
H7U
Anti-psychotic, dopamine & serotonin
serotonin antag.
antag.
H7V
Antipsychotic, dopamine antagonist,
H7X
Anti-psychotic, atypical D2 partial
iminodibenzyl derivative
agonist/5HT mixed
H7Y
Tx for ADHD, NRI-type
H7Z
SSRI & anti-psychotic, atypical
combination
H8B
Hypnotics, Melatonin MT1/MT2
H8M
TX for ADHD - selective alpha-2A receptor
agonist
Receptor Agonists
H8P
W5I
SSRI & 5HT1A partial agonist
antidepressant
Adrenergic, aromatic, non-catecolamine
amphetamine preps
Anti-virals, HIV spec. nucleotide
W5K
W5M
Anti-viral, HIV non-nucleoside
Anti-viral, HIV PI comb.
J5B
H8Q
W5C
W5J
W5L
W5N
W5P
Antivirals, HIV-Spec. NucleosideNucleotide Analog
W5T
W5Q
ARTV CMB Nucleoside, Nucleotide &
Non-Nucleoside
W5U
Antivirals, HIV-1 Integrase Strand
HSN 529
Transfer Inhibitors
HSN 1875
Naltrexone HCL (ReVia/Depade)
HSN 10731
HSN 24846 Suboxone (requires prior authorization)
W5O
Narcolepsy and sleep disorder therapy
Anti-virals, HIV spec. protease
inhibitors
Anti-viral, HIV nucleoside anal.
Anti-viral, HIV nucleoside comb.
Anti-viral, HIV fusion inhib.
Anti-viral, HIV specific, non-peptide,
protease inhibitor
Antivirals, HIV-Specific, CCR5 CoReceptor Anatagonists
Disulfiram (Antabuse)
Campral (requires prior authorization)
28
Section 12
MEDICAL SUPPLIES
PLAN A ONLY
.01 Any provider may request medical supplies for Plan A members only however coverage is limited to include some dressing/wound care supplies, ostomy supplies, catheter supplies
and some casting supplies
.02 Providers may contact Customer Service at (877) 327-0671 to inquire about covered
supplies
.03 Plan A members will need a valid prescription to receive a covered medical supply
.04 Syringes, test strips, and lancets are on the NHP/THP formulary and require a prescription.
Any pharmacy that participates with NHP/THP can fill these prescriptions
Customer Service
(888) 327-0671
29
Any covered service not deemed medically necessary
Any experimental or investigational treatment, supplies, devices, drugs, or any treatment not considered to be reasonable and
effective for the specific medical condition
Cardiac rehabilitation
Certain prescription medications not on the list of covered drugs (PLAN B – restricted to formulary medications)
Chiropractic care or services
Custodial care, rest therapy, and care in a nursing or rest home facility
Dental work and treatment
Diagnosis and/or treatment of an injury, illness, or disability which occurs or arises from an act of war, declared or
undeclared, or from the member’s actions in conjunction with the commission of a felony, an attempt to commit a felony, or
an illegal business or occupation
Educational classes other than diabetes education (exceptions may apply)
Emergency transportation by air or water to a hospital or emergency room and all other non-emergent transportation
Examinations, preparation, fitting, or procurement of hearing aids
Eyeglasses, contact lenses, and other vision care
Home health care services
Hospice care
Inpatient hospitalization, both professional and facility
.02
.03
.04
.05
.06
.07
.08
.09
.10
.11
.12
.13
.14
.15
.16
The following chart explains the services, conditions, and situations that are not covered for PLAN A and PLAN B members:
.01
Any condition for which the member is eligible to receive health care services or benefits through a public or private health
care benefit, program, or insurance plan (e.g. Healthy Kids for pregnant women and infants and Breast and Cervical Cancer
Control Program)
PLAN A & PLAN B
Section 13
SERVICES NOT COVERED
30
Lodging or transportation expenses
Medical equipment and some supplies, including but not limited to prosthetics, orthotics, corrective shoes, wigs, bandages,
braces, and canes (note: needles and test strips for diabetics are listed on the drug formulary)
Medical services provided to any person incarcerated in a local, city, state, or federal penal institution
Occupational, respiratory, and speech therapy
Office visits, exams/tests, treatments, and reports related to requirements or documentation of health medical status for
employment, SSI certification, insurance, travel, surrogate parenting arrangements, school, sports participation, citizenship,
or for legal proceedings and court
Oral surgery for conditions other than for the relief of pain or infection
Organ transplants
Oxygen, oxygen related supplies, and CPAP machines
Services considered to be cosmetic
Services for sickness or injury to the extent that are covered under No-Fault Law, Workers’ Compensation, Occupational
Disease Law, or similar legislation
Services or supplies related to a sex change
Services provided outside of Michigan
Services received before the effective date of coverage or after termination of coverage
Sleep apnea treatment
Smoking cessation counseling other than through designated providers
Travel shots
Urgent care clinic visits – facility charges
Visits to a psychiatrist, psychologist, or social worker other than those provided through the mihealth card
Weight reduction services and procedures.
.18
.19
.21
.22
.23
.24
.25
.26
.27
.28
.29
.30
.31
.32
.33
.34
.35
.36
.20
Items for personal comfort or convenience
.17
The following chart explains the services, conditions, and situations that are not covered for PLAN A and PLAN B members:
31
Allergy testing and treatment
Any service provided by the assigned primary care provider or specialist not specifically listed as a covered primary care or
specialty care service
Chemotherapy services
Contraceptive devices or aides and fertility drugs or sterilization
Dialysis care
Injectable medication, immunization, and radiology dye administered in any setting
Medical or hospital services needed as a result or related to an accident involving a motor vehicle
Medications not on the list of covered drugs
Mental health or substance abuse services other than those provided during a primary care provider visit
Outpatient hospital facility services other than laboratory or radiology
Outpatient services for primary diagnosis of tuberculosis or to rule out tuberculosis
Services to pregnant women whether or not such services are pregnancy-related
Substance abuse treatment services
Visits to the emergency room, both professional and facility services
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
.47
.48
.49
.50
The following chart explains the services, conditions, and situations that are also not covered for PLAN B members:
PLAN B
32
Section 14
MEMBER APPEAL PROCESS
PLAN A & B
.01 A NHP/THP member, member’s representative or medical provider shall have
the right to file an appeal with NHP/THP for actions consistent with the definition
of an appeal.
.02 An appeal is a request for review of the NHP/THP’s decision that resulted in any of the
following actions:
a)
The denial or limited authorization of a requested service, including the type or level
of service
The reduction, suspension or termination of a previously authorized service
b) c) The denial, in whole or in part, of payment for a properly authorized Covered
Service
d) The failure to provide a service in a timely manner, as defined by the State (Plan A
only)
e) .03 The failure of NHP/THP to act within the established timeframes for grievance and
appeal disposition
NHP/THP shall mail a notice to the member, at his/her last known address, informing of a
denial, reduction, suspension or termination of a requested covered service, reason for the
action, effective date of the action, and the right to an internal or external appeal.
a) Internal appeal with NHP/THP - must be received by NHP/THP within 90 days from the
date the letter is sent to the member
b) External appeal with the State Office of Administrative Hearings and Rules
(SOAHR) of the Michigan Department of Community Health (MDCH) - Plan A only
i. The member has the right to an “external” appeal with the MDCH SOAHR’s
division without first utilizing NHP/THP’s internal appeal process
ii. The appeal must be received by SOAHR within 90 days from the date the letter is
sent to the member
Disenrollment - Plan B Only
.04 NHP/THP will notify the member in writing if NHP/THP intends to disenroll. The notice
will include information on how the member can appeal the action to NHP/THP.
Customer Service
(888) 327-0671
33
.05 Disenrollment by NHP/THP may occur for the reasons stated in Section 2.10 (c) and are
subject to appeal. Reasons in Section 2.10 (a-b) are not subject to appeal.
Appeals:
.06 Appeals by the member must be in writing and addressed to:
Attn: Appeals
P.O. Box 1511
Flint, MI 48501-1511
.07 For more information about the appeal process, call Customer Service at (888) 327-0671.
Customer Service
(888) 327-0671
34
Section 15
PROVIDER RESPONSIBILITIES
.01 Participating providers rendering covered services are not required to enroll as providers
in the Medicaid program, but they must comply with all Medicaid provider requirements
as detailed in the Medicaid provider manuals. Participating providers are required to
accept NHP/THP’s rates for payment for covered services as payment in full and are
prohibited from billing the member for any amount other than co-pays.
.02 Participating providers are required to give NHP/THP access to provider’s records, data, and
reports related to covered services rendered to members, as may be permitted by law.
.03 Participating providers must cooperate with NHP/THP’s quality improvement and utilization
review activities.
.04 Participating providers may discuss treatment options with members that may not reflect
NHP/THP’s position or may not be covered by NHP/THP.
.05 Participating providers may advocate on behalf of the member in any grievance, appeal,
or utilization review process, or individual authorization process to obtain covered
services.
.06 Participating primary care providers are responsible for supervising, coordinating, and
providing all primary care to each assigned member. In addition, the primary care
provider is responsible for initiating referrals for specialty care, maintaining continuity
of care, maintaining the member’s medical records, and for assuring that the services
provided are of appropriate quality and intensity for the member’s condition.
.07 Participating primary care providers should have an established dispute resolution
procedure which describes a method for receiving and responding appropriately to
member complaints regarding denial of services, unreasonable or inappropriate
behavior, and issues related to the quality of care and treatment. Members should have
the opportunity to file a complaint and be assured it will be reviewed by someone who is
not subject to the complaint.
.08 Participating primary care providers should have an ongoing quality assurance program
designed to objectively and systematically monitor and evaluate the quality and
appropriateness of care and services to members and to pursue opportunities for
improvement.
.09 Participating providers may not intentionally segregate NHP/THP members in any way.
Customer Service
(888) 327-0671
35
Section 16
INFORMATION SERVICES
.01 NHP/THP will furnish providers with a system or method to verify eligibility of
NHP/THP members. This verification is furnished as a service and is not a guarantee
of payment.
.02 In order to verify eligibility, the provider has available the following resources:
a) NHP/THP is responsible for maintaining an electronic viewing system
that identifies active and inactive members. This system is available
to providers with access to the Internet. The viewing system is designed to
allow users to have “viewing rights only” (See Appendix D for information on how
to use the viewing system)
b) Participating primary care practices will be mailed a roster of members assigned to
that practice monthly
c) To verify eligibility during normal business hours contact Customer Service at
(888) 327-0671
d) .03 Verification of Plan A members can also be achieved by accessing the State of
Michigan Medifax System or using the Automated Voice Response System (AVRS)
by calling (888) 696-3510. Providers must be enrolled in Medicaid to access the
Michigan Medifax System
A member’s identification card is not a guarantee of eligibility. The provider is
responsible for verifying eligibility and determining the identification of the cardholder.
Customer Service
(888) 327-0671
36
Section 17
BILLING INFORMATION
General Information:
.01 Individuals determined eligible by DHS for the ABW program are automatically enrolled
in NHP/THP - Plan A. Local enrollment sites are responsible for determining eligibility for
Plan B members.
.02 Enrollment in NHP/THP - Plan A is effective on the first day of the next available month after
eligibility is approved. Eligibility begins the date the application is processed for Plan B
members.
.03
NHP/THP is responsible for covered services provided to the member from the effective date
of enrollment through the effective date of disenrollment.
.04 If the NHP - Plan A member moves out of Alpena, Antrim, Charlevoix, Cheboygan,
Emmet Montmorency, Otsego, or Presque Isle County, NHP retains responsibility for that
member until the member is disenrolled. If the THP - Plan A member moves out of
Crawford, Kalkaska, Lake, Manistee, Mason, Mecosta, Missaukee, Newaygo, Oceana, or
Wexford county, THP retains the responsibility for that member until the member is
disenrolled. The member will be disenrolled when the case is transferred
to the DHS in the new county of residence. The enrollment in the new County Health
Plan or the fee-for-service ABW program will begin the first day of the next available
month after the case has been transferred.
.05 Individuals enrolled in NHP/THP - Plan A will receive a plastic mihealth identification card
within 10 business days of the date upon which DHS deemed the member eligible.
Plan A members use the mihealth card for services provided directly through the State,
specifically psychotropic, HIV/AIDS, and substance abuse drugs, mental health services,
and substance abuse services. These services should be billed directly to the State of
Michigan. The State of Michigan will reimburse providers through Medicaid’s
fee-for-service payment system.
.06 Plan A members will also receive a NHP/THP ID card after the Department
of Community Health notifies NHP/THP of the member’s eligibility. Plan A
members use the NHP/THP card for all other covered services. These services should be
billed directly to NHP/THP. NHP/THP will reimburse providers through its
fee-for-service payment system. (See Section 6 for more information about covered
services).
.07 Plan B members will receive a NHP/THP ID card when the member is determined eligible
through the local enrollment agency. Plan B members use the NHP/THP card for all
covered services. Plan B members do not receive a mihealth card.
.08 Providers billing for services covered by NHP/THP do not need to be Medicaid
enrolled.
.09 Providers billing for services covered by the mihealth card must be Medicaid enrolled.
.10 Providers rendering services to NHP/THP - Plan A members must comply with all Medicaid
provider requirements outlined in the Medicaid provider manuals.
Customer Service
(888) 327-0671
37
.11 Co-pay amounts are expected to be paid at the time the service is provided.
.12 NHP/THP is not responsible for services received before the effective date of coverage or after
coverage has been cancelled.
.13 Medical exceptions are considered on a case-by-case basis. Please contact Customer Service at
(888) 327-0671 for more information.
.14 All covered services rendered to ABW beneficiaries prior to the start of NHP/THP should be
billed to the ABW fee-for-service program.
.15 Use the Medicaid Provider Manual for further claims/billing instructions not outlined in this
manual.
Verifying Eligibility:
.16
The mihealth and NHP/THP ID card do not display any eligibility information and do not
guarantee eligibility.
.17 NHP/THP maintains a web-based membership file that reflects an accurate and up-to-date
account of all current and disenrolled members. It monitors the enrollment status of the
NHP/THP membership and keeps an accurate account of member enrollment and
disenrollment dates. This eligibility system can be viewed on our website at
www.mclarenhealthadvantage.org.
.18 Plan A eligibility can also be verified through the Department of Community Health (DCH)
eligibility verification systems. However, these systems will not display the NHP/THP
member identification number needed for claim submission.
Submitting a Claim:
.19
All services covered by NHP/THP should be billed to:
P.O. Box 1511
Flint, MI 48501-1511
.20 Paper claims should be submitted using CMS 1500 (professional) or UB04 (facility) claim
forms.
.21 Claims are scanned into the claim processing system using an Optical Character Recognition
(OCR) scanner and converted to an EDI format. Paper claims may be prepared using a
computer or typewriter. To enhance the speed of processing claims, the following “DOs” and
“DON’Ts” should be observed:
a) Do use clean typewriters
b) Do use black ribbon/ink
c) Do use care in proper alignment of claim form
d) Do avoid small font. Use font size between 10-14 points
Customer Service
(888) 327-0671
38
e) Do try to prevent shadows
f) Do adjust printer to insure character clarity side to side, top to bottom
g) Don’t use script or slant type
h) Don’t highlight information on claim form
i) Don’t type over preprinted numbers and words
j) Don’t use special characters (i.e. #, $)
.22
When completing the CMS 1500 form, the following form locators must be completed or the
claim will be denied:
b) Locator 21
c) Locator 24-33
.23 Special attention should be given to the following form locators. Failure to provide
information may delay processing or cause the claim to be denied.
a) Locator 1-13
a) b) Locator 1a: Member’s NHP/THP ID Number (not Medicaid Recipient ID or Social
Security Number)
Locator 10 a, b, c: Indicate if member’s condition is related to employment, auto accident or
other accident
c) Locator 23: Authorization Number (if applicable)
d) Locator 24b: Place of Service. Please use the 2-digit code from the list of CMS approved
definitions:
07 – Tribal 638 Free-Standing Facility
11 - Office
12 - Patient’s Home
20 - Urgent Care Center
21 - Inpatient Hospital
22 - Outpatient Hospital
23 - Emergency Room
24 - Ambulatory Surgical Center
41 - Ambulance-Land
42 - Ambulance-Air or Water
50 - Federally Qualified Health Center
65 - ESRDT Center
71 - State/Local Public Health Clinic
Customer Service
(888) 327-0671
39
72 - Rural Health Clinic
81 - Independent Laboratory
e) Locator 25: Federal Tax ID number
f) Locator 33a: The billing provider’s National Provider Identification (NPI) number is
required on all claims submitted. Providers should report and register the NPI
number which corresponds to the billing entity listed in box 33
.24 When completing the UB04 claim form, the following form locators must be completed.
Failure to provide may cause the claim to be denied:
a) Locator 1-6
c) Locator 38
d) Locator 42-47
e) Locator 50-66
.25 Special attention should be given to the following form locators:
a) Locator 4: Type of bill should be 13X, 14X, or 72X
b) Locator 32 - 35: Please note codes 01-04, service may be covered under another source
b) Locator 12-20
c) Locator 60: Member’s NHP/THP ID Number (not Medicaid Recipient ID or Social
Security Number)
d) Locator 56: The Billing provider’s NPI number is required on all claims.
Providers should report and register the NPI number which corresponds to the billing
entity listed in box 1
.26 Claims submitted with incorrect member information, such as the member identification
number, date of birth, or spelling of member’s first and last name, will be rejected on the
provider’s remittance advice as member could not be identified. Claims submitted with
incorrect provider identification information will be returned to the office unprocessed.
.27 Claims require valid and complete diagnosis coding relative to the date of service listed in the
International Classification of Diseases, Clinical Modification (ICD-9-CM) publication.
Diagnosis codes should be reported to the highest degree of specificity. If applicable, 4th and
5th digit level descriptions are mandatory for claims reimbursement.
Customer Service
(888) 327-0671
40
.28 Adhering to the above mentioned criteria will help ensure proper claim submission and timely
payment of claims. Failure to provide necessary information will delay or deny payment.
Providers have the option of completing non-required fields.
.29 Providers may submit an initial claim up to 365 days from the date of service to be considered
for payment.
.30 Please see pages 48-51 for information on how to submit an electronic claim. As of January
1, 2012 all electronic claims must be submitted in the appropriate
.31 Providers submitting a claim for the first time or changing information listed in locator 33 or
25 of the CMS 1500 form or in locator 1 or 5 of the UB04 form, need to attach a copy of their
IRS W-9 form to the claim. Payment changes will not be entered without the
forms nor will claims be processed for a new provider.
Claim Status:
.32 Claims can be statused 45 days after submission by phone at (888) 327-0671 or
by fax at (877) 502-1567. The claims status fax form can be found in Appendix F or on
our website at www.mclarenhealthadvantage.org
.33 Claims can also be statused online at https:\\webfacts.mclaren.org/factsweb. FACTSWeb
provides real time access to claim history, status, and payment information. Providers must
obtain a password and login prior to use. A registration form can be downloaded on the
Provider Section of the NHP/THP website: www.mclarenhealthadvantage.org.
Claim Adjustments and Appeals:
.34 If a provider notices an error on a claim once it has already been processed for payment and a
correction needs to be made in one or more of the following fields: charge amount, units,
diagnosis, procedure code, or modifier, a claim adjustment should be submitted.
The claims adjustment form can be found in Appendix G or on our website at
www.mclarenhealthadvantage.org.
.35 When submitting a claim adjustment, providers should send a copy of the corrected claim and
a cover sheet or NHP Claim Adjustment-Appeal form describing the correction made. These
documents must be faxed to the customer services department. Failure to follow this step could
result in the corrected claim denying as a duplicate submission. Prior NHP/THP payments
should be refunded.
.36 If a provider receives an adverse claim determination, an appeal for the service may be
submitted using NHP/THP’s internal appeal mechanism (See Appendix H).
a) Claim Reconsideration Review: This appeal can be submitted either verbally or in writing
within 90 days from the date of the explanation of payment (EOP). Review
requests submitted after the time frame has expired will not be reviewed. The
appeal will be reviewed and responded to within 60 days of receipt.
Customer Service
(888) 327-0671
41
b)
.37 Level 1 Appeal: This appeal must be submitted in writing within 90 days after the claim
reconsideration review decision. Appeals submitted after this time frame will not be
reviewed. The appeal must include the reason for the request, name, address, and
telephone number of the person responsible for filing the appeal, copy of the claim, and
any documentation to support the appeal. Claim’s department staff not involved with the
claim reconsideration review shall research and review the appeal and consult with any
additional persons deemed necessary for the review. Appeals shall be resolved within 60
days of receipt. The requestor shall receive written notification of the NHP’s decision by
letter or provider payment remittance.
Appeals should be submitted to:
Attn: Provider Appeals
PO Box 1511
Flint, MI 48501-1511
Fax: (877) 502-1567
.38 Plan A members have the right to appeal an adverse claim decision directly with the
State Office of Administrative Hearing and Rules (SOAHR). The written request must
be submitted to SOAHR within 90 days of notice from the health plan. The
hearing request must be signed by the NHP/THP member or authorized representative.
Reimbursement:
.39
Members are financially responsible for co-payments, services that are not a contract
covered benefit,and services provided before and after the effective date of eligibility. Members
are expected to make payment arrangements with the provider for those services.
.40 For covered services, the health plan will reimburse at Michigan Medicaid fee schedule rates
or the provider’s usual and customary charge, whichever is less, minus the required co-pay
amount. Find the Medicaid fee screens at the Michigan Department of Community Health
website at www.michigan.gov/mdch. Click on Providers and proceed to information for
Medicaid providers.
.41 Medical suppliers are reimbursed at the Medicaid fee unless they are contracted with the heath
plan to receive a negotiated rate.
.42 NHP/THP is financially responsible for assuring timely and accurate payment for covered
services rendered by the provider to a covered member. Such payments will usually be
made to the provider within 45 days following receipt of a complete and undisputed claim.
Claims will not appear on an EOP prior to being adjudicated. Common reasons claims may
be considered incomplete include incorrect provider and/or member information, or the
claim form is missing required information.
Customer Service
(888) 327-0671
42
.43 Members are financially responsible for services if they choose to obtain services from an outof-network or non-participating provider. It is recommended that the provider obtain the
member’s acknowledgement of payment responsibility in writing for the specific services to
be provided.
.44 Members are financially responsible for services if the provider chooses not to accept the
patient as an ABW beneficiary/NHP/THP member and the patient had prior knowledge of the
situation. It is recommended that the provider obtain the member’s acknowledgement of
payment responsibility in writing for the specific services to be provided. By accepting
payment from NHP/THP, the provider is choosing to accept the patient as a NHP/THP
member and the Plan A member can not be billed for covered services.
.45 Plan A members cannot be billed for the following if the provider is enrolled as a State of
Michigan Medicaid Provider:
a) Difference between the provider’s charge and the NHP/THP reimbursement
b) Copying of medical records for the purpose of supplying them to another health care
provider
c) Missed appointments
d) NHP/THP denied services because of improper billing or failure to obtain authorization
(if required)
e) A procedure code not listed on the Medicaid fee schedule and member was not informed
that it was non-covered prior to the service being performed
Remittance Advice:
.46 An EOP will be sent to each provider once the claim has been processed. If multiple claims
are processed under the same provider, a bulk payment will be made. (See Page 47 for an
example of an EOP)
.47 When posting the EOP, each patient’s identifying information appears in the shaded box
above the service line information. If a service line is rejected, a two or three character code
appears next to the ineligible dollar amount. Explanation codes for rejected claims appear at
the end of the remittance advice.
.48 The following is a list of the most common Explanation Codes that may appear on a
provider’s EOP:
a) b) c) d) e) f) g) h) i) j) 01- Covered by other insurance
021 Medical Visit same day as significant procedure need modifier 25
05- Maximum benefit reached
10- Duplicate of charges previously considered
11- Adjustment of previously processed claim
012- Incorrect coding of lab panel components
12- Primary paid greater than health plan allowable
34- Claim not submitted on a timely basis
37- DOS prior to effective date of coverage
38- DOS after termination date of coverage
Customer Service
(888) 327-0671
43
k) B- Code not allowed and not paid under OPPS
l) C- Inpatient only procedures. Cannot be performed on an outpatient basis
m) ANT- Please submit total anesthesia time in minutes
n) ATH – Authorization required
o) CAP- Services are capitated
p) CPT- Procedure code does not exist or is invalid
q) ERR- Primary diagnosis does not support ER visit
r) HCP- Resubmit with appropriate HCPCS
s) ICD- This ICD-9 code does not exist or is invalid
t) ICP- Please collect co-pay, if applicable, listed on the members card
u) INB- Service/Procedure not covered. Refer patient to BCCCP program
v) INH- Procedure/Service not payable with a screening or family history dx
w) INL- This service/procedure not covered
x) INM- Mental Health office visits are not a covered benefit
y) INP- Services/procedures related to pregnancy are not covered
z) IPC – Inpatient services not covered by health plan
aa) MDF- Appropriate modifier is missing or invalid
bb) N- Incidental service packaged into the APC rate. No separate payment
cc) PPC – Payment reduced due to previously processed claim
dd) REP- Report individual tests for reimbursement
ee) TKB – Payment reduced due to previous overpayment
ff) UER- Additional documentation required when billing this procedure
For codes not appearing on this list, please refer to the end of the EOP for a detailed
description.
.49 If a claim does not appear on an EOP within 60 days of submission, the claim should be
statused or resubmitted. Prior to resubmitting, providers should verify that the correct
NHP/THP member ID number (not Medicaid ID or Social Security Number), date of birth,
and spelling of member’s first and last name was used on the claim.
.50 Claims can be statused by phone at (888) 327-0671, or fax at (877) 502-1567, 45 days after
submission.
.51 Real time access to claim history, status, and payment information is available online
at: https:\\webfacts.mclaren.org/factsweb. Providers must be issued a password and
login prior to use. An application form can be downloaded under the provider section of our
website: www.mclarenhealthadvantage.org.
.52 An EOP will not be mailed to members.
Refunds
.53 Providers may send refund or voided checks to NHP/THP when the amount paid for a claim
needs to be returned due to overpayment, either from a primary insurance or processing
error. A copy of the NHP/THP EOP and, if applicable, the primary insurance’s EOP, with
a check made out to NHP/THP should be sent to the following address:
Attn: Refunds
P.O. Box 1511
Flint, MI 48501-1511
Customer Service
(888) 327-0671
44
.54 Occasionally NHP/THP receives notice from the State of Michigan that they are retroactively
terminating a member’s benefit through the health plan. Usually this is a result of the member
being enrolled in another State program, such as Medicaid. For provider reimbursements
made during this period, NHP/THP will recover those payments. Providers will receive
a refund request for these overpayments. Refunds not received will be deducted from the
provider’s future checks.
Coordination of Benefits – Plan A:
.55 NHP/THP will provide coverage for covered services to Plan A members who are also
eligible for the State’s Children Special Health Care Services program (CSHCS), Native
American Tribal Coverage, or Veterans Administration (VA) insurance, provided the
services are not covered under the other payer.
.56 If a Plan A member is found to have other medical coverage, either through a government
program or commercial plan (other than those listed above), NHP/THP will report the
information to the State’s third party liability section.
.57 If the Plan A member has comprehensive health coverage under another carrier, the State will
disenroll the member effective the beginning of the following month after the information is
received and processed. The health plan will coordinate benefits with the health insurance
for covered services during the remaining part of the member’s NHP/THP enrollment.
.58 In situations when the Plan A member has other health coverage, the provider should collect
any payments available from health insurances. The provider should report any such
payments to NHP/THP.
.59 NHP/THP shall be the payer of last resort in all cases when private or commercial insurance,
including either health or automobile insurance, is available to a Plan A member. All other
coverages are considered primary.
.60 Claims submitted to NHP/THP must include the primary carrier’s EOP. NHP/THP’s
payment is the lesser of the member’s liability (including coinsurance, co-payment, or
deductibles), the provider’s charge, or the maximum NHP/THP fee screen, minus the
insurance payment and contractual adjustments.
Coordination of Benefits – Plan B:
.61 If a Plan B member has other medical coverage, either through a government program or
commercial plan, the individual is no longer eligible for benefits through NHP/THP. All
other coverages are considered primary (including Medicaid). NHP/THP - Plan B does not
coordinate benefits. Some exceptions may apply. If another payer (including Medicaid) can
reimburse a provider for services that NHP/THP has already made a payment on, a refund
should be sent to NHP/THP for the entire amount paid by NHP/THP.
.62 If a Plan B member is found to have active medical coverage under another policy, members
will be disenrolled from the health plan the day prior to the primary insurance becoming
effective. Please contact Customer Service at (888) 327-0671 for more information.
Customer Service
(888) 327-0671
45
Special Billing Requirements:
.63 Anesthesia services must be reported with the five (5) digit CPT anesthesia codes (ASA).
Only one anesthesia service should be reported for a surgical session. The code for the major
surgery should be used. Every anesthesia service must have the appropriate anesthesia
modifier reported on the service line. Providers should report time units on line 24G of the
HCFA 1500 form for each minute of anesthesia time. Do not include base units.
.64 Outpatient Hospital services are processed in accordance with MDCH Outpatient Prospective
Payment System (OPPS) guidelines. Many of these are modeled after the Centers of Medicaid
and Medicare Services (CMS) OPPS guidelines. The OPPS payment calculations are
dependent on CPT/HCPCS procedure codes and modifiers reported at the claim line level.
.65 Plan A only - NHP/THP follows Medicare’s observation care services coverage, claim
submission, and reimbursement policies
.66
Plan A only - All medical supplies not stated on the covered list require medical review.
Contact Customer Service at (888) 327-0671 for more information.
.67 Plan A only - A sterilization procedure is defined as any medical procedure, treatment, or
operation for the purpose of rendering an individual (male or female) permanently incapable
of reproducing. Surgical procedures performed solely to treat an injury or pathology are not
considered sterilizations under the NHP/THP’s definition of sterilization, even
though the procedure may result in sterilization (e.g., oophorectomy). The physician is
responsible for obtaining the signed consent form (MSA-1959 Informed Consent to
Sterilization). Providers must attach a copy of the completed Informed Consent to the claim
form and fax it to (877) 502-1567
.68 Plan A only - Attending emergency room physician services need to be billed with the
modifier UD or UA in conjunction with the appropriate E/M procedure code. UD is used to
designate that the member was treated and released from the emergency room. UA is used to
designate that the member was admitted to the hospital following treatment.
Customer Service
(888) 327-0671
46
is made, McLaren Health Plan may forward the account to a collection agency.
Understanding the Remittance Advice:
Sample Explanation of Payment (EOP)
The goal at McLaren Health Plan is to use a Provider Payment Report (PPR) format that makes our claims
processing information understandable. Please review the information on the following sample PPR form to
better understand the information and features of our PPR.
Sample Provider Payment Report
SAMPLE
Return Address Name
PO Box 999999
Anywhere, ZZ 12345
Easy to locate
customer service
phone number
Questions, call us at (888) 327-0671
Forwarding Service Requested
Group Name:
Group #:
Division:
Provider TIN:
Internal ID:
Check #:
Check Date:
Claim information
is easily located
within the shaded
area
ACME Sales, INC.
12345
456
9999999999
00123456
006543
1/05/2001
Voucher level
information grouped
together
COB information here
Provider Payment Report
No.
Date(s)
of
Service
Proc
Code
Description
of Services
Claim #: 21417166-01
Patient Account #: ABC-123
1
2
08/1/01/8
08/1/01/8
36415
84015
Total
Charges
Provider
Discount
Ineligible
Amount
Ineligible
Code
Deductible
Insured Name: John Doe
Patient Name: John Doe
Office Visit
Injection
Totals
40.00
35.00
75.00
0.00
4.42
17.84
Other
Carrier
Benefits
Paid
Insured ID: 999-99-999
40.00
0.00
0.00
10
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Other Credits or Adjustments
Total Net Payment
Reason Descriptions are centralized in a
separate section of the EOB
0.00
20.58
20.58
0.00
20.58
The statement total section summarizes all
claims for the voucher
Reason Code Description
10
Co-Pay
Co-Ins
CHARGES PREVIOUSLY CONSIDERED
STATEMENT TOTALS
Total
Charges
18.25
Provider
Discount
0.00
Ineligible
Amount
2.73
Deductible
0.00
Co-Pay
Other Carrier
Co-Ins
0.00
0.00
Other Credits or Adjustments
Total Net Payment
Benefits
Paid
20.58
0.00
20.58
27
(888) 327-0671
www.mclarenhealthplan.org
Customer Service
(888) 327-0671
47
Electronic Billing Instructions
.01 NHP/THP accepts both professional and institutional electronic claims through its
clearinghouse, Netwerkes. NHP/THP’s third party administrator, McLaren Health
Advantage receives and processes these claims.
.02 NHP/THP uses Electronic Data Interchange (EDI) for electronic claims submission. EDI
connects providers, payers, and other healthcare partners using computers, modems, and
ordinary phone lines. EDI eliminates the need for your office staff to prepare claims
manually or re-key repetitive transaction information. There are no paper forms, envelopes,
or stamps.
Submitting a claim:
.03 Claims can be submitted two ways.
a) Sent directly to Netwerkes. To do this, you must be a customer of Netwerkes. To
enroll in Netwerkes, call (262) 523-3600.
b) Sent by your Clearinghouse. To do this, your clearinghouse must have a forwarding
agreement with Netwerkes. This arrangement allows your clearinghouse to pass the
claim on to Netwerkes so NHP /THP can receive them. Contact your Clearinghouse to
see if this arrangement exists. Forwarding agreements are currently in place with
McKesson, and many others.
Claim Format:
.04 Hospital providers must use the ASCX12N 837 5010 TR3 institutional format when
submitting electronic claims. Practitioners must use the ASC X12N 837 5010 TR3
professional format.
.05 Special attention should be paid to the following fields:
b) Billing Provider: 85
c) Billing Provider Name:
a) Payer Identification number: 38338
i. Individual Provider - Enter each part of name in separate fields using the format
shown below. Do not use any punctuation.
LASTNAME FIRSTNAME MIDDLEINITIAL (not required)
ii. Group Practices/Companies - Enter as much of the full name as possible in last
name field using the format shown below. Do not use any punctuation.
GROUPNAME
Customer Service
(888) 327-0671
48
d) Billing Provider Address:
i. Street- Use standard US Post Office street abbreviations (ex. N, E,S, SW, NE) in
the format shown below. Do not use any punctuation. The billing provider address
must be a street address. Post office or Lock Box addresses are to be sent in the
Pay-To Address Loop (Loop 2010AB).
999 S Healthcare ST or PO BOX 123
ii. City, State, and ZIP - Use full city name and standard Post Office two-digit state
abbreviations. Use the valid nine digit zip code.
e) Billing Provider Identification Number: A required field. Enter your billing provider
NPI number. Incorrect provider identification numbers will cause the claim to be
rejected
Tax ID must be included as the “Billing Provider Secondary Identifier”
f) Member Name: A required field. Enter each part of the name into a separate field
using the format shown below. Incorrect spelling of a member’s name will cause
the claim to be rejected. The spelling must mirror the spelling on the member’s NHP/THP
ID card.
LASTNAME FIRSTNAME MIDDLEINITIAL
g) Member Identification Number (Loop: 2000B, Segment: SBR03): A required field.
All identification numbers must be the exact seven numeric digits shown in the format
below. An incorrect identification number will cause the claim to be rejected. The
identification number must mirror the number on the member’s NHP/THP card. This is
not the member’s Medicaid, Social Security, or group number.
1234567
h) Members Address:
i. Street- Use standard US Post Office street abbreviations (ex. N, E, S, SW, NE) in
the format shown below. Do not use any punctuation.
999 S Healthcare ST or PO BOX 123
i. City, State, and ZIP - Use full city name and standard Post Office two-digit state
abbreviations. Use the five digit zip code.
i) Member’s Date of Birth and all other Date Fields: Enter each part of the date in the
format shown below. Do not use any punctuation. An incorrect date of birth will
cause the claim to be rejected
CCYYMMDD
Customer Service
(888) 327-0671
49
j) Service Detail:
i. Units (professional claims: Loop: 2400, Segment: SV104, institutional claims:
Loop: 2400, Segment: SV205)- Value can not be zero. Do not use preceding zeros
in front of the value
k) Complete list of edits can be obtained at: http://204.250.122.62/pdfs/ErrorLookup.pdf
Claims Data Validation
.06 EDI claims will be validated at several points before they are loaded into the claims payment
system
a) Your clearinghouse validates the claim data. You should be provided with rejection
reports by your clearinghouse for claims that we do not receive. NHP/
THP/McLaren Health Advantage does not receive a copy of those reports and has no
control over the validation your clearinghouse performs.
b) Netwerkes validates the claim data.
c) NHP/THP’s claim system validates the claim data. As mentioned above, the member’s
name, identification number, and date of birth must be correct for the claim to be
processed. The billing and rendering provider identification number (NPI)
must also be correct. If any of these fields are incorrect, a copy of the original claim
will be returned with a cover letter explaining the rejection. These rejections may also
appear on an EOP with a rejection code stating the patient/provider could not be
identified
Testing/Questions
.07 .08 If you have questions about becoming a customer of Netwerkes, questions concerning
initial testing, or have problems with claim rejections received from the clearinghouse:
Contact Netwerkes Customer Service at (262) 523-3600.
.09 If you need the status of a claim that you have submitted or have questions concerning
rejections received by NHP/THP: Contact Customer Service at (888) 327-0671. For
new electronic claim submitters, a few initial claims should be statused 1-2 weeks after
submission to make sure NHP/THP has received them.
.10 Positive submission status received from the clearinghouse does not guarantee claim were
received by NHP/THP. Clearinghouse edits may differ from NHP/THP claim requirements.
If you have questions about the set up instructions above or if your electronic claims are not
being received by NHP/THP: Contact NHP/THP’s third party administrator, McLaren Health
Advantage, at (888) 327-0671.
Customer Service
(888) 327-0671
50
EDI CLAIM EXAMPLES
Forward these examples to your EDI vendor or programming staff.
Example I
Provider is a company/group
Provider ID Number = 1021234
Subscriber/Member ID Number = 123456
Our Payer ID = 38338
NM1*85*2*GENERAL HOSPITAL*****24*381234567~
Billing Provider Name and TIN
N3*345 ANY STREET~
Billing Provider Street Address
Billing Provider City, State, Zip
N4*FLINT*MI*48507~
REF*G2*1021234~
Billing Provider ID
PER*IC*JOHN DOE*TE*0000000000~
Billing Provider Contact
HL*2*1*22*0~
(Inserted by our clearinghouse)
SBR*P*18*999999******CI~
Subscriber Information and Member Group Number
NM1*IL*1*ADAMS*JOHN*Q***MI*123456~
Subscriber Name and ID
N3*345 OTHER ST~
Subscriber Street Address
N4*BURTON*MI*48529~
Subscriber City, State, Zip
DMG*D8*19020202*F~
Subscriber DOB
NM1*PR*2*MCLAREN HEALTH PL*****PI*38338~
Payer Name and ID
CLM*12345*150***13^A^1***Y*Y*********Y~
Claim Information/Assignment of
Benefits Indicator: Use Y when assigning benefits to provider
Example II
Provider is an individual person
Provider PIN = 1011234
Subscriber/Member ID Number = 912345678
Our Payer ID = 38338
NM1*85*1*SPOCK*BENJAMIN*M***24*201234567~
Billing Provider Name and TIN
N3*123 ANY STREET~
Billing Provider Street Address
N4*LANSING*MI*48991~
Billing Provider City, State, Zip
REF*G2*1011234~
Billing Provider ID
PER*IC*JANE DOE*TE*9893451184~
Billing Provider Contact
HL*2*1*22*0~
(Inserted by our clearinghouse)
Subscriber Information and Member Group Number
SBR*P*18*999999******CI~
NM1*IL*1*ROOSEVELT*FRANKLIN*D***MI*912345678~
Subscriber Name and ID
N3*555 FEDERAL~
Subscriber Street Address
N4*HOUGHTON LAKE*MI*48629~
Subscriber City, State, Zip
DMG*D8*19010101*F~
Subscriber DOB
Payer Name and ID
NM1*PR*2*MCLAREN HEALTH PL*****PI*38338~
CLM*123456*150***11::1*Y*A*Y*Y*C~
Claim Information/Assignment of Benefits Indicator: Use Y when assigning benefits to provider
Customer Service
(888) 327-0671
51
DIRECTORY
This directory is an alphabetical listing of NHP/THP staff, programs, and key contacts.
.01 Administration:
For questions related to primary care site administration, recurring problems or concerns, or
payment of services, contact:
McLaren Health Advantage
P.O. Box 1511
Flint, MI 48501-1511
(888) 327-0671
FAX: (877) 502-1567
.02 Benefit Determination:
To authorize procedures performed by a physician in an office or outpatient hospital setting
(other than laboratory or radiology), fax a completed Benefit Determination Form to (877)
502-1567 or contact Customer Service at (888) 327-0671.
Billing problems/concerns:
.03 Northern Health Plan/Tencon Health Plan
Attn: Provider Claims Inquiry
P.O. Box 1511
Flint, MI 48501-1511
Customer Service
(888) 327-0671
Fax: (877) 502-1567
.04 Breast and Cervical Cancer Screening Services:
To refer women age 40 and over to an authorized breast and cervical cancer screening site,
call:
Alpena Charlevoix Emmet Otsego (800) 221-0294 (800) 432-4121 (800) 432-4121 (800) 432-4121 Antrim Cheboygan Montmorency Presque Isle (800) 432-4121
(800) 221-0294
(800) 221-0294
(800) 221-0294
Crawford
Lake Mason Missaukee Oceana
(989) 348-7800 (231) 745-4663
(231) 845-7381 (231) 839-7167
(231) 873-2193
Kalkaska Manistee Mecosta Newaygo Wexford
(231) 258-8669
(231) 723-3595
(231) 592-0130
(231) 689-7300
(231) 775-9942
Customer Service
(888) 327-0671
52
DIRECTORY
.05 Community Mental Health Services Program:
For mental health services, call:
Alpena Charlevoix Emmet Otsego (800) 834-3393
(800) 834-3393
(800) 834-3393 (800) 834-3393
Antrim Cheboygan Montmorency Presque Isle (800) 834-3393
(800) 834-3393
(800) 834-3393
(800) 834-3393
Crawford
Lake Mason Missaukee Oceana
(800) 492-5742 (231) 845-6294
(231) 845-6294 (800) 492-5742
(231) 845-6294
Kalkaska Manistee Mecosta Newaygo Wexford
(800) 834-3393
(877) 398-2013
(231) 796-5825
(231) 689-7330
(800) 492-5742
Customer Service
(888) 327-0671
53
DIRECTORY
.06
Covered Services:
For questions related to services covered by NHP/THP contact Customer Service at (888) 3270671.
For questions related to services covered by the ABW program or the Plan First program
contact Provider Inquiry, Department of Community Health at (800) 292- 2550 or e-mail
[email protected].
.07 Customer Service:
To obtain information about eligibility, policies and procedures, enrollment verification,
member co-payments and primary care site assignment, urgent referral authorizations,
assistance with prescription authorizations, durable medical supply information, to request a
member special disenrollment, and to resolve clinical issues call:
.
08 Northern Health Plan/Tencon Health Plan
Customer Service
(888) 327-0671
Fax: (877) 502-1567
Monday - Friday, 8:30am - 5:00pm
To verify NHP/THP eligibility, contact Customer Service at (888) 327-0671. Enrolled
NHP/THP providers can access our website, www.mclarenhealthadvantage.org to verify
eligibility through FACTSWeb. For Plan A eligibility information, enrolled Medicaid
providers may use the Automated Voice Response System by calling (888) 696-3510.
.09 Family Planning Services:
To refer a member for family planning services, including contraceptives, call:
Eligibility Verification:
(800) 221-0294
(800) 221-0294
(800) 221-0294
Crawford Lake Mason Missaukee
Oceana
(989) 348-7800
(231) 745-4663
(231) 845-7381
(231) 839-7167
(231) 873-2193
Kalkaska Manistee Mecosta Newaygo
Wexford
(231) 258-8669
(231) 723-3595
(231) 592-0130
(231) 689-7300
(231) 775-9942
.10
General Information:
Contact Customer Service at (888) 327-0671
Customer Service
(888) 327-0671
54
DIRECTORY
.11 HIV/AIDS Services:
To refer a member for HIV/AIDS services, contact:
(800) 221-0294
(800) 221-0294
(800) 221-0294
Crawford
Lake Mason
Missaukee
Oceana
(989) 348-7800
(231) 745-4663
(231) 845-7381
(231) 839-7167
(231) 873-2193
Kalkaska
Manistee
Mecosta
Newaygo
Wexford
(231) 258-8669
(231) 723-3595
(231) 592-0130
(231) 689-7300
(231) 775-9942
.12
Ordering Materials:
To order NHP/THP member or provider materials, or schedule trainings, call or fax your
request to:
Customer Service
(888) 327-0671
Fax: (877) 502-1567
.13 Pharmacy:
To obtain a NHP/THP drug formulary or for assistance with filling medications covered by
NHP/THP, visit our website at www.mclarenhealthadvantage.org or contact Customer
Service at (888) 327-0671.
.14 Smoking Cessation:
For smoking cessation assistance, call:
Alpena Charlevoix Emmet Otsego (800) 221-0294 (800) 432-4121
(800) 432-4121 (800) 432-4121 Antrim Cheboygan Montmorency Presque Isle (800) 432-4121
(800) 221-0294
(800) 221-0294
(800) 221-0294
Crawford
Lake
Mason
Missaukee
Oceana
(989) 348-7800
(231) 745-4663
(231) 845-7381
(231) 839-7167
(231) 873-2193
Kalkaska
Manistee
Mecosta
Newaygo
Wexford
(231) 258-8669
(231) 723-3595
(231) 592-0130
(231) 689-7300
(231) 775-9942
Michigan Department of Community Health “I Can Quit” program at (800) 480-7848
Customer Service
(888) 327-0671
55
DIRECTORY
.15 Substance Abuse Services:
To refer a member for substance abuse services, contact:
Alpena Charlevoix Emmet Otsego (989) 356-7242 (989) 356-7242 (989) 356-7242 (989) 356-7242
Antrim Cheboygan Montmorency Presque Isle (989) 356-7242
(989) 356-7242
(989) 356-7242
(989) 356-7242
THP
Central Diagnostic and Referral Services (800) 686-0749 or (989) 732-0864
.16 Tuberculosis Services:
To refer a member with a positive PPD, call:
(800) 221-0294
(800) 221-0294
(800) 221-0294
Crawford
Lake
Mason
Missaukee
Oceana
(989) 348-7800
(231) 745-4663
(231) 845-7381
(231) 839-7167
(231) 873-2193
Kalkaska
Manistee
Mecosta
Newaygo
Wexford
(231) 258-8669
(231) 723-3595
(231) 592-0130
(231) 689-7300
(231) 775-9942
.17 Web Site:
Customer Service
(888) 327-0671
56
Appendix A
FAMILY PLANNING AND BCCCP SERVICES
THIS INFORMATION IS BEING PROVIDED TO YOU FOR REFERENCE PURPOSES
Some services are available free of charge to NHP/THP members.
Service
Fees
Comments
Family Planning
Program
Services are provided
on a sliding fee scale
based on the number of
people in the household
and household income.
Services are available at Available to women of
childbearing years.
authorized family
planning clinics.
Contact the county
health department
Family Planning
Program. For more
information see
Directory.
Services must be
provided at an
authorized family
planning clinic.
$0.00
Contact the county
health department
Breast and Cervical
Cancer Control
Program (BCCCP). For
more information see
Directory.
Available to women age
40 and over.
Refer members to their
local DHS office for the
application. Eligibility
is for a one (1) year
period.
Available to women 1944 years old who are not
covered by Medicaid or
ABW and are a US
citizen.
Services may include
pelvic exam, Pap test,
breast exam, birth
control information and
contraceptive supplies,
STD counseling, testing
and treatment,
diagnosis and treatment
of gynecological
problems, weight loss
counseling, and
sterilization referral.
Breast and Cervical
Cancer Screening
Services
Screening services
include pelvic exam,
Pap test, clinical breast
exam, and
mammogram. Followup services available to
women with abnormal
findings.
Possible charges for
non-covered services.
Plan First Program –
Plan B ONLY
$0.00
Office visits for
contraceptive
management,
contraceptives,
labs/tests related to
family planning,
sterilization, etc.
Possible charges for
non-covered services.
Customer Service
(888) 327-0671
Provisions
Services must be
provided by an
authorized BCCCP
provider.
57
Appendix B
e rn He
North
a
lth
Member Information Change Form
Administered by McLaren Health Advantage
Customer Service: (888) 327-0671
Fax: (877) 502-1567
P
la
n
Date:
Requesting Office:
Office Name:
Office Contact:
Office Information
Group #:
Phone:
Member Information
Last Name:
ID #:
First Name:
Date of Birth:
Member Primary Care Provider (PCP) Change/Request
 Change PCP Office (must be a participating provider with Northern/Tencon Health Plan)
Current PCP Office Group #:_______________________
Requested PCP Office Group #: ____________________
PCP Changes are effective the first day of the month following the request
New Street Address:
City:
Phone #:
 Moved out of County
Member Address Change
*Member Signature Required Below
State:
Zip:
Other Requests
 Order New ID Card
 Discharged From PCP Office (Attach Discharge Letter)
 Pregnant/Due Date:
 Deceased/Date:
 Other Medical Coverage:
Insured & Contract #:
Effective Date:
 Other (briefly explain):
* Member Signature: I verify that the above information is correct and authorize McLaren Health
Advantage on behalf of Northern and Tencon Health Plans to update my records.
Member’s Signature: ________________________________________________ Date: ___________
This electronic message, including any attachments, is confidential and intended solely for use of the intended
recipient(s). This message may contain information that is privileged or otherwise protected from disclosure by
applicable law, including Health Plan member protected health information (PHI), and is being sent under
circumstances where member authorization is not required. Member PHI shall only be disclosed to permitted
recipients for purposes of treatment, payment, or health care operations for the member. The disclosure or request for
PHI shall be limited to the PHI that is the minimum amount necessary to achieve the intended purpose of the use,
disclosure, or request. Any unauthorized disclosure, dissemination, use or reproduction is strictly prohibited. If you
have received this message in error, please destroy it and notify the sender immediately.
Form # CHP10007
58
Appendix B
Completing the Member Information Change Form
.01 a) General Guidelines:
b) Failure to complete all pertinent information may delay the change process
All information should be printed on the form
c) Forms can be faxed to NHP/THP Customer Service. The fax number is located at the
top of the form
.02 How to complete the Member Information Change Form:
a) Requesting Office: Complete the date, office name, staff person completing the form,
and phone. It is important to include staff person and phone if more information is
needed to process the request
b) Member Information: complete last name and first name of member, member ID #, and
date of birth
c) Member Change/Request: Select the change/request you are completing the form for.
If the change is a Member Address Change the member’s signature is required to
process the change. If the member’s signature cannot be obtained, include the
member’s phone number to verify the change
Customer Service
(888) 327-0671
59
Appendix C
COUNTY HEALTH PLAN’S
Copay per Plan A
Urgent
Care
$3.00
X-Ray
Lab
Prescription
NHP
Office
Visits
$3.00
$0.00
$0.00
$1.00/$1.00
THP
$3.00
$3.00
$0.00
$0.00
$1.00/$1.00
COUNTY HEALTH PLAN’S
Copay per Plan B
Urgent
Care
$5.00
X-Ray
Lab
Prescription
NHP
Office
Visits
$5.00
$0.00
$0.00
THP
$5.00
$5.00
$0.00
$0.00
50%
coinsurance
$5.00/$10.00
60
Appendix D
ELIGIBILITY VIEWING SYSTEM
The Eligibility Viewing System has been designed to assist participating health care providers in
verifying eligibility of a member. The eligibility screen will allow users to have viewing rights
to current and past member information, including enrollment and disenrollment dates and
primary care practice assignments. Since the membership is constantly changing, the FACTSWeb
is the most accurate information available as it is updated daily.
Important Information:
.01 Access to the Internet is required to use FACTSWeb. It has been designed to allow users
to have “viewing rights only”.
.02 To access the FACTSWeb the user must first complete a FACTSWeb application. NHP/THP
will assign logins and passwords to each user requesting access. The application form is
available by accessing our website at: www.mclarenhealthadvantage.org or calling
Customer Service at (888) 327-0671.
.03 Any member information the user attempts to enter will not add to, alter, or delete any
existing information regardless of the user keystrokes. Primary care practices should
continue to complete and forward the Member Information Change Form when updating
or changing member information.
.04
Once the FACTS Web application has been processed, the user will receive an email
containing login and password instructions. The user will also receive a detailed guidebook
with step by step instructions on how to view eligibility in the system.
Customer Service
(888) 327-0671
61
Appendix E
Appendix D
MICHIGAN COUNTY CODES
01
Alcona
31
Houghton
61
Muskegon
02
Alger
32
Huron
62
Newaygo
03
Allegan
33
Kalamazoo
63
Oakland
04
Alpena
34
Ionia
64
Oceana
05
Antrim
35
Iosco
65
Ogemaw
06
Arenac
36
Iron
66
Ontonagon
07
Baraga
37
Isabella
67
Osceola
08
Barry
38
Jackson
68
Oscoda
09
Bay
39
Kalamazoo
69
Otsego
10
Benzie
40
Kalkaska
70
Ottawa
11
Berrien
41
Kent
71
Presque Isle
12
Branch
42
Keweenaw
72
Roscommon
13
Calhoun
43
Lake
73
Saginaw
14
Cass
44
Lapeer
74
St. Clair
15
Charlevoix
45
Leelanau
75
St. Joseph
16
Cheboygan
46
Lenawee
76
Sanilac
17
Chippewa
47
Livingston
77
Schoolcraft
18
Clare
48
Luce
78
Shiawassee
19
Clinton
49
Mackinac
79
Tuscola
20
Crawford
50
Macomb
80
VanBuren
21
Delta
51
Manistee
81
Washtenaw
22
Dickinson
52
Marquette
82
Wayne
23
Eaton
53
Mason
83
Wexford-Missaukee
24
Emmet
54
Mecosta
25
Genesee
55
Menominee
26
Gladwin
56
Midland
27
Gogebic
57
Missaukee
28
Grand Traverse
58
Monroe
29
Gratiot
59
Montcalm
30
Hillsdale
60
Montmorency
62
Appendix F
North
e rn He
alt
hP
la
n
Provider Claims Status Fax Form
Fax: (877) 502-1567
con
Health Plan
Please complete form and fax to McLaren Health Advantage (MHA) and we will fax back a status response.
Date:
From:
Phone Number:
Fax Number:
Number of Pages Faxed:
 Please allow 15 days for MHA to process and/or respond to all claims status fax forms
 Claims will not be reviewed if status is requested less than 30 days from the date MHA received the
original claim
 Attach a copy of the original claim
Please complete the following information (required for each claim)
Member Name:
Member ID #:
MHA Claim Number:
Date of Service:
Provider name:
Provider NPI#:
Procedure Code:
Charges:
Comments:
Claim Processed
Claim Denied
Corrected Claim Needed
Comments:
MHA Status Response (for MHA use only)
EOB Date:
Check #:
Reason:
Correction Needed:
Amount:
If you have any questions, please contact Customer Service at (888) 327-0671.
Important: This message, including any attachments, is confidential and intended solely for the use of the intended recipient(s). This message may
contain information that is privileged or otherwise protected from disclosure by applicable law. Any unauthorized disclosure, dissemination, use, or
reproduction is strictly prohibited. If you have received this message in error, please destroy it and notify the sender immediately.
McLaren Health Advantage Customer Service (888) 327-0671
CHP10038
63
Appendix G
North
e rn He
alt
hP
la
n
Provider Claim Adjustment
Request Form
con
Health Plan
WHEN TO USE THIS FORM:
A Claim Adjustment - is a request for payment reconsideration for a paid or denied claim. Any claim for which an
Explanation of Payment (EOP) was issued that was paid inappropriately, or was denied, must be resubmitted on a
paper claim (not EDI) with supporting documentation as an adjustment.
Claim Adjustment Request Time Frame - All claim adjustment inquiries and requests must be made to McLaren
Health Advantage (MHA) within 90 calendar days of the most current MHA EOP. Any inquiry or request made
after 90 calendar days will not be given consideration. The acknowledgement of receipt date will only be considered
when a completed request form and supporting documentation is received by MHA.
COMPLETE THE FOLLOWING REQUIRED INFORMATION:
Member Name:
ID #:
MHA Claim #:
DOS:
Provider ame:N
Tax ID #:
NPI #:
Office Contact:
Phone #:
Date Provider Claim Adjustment Request Form Submitted:
Reason for Request (please check appropriate box):
For a correction to a
previously submitted claim:
 Anesthesia Time
 Date of Service
 Diagnosis Code
 Modifier
 MS DRG
 Place of Service
 Procedure Code
 Provider/Tax ID
 Other
For reconsideration:
(supporting documentation required)
 Service denied for lack of authorization
(attach copy of referral)
 Service denied as other insurance primary (COB)
(attach copy of primary EOB)
 Service denied as a duplicate
(attach documentation)
Send this completed Provider Claim Adjustment Request form along with
the paper claim form (not EDI) and supporting documentation to:
Attention: Customer Service
P.O. Box 1511
Flint, MI 48501-1511
Or Fax to: (877) 502-1567
For questions regarding the Provider Claims Adjustment Process, call Customer Service at (888) 327-0671.
The Provider Claims Adjustment Request form is available on our website at:
CHP10039
64
Appendix H
North
e rn He
alt
Provider Request for Appeal
hP
la
n
con
Health Plan
A formal Provider Appeal process is made available to any provider who challenges administrative
action taken by McLaren Health Advantage (MHA).
Appeal Time Frame – A Provider Request for Appeal (PRA) must be made to MHA within 90
calendar days of the administrative action. The PRA form must be complete and supporting
documentation must be included.
The right to appeal is forfeited if the provider does not submit a completed PRA form with supporting
documentation (within the 90 calendar day time frame), and any charges in dispute must be written off.
Please complete the REQUIRED information below:
Member name: _____________________________
ID #: ___________________
DOS: ______________________ MHA Claim #: ___________________________
Provider name: __________________________ Tax ID #: _____________________
Service being appealed: __________________________________________________
Reason for appeal: ______________________________________________________
______________________________________________________________________



REQUIRED ATTACHMENTS:
Letter documenting the rationale for the appeal request
Supporting documentation
Paper claim for the services being appealed
Name of person submitting appeal: _____________________________
Phone #: ____________________ Date submitted: _______________
Address to send response: _____________________________________
Mail to:
Attention:
Provider Appeals
P.O. Box 1511
Flint, MI 48501-1511
___________________________________________________________
For questions regarding the Provider Request for Appeal Process, call Customer Service at (888) 327-0671
The Provider Request for Appeal Form is available on-line at:
CHP10040
65

con NORTHERN & TENCON HEALTH PLAN

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