Provider Manual

Transcription

Provider Manual

Provider Manual
For
SeaView IPA
Valley Care IPA
Valley Care Select IPA
Santa Barbara Select IPA
Leisure World Managed Care Medical Group
Pioneer Provider Network
Management Services Administrator for
Contracting Physician Organizations
PART 1: PRACTITIONER ORGANIZATION INTRODUCTION
Strict
federal and state regulations and accreditation requirements govern the administrative
operations of practitioner organizations (POs), such as medical groups and independent physician
associations (IPAs), with respect to their patients who are enrolled in managed care health plans, also
known as health maintenance organizations (HMOs). In order for POs contracting with MED3OOO to
maintain their state licenses and the contractual arrangements with managed care organizations that
help them meet market demands, practitioners employed by or under contract with them are required
to meet stringent standards of performance. Practitioners granted panel privileges must share an
ongoing commitment to participating in and complying with patient management, credentialing,
utilization management and quality improvement program activities, which define many aspects of a
practitioner’s practice.
The information that follows highlights the key requirements for HMO practice management that are
highly important and require your active participation as a practitioner contracting with the following
MED3OOO affiliated POs:
SeaView IPA
Valley Care IPA
Section
Part 1:
Part 2:
Pages
Practitioner Organization Introduction
5
Mission Statement
6
Independent Physician Association
7
Committees and Members
8
MED3OOO Overview
11
Management Contacts
12
Primary Care Physician Responsibilities
13
PCP Functions
14
Advanced Directives
20
Eligibility Verification
21
Member Relations
22
Provider Relations
23
Finance
24
PCP Capitation EOB
27
Page 2
Part 3:
Part 4:
Part 5:
Part 6:
Specialist Capitation EOB
29
Eligibility
30
Network Development
31
Policies and Procedures (available on the SVIPA web site)
Physician Compensation
32
Billing Instructions
33
Claim Submission
34
Co-Payment/Co-Insurance Collection
35
Dual Coverage and COB
35
EOB
36
Encounter Data Submission
37
California Children Services
37
Provider Satisfaction Survey
37
Patient Access to Care and Service
38
Patient Rights and Responsibilities
38
Patient Access Standards
40
Practitioner-Patient Relationships
43
Credentialing Program
48
The Credentialing Mandates
48
Licensure and DEA/CDS Certification
49
Board Certification
49
Malpractice Liability Coverage
49
Other Credentialing Requirements
49
Availability of Credentialing Program Description
50
Credentialing Information Contact
50
Utilization Management Program
51
UM Program Responsibility
51
Decision-Making Policies
51
Availability of Utilization Management
Program Description
52
UM Department Business Hours
52
Page 3
Requirements for Specialty Care, Ancillary Service
and Inpatient Referrals
52
Services Subject to Review
52
Services Not Subject to Review
53
Services Coordinated Through Patients’ Health Plans
54
Information Required for Case Reviews
55
Initiating a Case Review
56
Reporting Emergency Inpatient Admissions
57
Authorized Referral Providers
58
Authorization Problems
58
UM Decision-Making Criteria and Guidelines
59
Case Management Programs
60
Quality Improvement Program
61
Availability of Quality Improvement Program Description
61
Physician Supervision of Non-Physician Practitioners
61
Medical Records Requirements and Audits
62
Facility Operations Requirements and Audits
63
Access Audits
63
Part 8:
How to Contact Us
64
Part 9:
Appendix
Part 7:
Waiver Form
65
Sample Member Introduction Letter for PCPs
66
Referral Authorization Form
68
See Internet for current PCP & Specialist listings
and EZNet User Manual
Part 10:
Glossary
74
Page 4
Dear Physician and Office Manager:
I would like to thank you for your participation with the IPA or Medical Group. We appreciate the
opportunity to work with you and your staff in a joint effort to provide high quality, effective patient care
and service to our members.
This Provider Manual was developed to provide you and your staff with information to assist you
regarding the procedures that should be followed in the areas of authorizations, case management,
quality improvement, credentialing, finance, eligibility, claims, contracting, provider relations, member
relations and health education.
I am confident that this manual in conjunction with communication with the appropriate departments
will ensure smooth operations for your office and the members, which is our primary objective.
The Provider Manual will be revised periodically and I welcome any suggestions or comments for
improvement. Should you have any questions or require additional assistance, please do not hesitate
to contact the Management Team. We look forward to a continued strong partnership with you and a
successful future.
Sincerely,
Lynn Haas,
Executive VP, MED3OOO
Page 5
MISSION STATEMENT
MED3OOO is the leader in quality cost effective health care management. We are responsive to
changing markets through innovative diversified planned delivery systems.
MED3OOO is committed to providing quality patient care by combining case management with
medical technology.
The partnership between MED3OOO and its customers realize fulfillment through a shared
commitment in continuous quality improvement.
Page 6
INDEPENDENT PHYSICIAN ASSOCIATIONS
In the managed care industry, the Independent Physician Association (IPA) physicians, practice
independently in their own offices and care for patients with HMO insurance coverage.
These physician-oriented organizations were formed in order to contract with prepaid health plans (i.e.,
HMOs) and to function as Accountable Care Organizations. More and more third party payors,
including HMOs, consider it to be cost-effective to purchase managed health care through a
coordinated group of physicians. These purchasers are also looking for a long-term partnerships with
physician groups to provide quality, cost-effective health care with high levels of customer satisfaction.
MED3OOO provides full or partial management services to the following IPA’s prepaid physician
organizations:
SeaView IPA
Valley Care IPA
MED3OOO OFFICE LOCATIONS:
Oxnard Main Office:
1901 N. Solar Dr., Suite 265
Oxnard, CA 93036
Phone: (805) 988-2280
Fax: (805) 988-5164
Cerritos Satellite Office:
17777 Center Court Drive, Suite 425
Cerritos, CA 90703
Phone: (562) 865-0208
Fax: (805) 278-4275
PROVIDER & MEMBER SERVICES CONTACT NUMBERS:
Member
Services
Provider
Services
SeaView
IPA
Valley Care
IPA
Valley Care
Select IPA
Santa
Barbara
Select IPA
Leisure World
Managed
Care
Pioneer
Provider
Network
(805) 988-5188
(877) 311-5411
(805) 604-3332
(877) 299-5599
(805) 604-3332
(877) 299-5599
(805) 278-6823
(800) 705-0831
(805) 604-3317
(855) 415-4455
(805) 988-5164
(888) 720-2323
(805) 604-3325
(805) 604-3308
(805) 604-3308
(805) 278-6823
(800) 705-0831
(805) 604-3317
(855) 415-4455
(805) 988-5164
(888) 720-2323
Page 7
BOARDS OF DIRECTORS
SeaView IPA
Edward Banman, MD –
Chairman
Gary Proffett, MD – Medical
Director
Chris Arnold, MD
Michael Bailey, MD
Andrew Weymer, MD
Timothy Bryant, MD
Stephen Feinberg, MD
Jon Schrock, MD
Valley Care IPA
Gary Deutsch, MD - President
Jerome Kay, MD - President
Michael Swartout, MD –
Medical Director
Michael Tushla, MD Treasurer
Jeffery Tubbs, MD - Secretary
Gary Wikholm, MD
Geoffrey Loman, MD
Logan Bundy, MD
Gosta Iwasiuk, MD
Ramsey Ulrich, MD
Stanley Patterson, MD
Kirk Gilbert, MD - Medical
Director
Gary Ponto, MD
Jesse Chang, MD
Mario Curti, MD
Ellen Dayon, MD
L. Wayne Freeman, MD
Rudolf Haider, MD - Chairman
Daniel Rodiles, MD
Mary Sherman, ND
Victor Tacconelli, MD
John Wrench, MD
David Laub, MD
Paul Aijian, MD - Treasurer
Pinal Doshi, MD
Jerry Floro, MD
Don Garcia, MD
Sanat Kumar Patel, MD - Chairman
Edwardo Tellez, MD
COMMITTEES
UTILIZATION MANAGEMENT COMMITTEES
SeaView IPA
Gary Proffett, MD - Chairman/
Medical Director
Michael Bailey, MD
Imelda DeForest, MD
Theodore Hostetler, MD
Cary Savitch, MD
Joseph Lopresti, MD
Arthur Inoshita, MD
Irene Wakam,
Carl Gross, MD
Alon Steinberg, MD
Saumil Gandhi, MD
Lorna Barte, MD
Valley Care IPA
Medical Director
Robert Dekkers, MD Chairman
Kathleen Beuttler, MD
Mikael Hakansson, MD
Alexander Meyer, MD
Gary Wikholm, MD
Kirk Gilbert, MD - Chairman/
Medical Director
Dennis Ashley, MD
Dean Given, PhD
Gary Ponto, MD
Kenneth Wagner, MD
John Wrench, MD
Page 8
UTILIZATION MANAGEMENT COMMITTEES
Nancy Smith, MD - Chairman
Rudolf Haider, MD
Ellen Dayon, MD
Prakash Narain, MD
Mary Sherman, MD
Gary Nemhauser, MD
Abes Bagheri, MD
Don Garcia, MD - Chairman
Emerico Csepanyi, MD
Pinal Doshi, MD
Jerry Floro, MD – Chairman
David Middleton, PHD
Angelyn Moultrie-Lizana, DO
Sanatkumar Patel MD
Edward Tellez, MD
Joseph Lombardo, MD
QUALITY IMPROVEMENT COMMITTEES
SeaView IPA
John Ford, MD - Chairman
Gary Proffett, MD - Medical
Director
Danielle Onstot, MD
Sanjiv Verma, MD
Lin Tesu, MD
Scott Roberg, DPM
Lisa Babashoff, MD
Sahin Yanik, MD
Jodi Ferro, MD
Valley Care IPA
Medical Director
Robert Dekkers, MD Chairman
Kirk Gilbert, MD Chairman/
Medical Director
Dennis Ashley, MD
Kathleen Beuttler, MD
Mikael Hakansson, MD
Alexander Meyer, MD
Gary Wikholm, MD
Dean Given, PhD
Gary Ponto, MD
Kenneth Wagner, MD
John Wrench, MD
Nancy Smith, MD - Chairman
Rudolf Haider, MD
Ellen Dayon, MD
Prakash Narain, MD
Mary Sherman, MD
Gary Nemhauser, MD
Abes Bagheri, MD
Terri Furlow 0 LWHC Administrator
COMPENSATION & CONTRACTING
SeaView IPA
Edward Banman, MD –
Chairman
Gary Proffett, MD – SVIPA
Medical Director
Timothy Bryant, MD
Jon Shrock, MD
Andrew Weymer, MD
Valley Care IPA
NA
NA
Page 9
COMPENSATION & CONTRACTING
NA
NA
CREDENTIALS COMMITTEES
SeaView IPA
Arthur Inoshita, MD - Chairman
Valley Care IPA
Gary Proffett, MD - SVIPA
Medical Director
Carey Chronis, MD
Theodore Hostetler, MD
Cheryl Geer, DO
Lynn Pluche, MD
Robert O’Hara, MD
Michael Swartout, MD – VCIPA
Medical Director
Mary Sherman, MD
Rudolf Haider, MD - Chairman
Ellen Dayon, MD
Nancy Smith, MD
Gary Nemhauser, MD
Prakash Narain, MD
Kirk Gilbert, MD Chairman/
Medical Director
Dennis Ashley, MD
Dean Given, PhD
Gary Ponto, MD
Kenneth Wagner, MD
John Wrench, MD
Jerry Floro, MD – Chairman
Don Garcia, MD - Chairman
Pinal Doshi, MD
Emerico Csepanyi, MD
Edward Tellez, MD
Angelyn Moultrie-Lizana, DO
Sanatkumar Patel MD
Page 10
PART 2: MED3OOO OVERVIEW
The following are representative of some of the Operational Tasks preformed by the administrative
staff of MED3OOO: (This does not imply that all PO’s have contracted with MED3OOO for the same
services)

Accounting

Authorizations

Benefit Interpretation/Compliance

Capitation

Case Management

Claims Encounter and/or Payment

Contract Negotiations

(Health Plan, Physician, Hospital and Ancillary)

Detail Record-keeping

EZ-CAP (MIS System) Usage and Maintenance

Financial Management

Health Plan Communication

Legislature Compliance

Member Eligibility

Member Services

Office Managers Education/Communication

Physician Education/Communication

Provider Credentialing

Quality Improvement
Page 11
MANAGEMENT CONTACTS
Staff Name
Title
Area of Responsibility
Phone Number
Lynn Haas, CPA
CEO
Overall Operations
(805) 988-2280
Debbie Tuttle, CPA
CFO
Finance
(805) 988-2280
Janet Plait
Accounting Director
Leslie Young
Director of Contracting
Dione Webster
Contracts Manager
Lisa Barnes, RN
Veronica Vasquez
Director of Health
Services
Information Systems
Manager
Capitation, Eligibility,
Accounting
Contracting, Network
Development
Contracting, Network
Development
(805) 988-5187
(805) 988-5101
(805) 988-5182
Health Services
(805) 604-3314
Information Systems
(805) 988-5155
Kevin Taylor
Director of Operations
Member Services, Prov.
Relations, Claims
(805) 604-3324
Adrienne Gardner
Claims Manager
Claims
(805) 988-5145
Member & Provider
Relations Manager
Provider Network
Manager – PPN & LW
Member and Provider
Services
Contracting & Provider
Relations – Cerritos Office
Christina Muro
HCC & P4P Supervisor
HCC & P4P
(805) 278-6848
Robin Broms, LVN
Case Mgmt./Quality
Improvement Manager
Case Management
Quality Improvement
(805) 988-5129
Melissa Frayre, RN
Authorizations Manager
Authorization Department
Irene Ybarra
Gabbie Nguyen
Jennifer Moore
Sonya Araiza
Executive Director
SBSIPA
Executive Director
VCIPA
Valley Care IPA
(805) 988-5116
(805) 278-6877
(805) 988-5142
(805) 988-5166
(805) 278-6818
Lynn Haas
COO
Leisure World Managed
Care Medical Group
(805) 988-2280
John M. Kirk
CEO
(562) 229-9452
Page 12
PRIMARY CARE PHYSICIANS RESPONSIBILITIES
Generally, primary care services are provided by internal medicine providers, family providers,
pediatricians, general providers, Nurse Practitioners, and Physician Assistants, under the supervision
and direct monitoring of the PCP, may also be included.
The scope of service for the PCP is defined as noted in the [Health and Safety Code of California
(section 1367.69) and existing Knox-Keene] regulations as physicians who have the “responsibility for
providing initial and primary care for patients, for maintaining the continuity of patient care, and for
initiating referral for specialty care”. This includes, but is not limited to, preventive services (as
outlined in the current HEDIS clinical indicators), acute and chronic conditions and psychosocial
issues.
The PCP is responsible for the direction and coordination of the patient’s complete medical care for
covered services. The PCP will arrange for laboratory diagnostics, imaging diagnostics, referrals to
specialist, hospitalization or any other covered benefit that is medically necessary. A referral is
required for cases beyond the scope of expertise and practice of the PCP.
The PCP must accept new members without regard to race, ethnicity, religion, gender, color, national
origin, age, sexual orientation, genetic information, source of payment, any factor related to physical or
mental health status including but not limited to medical condition, claims experience, receipt of
healthcare, medical history, genetic information, evidence of insurability, disability, or on any other
basis deemed unlawful under federal, state or local law.
PCP authorizes MED3OOO, the Provider Organization (PO), health plans, the Secretary of Health and
Human Services, the General Accounting Office or their designees the right to audit, evaluate or
inspect any books, contracts, medical records, patient care documentation and other records of the
provider that pertain to services performed, reconciliation of benefit liability, determination of amounts
payable or any other relevant matters as such person auditing deems necessary for the later of six (6)
years, or for periods exceeding six (6) years, for reasons specified in the federal regulation.
RESPONSIBILITIES:
1. The PCP is responsible for providing the majority of and coordinating all the services required
for the member, except when emergent circumstances preclude the role of the PCP.
2. The PCP is to provide periodic evaluation of all body systems, preventive services, acute and
chronic care and to address psychosocial issues.
3. For Medi-Cal members, the PCP is required to conduct an Initial Health Assessment within
120 days of member’s enrollment with the PCP.
4. For Senior HCFA members, the PCP is required to conduct an Initial Health
Assessment within 90 days of members’ enrollment with the PCP.
5. The PCP is required to perform all duties expected of a PCP such as on-call rotation and/or
coverage for emergencies.
6. When care by a Specialist is necessary, the PCP coordinates all services required by the
Specialist.
Page 13
7. The PCP provides those services within the skills of that specialty and obtains authorization
for consultations when additional expertise or skills are required.
8. The PCP is expected to relay the PO or health plan decisions in a positive manner. When
the purpose of the visit is for a non-covered service/benefit, the PCP must inform the member
that the service is non-covered. This needs to be documented in the medical record.
9. In the event of the PO’s or health plan’s insolvency or other cessation of operations or
termination of the health plan’s Medicare agreement, Provider will continue to provide
covered services to Medicare members through the period for which premium has been paid
to health plan or in the case of Medicare members who are hospitalized, benefits shall
continue until discharge from facility, whichever time is greater.
In the event the Provider’s contract is discontinued, the PO allows members to have continued access
to that Provider if they are undergoing active treatment for a chronic or acute medical condition
through the current period of active treatment or for up to 90 days, whichever is shorter.
PCP FUNCTIONS
Listed below, but not limited to, are services considered PCP functions. This is dependent on the level
of training the physician has received, the limitations of scope of practice and consistent with State and
Federal rules and regulations.
These guidelines are based on routine uncomplicated cases that are ordinarily seen by a PCP.
OFFICE/CLINIC
Allergy:

Treat seasonal allergies

Treat hives

Treat chronic rhinitis

Allergy history

Environmental counseling

Minor insect bites/stings

Asthma, (chronic/acute) active with or without co-existing infection
Cardiology:

Perform electrocardiograms

Interpret electrocardiograms

Evaluate chest pain, murmurs, palpitations
Page 14

Evaluate and treat coronary risk factors, including smoking, hyperlipidemia, diabetes,
Hypertension (HTN), lifestyle

Evaluate and treat Congestive Heart Failure (CHF), stable angina, non life-threatening
arrhythmias

Evaluate syncope (cardiac and non-cardiac)
Dermatology:

Treat acne (acute and recurrent)

Treat painful or disabling warts with topical suspensions, electrocautery, liquid nitrogen

Diagnose and treat common rashes including: Contact dermatitis, dermatophytosis, herpes
genitalis, herpes zoster, impetigo, pediculosis, pityriasis rosea, psoriasis, seborrheic
dermatitis and tinea versicolor

Identify suspicious moles

Screen for basal or squamous cell carcinomas

Biopsy suspicous lesions

Punch Biopsy (Bx)

Excisional Bx

Actinic Keratosis

Diagnose and treat common hair and nail problems and dermal injuries

Common hair problems include: fungal infections, ingrown hairs, virilizing causes of
hirsutism, or alopecia as a result of scarring or endocrine effects

Common nail problems include: trauma, disturbances associated with other
dermatoses or systemic illness, bacterial or fungal infections, and ingrown nails

Dermal injuries include: minor burns, lacerations, and treatment of bites and stings

Counsel patients regarding removal of cosmetic (non-covered) lesions
Endocrinology:

Diabetic management, including Type I and Type II patient

Patient education

Supervision of home (SBGM) testing

Medication management

Diagnose and treat thyroid disorders
Page 15

Identify and treat hyperlipidemia

Diet instruction and Exercise Instruction

Provide patient education for osteoporosis risk factors
Gastroenterology:

Diagnose and treat lower abdominal pain

Diagnose and treat acute diarrhea

Treat protracted vomiting

Occult blood testing

Diagnose and treat heartburn, upper abdominal pain, hiatal hernia, acid peptic disease

Diagnose and treat irritable bowel syndrome

Diagnose and treat chronic jaundice under Standard Practice of Care (SPC)
recommendations

Diagnose and treat chronic ascites under SPC recommendations

Diagnose and treat symptomatic, bleeding or prolapsed hemorrhoids

Manage inflammatory bowel disease under SPC recommendations
General Surgery:

Evaluate and follow small breast lumps

Order mammograms

Aspirate cysts

Foreign body removal

Laceration repairs (minor)

Local minor surgery for hemorrhoids

Minor surgical procedures
Gynecology:

Perform routine pelvic exams and PAP smears

Perform lab testing for sexually transmitted diseases

Wet mounts
Page 16

Diagnose and treat vaginitis and sexually transmitted diseases

Evaluate lower abdominal pain to distinguish gynecological from gastrointestinal causes

Diagnose vaginal bleeding

Diagnose and treat endometriosis with hormone therapy

Manage premenstrual syndrome with non-steroidal anti-inflammatory agents, hormones and
other symptomatic treatment
Hematology:

Initial differential diagnosis of anemias

Hemoglobinopathies
Infectious Disease:

Common infectious diseases

Initial evaluation for Human Immunodeficiency Virus (HIV) positive

Viral disorders

Tuberculosis prophyaxis
Neurology:

Diagnose and treat all psychophysiological diseases; headaches, low back pain, myofascial
pain syndromes, neuropathies

Diagnose and treat tension and migraine headaches

Treat syncope (cardiac and non-cardiac)

Treat uncomplicated seizure disorders after SPC neurological evaluation

Manage degenerative neurological disorders with respect to general medical care (i.e.,
Parkinson's)

Treat stroke and Transient Ischemic Attack (TIA) patients

Manage dementia, Alzheimer’s disease
Ophthalmology:

Perform thorough ophthalmologic history including symptoms and subjective visual acuity

Perform common eye related services including: Distant/near testing, color vision testing,
gross visual field testing by confrontation, alternate cover testing, direct funduscopy without
dilation, extraocular muscle function evaluation, red reflex testing in pediatric patients
Page 17

Diagnose and treat common eye conditions including: viral, bacterial and allergic
conjunctivitis, blepharitis, hordeolum, chalazion, small subconjunctival hemorrhage,
dacryocystitis and sty
Orthopedics:

Treat low back pain

Treat sprains, strains, pulled muscles, overuse syndromes

Treat inflammatory conditions

Conservative treatment of chronic knee problems

Manage chronic pain problems

Diagnose and treat common foot problems: Ingrown nails, corns/callouses, bunions

Closed emergency reduction of dislocation: Digit, elbow, patella, shoulder

Treatment of minor fractures

Arthrocentesis
Otolaryngology:

Treat tonsillitis and streptococcal infections

Perform throat cultures

Evaluate and treat oropharyngeal infections: Stomatitis, Herpes simplex

Treat acute otitis media

Treat serous effusion

Evaluate tympanograms/audiograms

Treat acute and chronic sinusitis

Treat allergic or vasomotor rhinitis

Remove ear wax

Diagnose and treat acute parotitis and acute salivary gland infections

Evaluate neck masses
Pulmonology:

Diagnose and treat asthma, acute bronchitis, pneumonia

Diagnose and treat chronic bronchitis
Page 18

Diagnose and treat chronic obstructive pulmonary disease

Manage home aerosol medications and oxygen

Work up possible tuberculosis or fungal infections

Treat opportunistic infection
Rheumatology:

Diagnose and treat non-articular muscloskeletal problems: Overuse syndromes, injuries and
trauma, soft tissue syndromes, bursitis or tendonitis

Provide steroid injections

Manage osteoarthritis

Diagnose gout, pseudogout

Diagnose and treat rheumatoid arthritis

Diagnose and treat inflammatory arthritic diseases

Diagnose and treat uncomplicated collagen diseases
Urology/Nephrology:

Diagnose and treat initial and recurrent urinary tract infections

Provide long term chemoprophylaxis for recurrent Urinary Track Infection (UTI)

Diagnose and treat urethritis

Explain hematospermia

Evaluate hematuria

Evaluate incontinence

Diagnose and treat epididymitis and prostatitis

Differentiate scrotal or peritesticular masses from testicular masses

Evaluate prostatism and prostatic nodules

Manage urinary stones
Vascular Surgery:

Diagnose abdominal aortic aneurysm

Diagnose and treat venous diseases, i.e., Deep Vein Thrombosis (DVT), varicose veins,
stasis dermatitis
Page 19

Treat non-surgical stasis ulcers

Manage intermittent claudication

Manage transient ischemic attacks

Manage asymptomatic bruits
Other:

Basic life support

Heimlich maneuver

Endotracheal intubation. if Advanced Cardiac Life Support (ACLS) certified

Advanced life support, if ACLS certified

Tracheostomy (emergency), if ACLS certified
ADVANCED DIRECTIVES
It is the policy of MED3OOO that information describing the patient’s rights to formulate advance
directives as well as advance directive forms and literature will be provided by providers to all adult
members who may complete a Durable Power of Attorney for Health Care, or any other advance
directive. Client and/or provider will not refuse to treat or otherwise discriminate against a member
who has completed advance directive forms. MED3OOO and/or provider will honor advance directives
and assist and guide patients with regard to these sensitive issues. The provider will document
execution of an advance directive in the patient medical record and educate staff regarding issues
concerning advance directives. An adult is defined as being 18 years of age or older.
1. The provider will become well informed about advance directives and take an active role in
assisting patients to understand the benefits of these documents.
2. The provider will have available for the member advance directive forms and literature.
3. The provider will not refuse to treat or otherwise discriminate against a member who has
completed an advance directive form.
4. The provider will honor advance directive forms completed by the member.
5. The provider will document discussion and/or execution of an advance directive in the
member’s medical record.
Page 20
ELIGIBILITY VERIFICATION
Members should have a membership card, which identifies their PCP, identification number, co-pay,
and enrollment information in the health plan, which is contracted for medical care and service with the
PO. The identification card does not guarantee current eligibility. It is only used to identify the
member information.
1. For electronic verification of eligibility you may query the MED3OOO system (see EZ-NET
instructions in Chapter 4). However, the provider is advised this information is not as current
as each Health Plan’s information. Therefore, to be relied upon, eligibility should be
confirmed directly with the member’s health plan at the time of service. PCPs will receive
computer-generated eligibility lists on a monthly basis. If these lists are not received, please
notify the Eligibility Department or your Provider Relations Representative.
1. When a member presents for service, check the most current eligibility list. If the member’s
name appears, they are eligible to be treated.
2. If the member’s name does NOT appear on the most current eligibility list, please ask the
member for the following information:

Membership card or health plan enrollment form

Member’s full name

Subscriber’s full name

Subscriber’s date of birth

Member’s date of birth

Subscriber’s employer (and employer telephone if possible)

Effective date of coverage (if known)
3. Call MED3OOO Eligibility Department with the above information for verification.
SeaView IPA
(805) 604-3325
(877) 311-5411
Valley Care IPA
(805) 604-3308
(877) 299-5599
(805) 604-3308
(877) 299-5599
(805) 278-6823
(800) 705-0831
Leisure World MCMG
(805) 604-3317
(800) 415-4455
(805) 988-5164
(800) 720-2323
4. If eligibility cannot be verified, and the member MUST be seen, a waiver form is to be
completed. (See the Waiver Form in the appendix page 66)
Page 21
DEPARTMENT:
Member Relations
CONTACT: Irene Ybarra, Member Relations Manager
PHONE: (805) 988-5116
FAX: (805) 988-5163
Summary
The Member Relations Department of MED3OOO is responsible to service the providers, health plans,
members and MED3OOO staff including providing information and problem resolution which will assist
in offering high quality services.
Function
The Member Relations Department is the liaison to all other departments within MED3OOO,
(Authorizations, Claims, Eligibility, etc.) for members, providers and health plan representatives. Each
call is fielded by a Member Relations Associate (MRA) or Lead Member Relations Associate (Lead
MRA) and documented in the customer service module of EZ-Cap for tracking purposes. If a MRA is
unable to answer a question or give a specific status at the time of the call, the MRA may request
assistance or direction from the Lead MRA or submit an inquiry via the EZ-Cap system to the
respective department for a reply. Turn-around time for inquiries routed to other departments range
from twenty-four (24) hours to five (5) working days based on the level of the inquiry (stat, urgent,
routine, etc.).
Issues to Refer
Inquiries regarding:

Authorizations

Claims

Education

Eligibility

Health plans

Physicians (Primary Care Physicians and Specialists)

Providers (ancillary, hospitals)
Page 22
DEPARTMENT:
Provider Relations
CONTACT: Irene Ybarra, Provider Relations Manager
PHONE: (805) 988-5116
FAX: (805) 988-5163
Summary
The Provider Relations Department of MED3OOO is responsible for providing services to the
providers, health plans and staff including problem resolution which will assist the providers in offering
high quality services. The Provider Relations staff acts as a liaison with other departments,
participating in projects and analysis that assist in addressing and resolving concerns.
Function
The Provider Relations Department is the liaison to all of the other departments (Authorizations,
Claims, Eligibility, etc.) for providers and health plan representatives with concerns that are out of the
Member Relations Department’s function or scope. Turn-around time for replies to inquiries rerouted
to other departments range from twenty-four (24) hours to five (5) working days, based on the level of
the inquiry (stat, urgent, routine, etc.).
Issues to Refer
Problem resolution regarding:

Eligibility

Health Plans

Physician office orientations

Provider manuals

Provider rosters

Reimbursement

Updates regarding physician practice

Address changes
Page 23
DEPARTMENT:
Finance
CONTACT: Janet Plait, Accounting Director
PHONE: (805) 988-5187
FAX: (805) 988-5167
Capitation Procedure – Primary Care Physicians
Each PO has entered into agreements with certain primary care physician providers whereby they are
paid an amount of capitation per member per month in lieu of fee-for-service reimbursement for
services they will render to their assigned patients. The actual amount of this capitation paid varies
with the age and sex of the individual health plan member. Primary Care Physician (PCP) capitation
checks are mailed on or before the 20th day of the month for the current month.
Please refer to the sample PCP Capitation EOB report (Attachment 1). The following describes the
calculation methodology used to compute the monthly capitation payment:

Column (A) HP Code – Health plan code.

Column (B) Member Months to Date – Member months by health plan for the last six (6)
months.

Column (C) Capitation $ Earned to Date - Member months (Column B) multiplied by
applicable capitation rate table.

Column (D) Capitation $ Previously Earned – Amount of capitation previously paid for the
prior five (5) months.

Column (E) Gross Capitation Due – Current month capitation plus/minus retroactivity for prior
five (5) months.

Column (F) Adjustments – Adjustments such as deduction from PCP for failure to follow
applicable referral procedure, which results in a fee-for-service claim paid to a non-contracted
provider.

Column (G) Net Capitation Due – Payment for the current month. This equals Column E
plus/minus Column D.
In addition, the PCP receives a PCP Reconciliation Report. This report shows the detail of capitation
paid by member for the current month and the retroactivity for the prior five months.
Please refer to the sample PCP Reconciliation Report (Attachment 2).

Column (A) MEMBER NAME - Member Name

Column (B) MEMBID – Member I.D. as assigned by the health plan

Column (C) HP CODE & OPT – Health plan code and benefit option

Column (D) EFFEC DATE – Effective date with PCP

Column (E) TERM DATE – Termination date from IPA
Page 24

Column (F) AGE – Member’s age

Column (G) DOB – Member’s date of birth

Column (H) SEX – Member’s sex

Column (I) COPAY – Office visit co-pay

Column (J) CURRENT ENROLLMENT MM – Member months paid in current month

Column (K) CURRENT ENROLLMENT CAP$ - Column J member months multiplied by
applicable age/sex cap rate table

Column (L) MANUAL ADJ MM – Adjustment to member months calculation

Column (M) MANUAL ADJ CAP$ - Column L member months multiplied by applicable
age/sex cap rate table

Column (N) PREVIOUS CALC MM – Member months previously paid

Column (O) PREVIOUS CALC CAP $ - Column N member months multiplied by applicable
age/sex cap rate table

Column (P) NET TO PAY MM – Net member months paid. Equals Column J plus/minus
Column L minus Column N.

Column (Q) NET TO PAY CAP$ - Monthly capitation paid to provider. Equals Column K
plus/ minus Column M minus Column O.
Subtotals by month are included for the current month plus the five (5) prior months.
Capitation Procedure – Specialists
Each PO has entered into agreements with certain specialty providers whereby they are paid an
amount of capitation per member per month in lieu of fee-for-service reimbursement for services they
will render to their assigned patients. Specialty capitation checks are mailed on or before the twentyfifth (25th) day of the month for the current month.
Please refer to the sample specialty capitation summary report (Attachment 3). The following
describes the calculation methodology used to compute the monthly capitation payment:

Column (A) HP Code – Health plan code

Column (B) Current Month Members – Member from the current month’s eligibility list.

Column (C) Retroactive Members – Retroactive additions or deletions for the prior five (5)
months.

Column (D) Net Member Months – Current month eligibility plus/minus retroactivity for prior
five (5) months. This equals Column B plus/minus Column C.

Column (E) Total Due by HP – Total capitation due to provider by health plan.
Page 25

Column (F) Current Adjustments – Adjustments such as deduction from specialist for inability
to provide medical care for referred procedure which results in a fee-for-service claim pair to
a non-contracted provider.

Column (G) Current Net – Payment for the current month. This equals Column E plus/minus
Column F.
Page 26

ATTACHMENT 1
01/01/XX
Page
1
Practitioner Organization Name
CAPITATION EOB FOR JANUARY, 20XX
Primary Care Physician
FOR PROVIDER: XXXXXX
(A)
PCP NAME
(B)
(C)
MEMBER CAPITATION $
MONTHS
EARNED
HP
CODE
HEALTH PLAN
AE
BSH
HN
PC
SH
AETNA HEALTH PLANS
BLUE SHIELD
HEALTHNET
PACIFICARE
SECURE HORIZONS
PROVIDER TOTALS
TO DATE
(D)
(E)
CAPITATION
PREVIOUSLY
GROSS
CAPITATION
EARNED
DUE
TO DATE
$
$
$
(F)
(G)
NET
CAPITATION
ADJUSTMENTS
$
DUE
__________
$
Page 27
ATTACHMENT 2
____________ IPA
PCP Capitation Reconciliation Report By Vendor, Provider
June 20XX Through November 20XX
04/25/20XX
VENDOR
PROVIDER :123456
CAPITATION MONTH:
Name, MD
Last Name
June, 20XX
CURRENT
ENRLMT
MEMBER NAME
CAPITATION MONTH:
TOTALS FOR MONTH:
CAPITATION MONTH:
TOTALS FOR MONTH:
MEMBER ID
June,
HP & OPT
July, 20XX
TERM
DATE
DATE
AGE
DOB
SEX
COPAY
MM
CAP $
MM
CAP $
PREVIOUS
CALC
MM
CAP $
NET TO PAY
MM
CAP $
20XX
June, 20XX
July,
EFF
MANUAL ADJ
0
$0.00
0
$0.00
0
$0.00
0
$0.00
0
$0.00
0
$0.00
0
$0.00
0
$0.00
20XX
Page 28
ATTACHMENT 3
Specialty Cap Payment Summary for the month of:
May-20XX
TO: SAMPLE SPECIALIST
(A)
SPECIALIST:
(B)
HP CODE
(C)
(D)
(E)
(F)
(G)
May-XX
RETROACTIVE
NET
MEMBER
TOTAL
DUE
CURRENT
CURRENT
MEMBERS
MEMBERS
MONTHS
BY HP
ADJUSTMENTS
NET
Commercial
AE
CA
CC
CI
HN
PC
________ ________ ________ _______
_________
TOTAL
$
$
Specialty Cap Payment Summary for the month of:
May-20XX
TO: SAMPLE SPECIALIST
(A)
SPECIALIST:
(B)
May-XX
HP CODE
(C)
RETROACTIVE
(D)
NET
MEMBER
(E)
TOTAL
DUE
MEMBERS MEMBERS MONTHS BY HP
(F)
(G)
CURRENT
CURRENT
ADJUSTMENTS
NET
Senior
CCS
SH
CASH
________ ________ ________ _______
_________
TOTAL
$
$
.
TOTAL DUE:
$
Page 29
DEPARTMENT:
Eligibility
CONTACT: Janet Plait, Accounting Director
PHONE: (805) 988-5187
FAX: (805) 988-5167
Verify Eligibility
1. Call the corresponding PO at MED3OOO to speak to a Provider Relations Representative.
SeaView IPA
Valley Care IPA
Leisure World MCMG
(805) 604-3325
(805) 604-3308
(805) 604-3308
(805) 278-6823
(805) 604-3317
(805) 988-5164
(877) 311-5411
(877) 299-5599
(877) 299-5599
(800) 705-0831
(855) 415-4455
(888) 720-2323
2. Be prepared to provide the member name or the health plan ID # to the representative.
3. The representative will check the member database to determine if the member is currently
eligible.
4. The representative will advise you either:
a) the member is currently eligible
b) the member’s name or ID # could not be located in the database
5. If the member’s name could not be located in the database, the representative will complete
an eligibility request form that is forwarded to the appropriate person for research. The
member’s eligibility status will be researched and reported back to the Provider Relations
representative.
6. Within 1-2 working days, the member resources representative will call you back to advise
you of the member’s eligibility status.
Procedure for EZ-Net Users to check eligibility
1. Log on to EZ-Net. (see Chapter 4 in the EZNet user manual located in the appendix)
2. Select Eligibility from the Main Menu.
3. Type LAST NAME, FIRST (partial or complete), ID or HP to list the member.
4. Select a member from a list of names and click the blue hyperlink for detail.
Click on “Inquire about this member,” at the bottom of the screen if you would like to send an e-mail
to MED3OOO regarding the member’s eligibility.
Page 30
DEPARTMENT:
Contracting & Network Development
CONTACT for SVIPA, VCIPA, VCSIPA: Leslie Young, Director of Contracting or Dione
Webster, Contracts Manager
PHONE: (805) 988-5101 or (805) 988-5182
FAX: (805) 988-5194
CONTACT for SBSIPA: Jennifer Moore, Executive Director
PHONE: (805) 988-5166
FAX: (805) 988-5167
CONTACT for Leisure World or Pioneer Provider Network: Gabbie Nguyen, Provider
Network Manager
Phone (805) 278-6877
FAX: (805) 278-4275
Summary
The Contracting & Network Development Department of MED3OOO and or the Executive Directors
for each IPA is responsible for contract negotiations and providing contract information which will
assist the providers.
Issues to Refer

Contracts (primary care, specialist, ancillary, hospitals, health plans, etc.)

Letters of Agreement (specific one time case rate contracts)

Prospective (interested) providers

Questions regarding provider’s or IPA’s contracted responsibilities

Questions regarding interpretation of contract rates

Third party liability & workers comp cases
Function
It is the Contracting & Network Development Department’s function to ensure that there is adequate
provider representation to service our membership. Recruitment of providers is based on current
and anticipated needs and from information provided by other departments (Health Services,
Credentials, Quality Improvement and Provider Relations). The department negotiates contracts
with providers and prospective providers based upon decisions made by the Compensation and
Contracting
Committees,
Credentials
Committees
and the Boards
of
Directors.
Page 31
PART 3: POLICIES AND PROCEDURES
PHYSICIAN COMPENSATION
Each PO receives a fixed monthly pre-payment from their contracted health plans and the PO pays
their contracted PCPs capitation. The PO pays PCP capitation from these monies. The capitation
rate is based upon a fixed dollar amount multiplied by the number of members enrolled with the PCP
for the month. It may also be based on a percent of the IPA’s capitation revenue for each member.
The capitation amount also includes any adjustments for members who are retroactively enrolled or
disenrolled with the PCP. The PCP accepts the capitation as payment in full, except for applicable copayments and/or co-insurance, for all capitated-covered services provided by the doctor to the
member. Capitation is paid regardless of whether or not the member receives care.
Additional compensation for services rendered that are not part of the capitation will be reimbursed
according to your contract less any applicable co-payments and/or co-insurance. Please note:
Payments for Medicare members are being paid for with Federal Funds, and as such, payments for
such services are subject to laws applicable to individuals or entities receiving Federal Funds.
The Capitation by Detail Report reads left to right and line-by-line. Below is an explanation of each
column:
Period
Report for the Month
Member #
Health plan eligibility number
Member Name
Member’s last name and first name
Birth Date
Date of Birth
Age
Member’s age
Sex
Member’s sex
EFFDAT
Member’s effective date with the PCP
EXPDAT
Member’s termination date
Period
Report for the Month
Amount
Capitation dollars received for the member
S/C
Senior member = S / Commercial member = C
HMO
Parent code for health plan
HMO Name
Member’s health plan
Group
Meridian’s internal code
Members: Current
Current member months
PCP xxxx
Total member months for which PCP is receiving capitation
Eligible Members
Current members’ eligible
Page 32
Billing Instructions
Standard claims forms must be submitted every time services are provided to a member, whether
these are payable fee-for-service claims or capitated encounter claims. It is a contractual obligation
and a regulatory requirement that the PO must receive these claims/encounters and supply full
encounter records to the health plans to which the members belongs. It also assists the practitioner
organization in tracking eligibility, capitation, and compensation rates to determine if the capitation is
appropriate for the population.
Federal and state law requires health plans to report services provided to their members. The
encounter is the interaction between the member and the physician. Contractually, the provider is
required to report medical services to the PO members monthly. The PO then reports these
encounters to the health plans
1. Please use a separate claim form (electronic or paper) for each member visit.
2. All claims must be submitted no later than 90 days from the date of services. Provider shall
certify to their best knowledge, information, or belief, as to accuracy, completeness and
truthfulness of the encounter data submitted.
3. Please indicate all services provided on the forms along with your charges.
4. Please complete the form entirely and legibly, if not it may be returned.
The following information is required to ensure the timely reimbursement of claims:












Patients full name
Subscriber employer
Subscriber number
Eligibility number
RVS/CPT Code(s)
Procedure codes
Co-payment amount
Date of service(s)
Amount billed
Referral authorization
Name of PO
Health plan











Member name
Member date of birth
Member identification number (ID)
Diagnosis
ICD-9 Code(s)
Authorization number
EOB from primary insurance carrier (if applicable)
Provider name
Provider tax ID number
Physician name and signature
National Provider Identification number
Do not bill the member. PO members are not to be billed for authorized covered services, except for
allowable co-payments and deductibles.
Page 33
Provider Claim & Encounter Submission
Complete and forward all claims for processing and payment to the corresponding MED3OOO PO:
SeaView IPA
C/O MED3OOO
1901 N. Solar Drive,
Suite 265
Oxnard, CA 93036
Valley Care IPA
C/O MED3OOO
Suite 215
Oxnard, CA 93036
C/O MED3OOO
1901 N. Solar Drive, Suite 270
Oxnard, CA 93036
C/O MED3OOO
Suite 250
Oxnard, CA 93036
C/O MED3OOO
Suite 200
Oxnard, CA 93036
C/O MED3OOO
Oxnard, CA 93036
All claims received by MED3OOO are either date stamped or embedded with the date received in the
document control number.
All claims submitted must be on a standard current CMS 1500 form or UB04 Claim form, if applicable.
Claims submitted must be clean claims (Definition: A claim which can be processed as soon as it is
received, because it is complete in all aspects, including complete coding, itemization, date of services
and billed amounts). The CMS standard for processing clean claims is 60 days. All clean and
approved claims that are in the PO’s financial responsibility are processed and paid within sixty (60)
calendar days of the stamped receipt date.
Claims must be received within 90 days of the date of service. All initial billings received later than 90
days will be denied for untimely filing. If there are extenuating circumstances causing the billing to be
delayed, the case will be presented to the PO for resolution.
Hospital Claim Submission
Claims should be submitted on the UB04 with the following information:

Patient’s full name

Date of birth

Member identification number (ID)

Authorization number

Diagnosis and diagnostic code (ICD-9)

Itemization of services, including procedure codes and date of each service

Emergency room reports

Admitting physician and name of contracted PO

Date of admission and discharge

Provider tax ID number
Page 34
All claims that are the PO’s financial responsibility are processed and paid within forty-five (45)
working days of the stamped receipt date (60 calendar days, if Medicare).
Health Plan Claims Responsibility
Claims that are the health plan’s financial responsibility are forwarded to the health plan within 2weeks of the date received.
Claims Payment
Claims are paid on a weekly basis. Checks are dated and mailed out every Friday. An exception
occurs when a holiday falls on a Friday – then the checks will be mailed the following business day.
CO-PAYMENT/CO-INSURANCE COLLECTION
Depending on the benefit plan, members are required to pay and provider is obligated to collect an
out-of-pocket charge for professional services called a co-payment. The co-pay amount may vary for
PCP and specialists for each service and benefit plan. Co-payments are deducted prior to payment on
all fee-for-service claims.
Some health plans set a limit on the total cost in co-payments that a member is required to pay during
the calendar year. Once the co-payment maximum is reached, no further co-payments are required
for services rendered during the remainder of the calendar year. It is the member’s responsibility to
keep a record of his/her co-payments and to know when the maximum amount is reached.
Some members are also responsible for co-insurance for certain services. Co-insurance refers to the
percentage of the contracted fee for which the member is financially responsible. Co-insurance
payments are deducted prior to payment on all fee-for-service claims.
1. Verify eligibility and determine if the member has a co-payment and/or co-insurance. The copayment amount is identified on the member’s ID card and the co-insurance, if any, can be
identified by contacting the health plan. Note: Co-pay amounts may differ for PCP and
specialist office visits.
2. Collect the office visit co-payment and/or co-insurance the day services are rendered. NOTE:
A co-payment may not be collected from Medicare members for the influenza or
pneumococcal vaccine or for any other preventive care services.
3. For electronic verification of co-payment amounts, see EZ-NET instructions in Chapter 4.
DUAL COVERAGE AND COB
Sometimes a member is covered by insurance other than the managed care policy. A physician may
be entitled to collect additional monies from the member if he/she has other coverage. Health plans
also coordinate payment for medical services if a member has dual coverage. When covered services
are provided to a member who has dual coverage, the determination of the order in which benefits are
payable and the order in which they are recovered is referred to as “coordination of benefits” (COB).
Page 35
1. Instruct the office staff to inquire if the member has other coverage and document the
information in member’s chart.
2. Determine which plan is the primary and secondary payor when coordinating benefits
between two health plans. There are established rules to determine the primary payor.
Please call your Provider Relations Representative if you need assistance.
3. The Birthday Rule is used to establish which health insurance plan is primary for children.
The parent whose birthday (month and day only) falls closest to January is considered
primary.
Example:
Father’s Date of Birth is 6/17/54
Mother’s Date of Birth is 2/27/56
The mother’s insurance is considered primary in this case.
4. If the parents are divorced or legally separated, the insurer of the parent who has been
ordered by the court to take responsibility for the health care of the child/children is primary.
5. If the parents are divorced or legally separated and the court has awarded joint custody
without designating who has responsibility for providing health care of the child/children, the
birthday rule applies.
When the PO is primary, the secondary plan should be billed for covered services. Do not bill the
member, except for the co-payment and/or co-insurance, even if the secondary plans have
denied the claim. The PCP has been paid for these services through capitation.
Specialists should coordinate COB with the PO.
Explanation of Benefits – “EOB”
The sample EOB found in Part 2 under Finance reads from left to right and line by line. Below is an
explanation of each column:
Member #
Patient #
Claim #
Member Name
Provider
Group #
Service Code
Service Dates
Diag
Charged
Allowed
Discount
Deduct
Copay/Coins
Not Allowed
Prepaid
Withold
Health plan eligibility number
Member’s account number on bill
Provider group claim reference number
Member’s last name and first name
Provider name
Health plan employer identification number
RVS Procedure code
Dates of service
ICD9 Code
Amount billed for the procedure
Amount allowed for the procedure
Discount amount for procedure
Member’s deductible
Member’s co-pay to be collected by Provider
Disallowed dollar amount
N/A
Withheld dollar amount based on Provider’s contract
Page 36
COB
Paid
Write Off
EP Codes
Dollar amount paid by other insurance
Dollar amount paid
Dollar amount of write off
Three digit code for explanation of payment codes (See bottom
of EOB for a more detailed explanation of EP Codes)
ENCOUNTER DATA SUBMISSION
Federal Law requires health plans to report services provided to their members. The encounter is the
interaction between the member and the physician. Contractually, the Provider is required to report
medical services to the PO monthly for their members. The PO then reports these encounters to the
health plans.
NOTE: ENCOUNTER FORMS MUST BE COMPLETED FOR ALL SERVICES INCLUDING
INPATIENT VISITS.
Use the same claim submission process as listed previous. Encounter claims are sent in the same
method as other claims to the same locations noted.
CALIFORNIA CHILDREN SERVICES
The California Children Services (CCS) program provides case management and associated services
for physically disabled children under age 21 with CCS-eligible conditions or diagnoses whose families
are partially or wholly unable to provide for such services.
Some diagnosis usually covered under CCS includes congenital anomalies, scoliosis, cardiac
conditions and renal failure. Because CCS will not retroactively authorize services, it is critical that
your office immediately contact your PO. The telephone numbers can be found in Part 8 How to
Contact Us. If CCS approves the diagnosis, they will be responsible for only the services associated
with the approved CCS diagnosis. The PO is responsible for all other care to the member.
The program’s working hypothesis is that children with complex, disabling conditions receive improved
care and achieve better long-term outcomes when services are provided and coordinated through
special care centers and/or certified CCS Providers.
For more information on the CCS program, please contact your Provider Relations Representative.
Provider Satisfaction Survey
MED3OOO conducts a yearly provider satisfaction surveys that measure the effectiveness of
managing the IPA’s as well as learn what can be improved upon. The surveys are usually conducted
in the first quarter of every year for the prior year’s performance. The data from the surveys are
collected and distributed to the QI committees for review and recommendations.
Page 37
PART 4: PATIENT ACCESS TO CARE AND SERVICE
Equitable access to care and service is inherent in the right of every patient. To ensure that access,
practitioners are expected to operate their HMO practices according to specific principles and
standards.
STATEMENT OF PATIENT RIGHTS AND RESPONSIBILITIES
Certain rights and responsibilities are conveyed to HMO members by federal and state law, as well as
by accreditation organizations. Many of those rights and responsibilities are directly related to UM
program activities. The following is the statement of patient rights and responsibilities advocated by
our POs, all of which directly or indirectly affect MED3OOO’s and your relationships with your patients:
We honor our patients’ rights. All of our patients are entitled to be treated in a manner that respects
their rights. We recognize the specific needs of our patients and maintain a mutually respectful
relationship with them. This is our commitment to the rights of our patients and individuals other than
the patient who have legal responsibility for making health care decisions for the patient.
As our patient, you have the right to:
1. Receive health care services regardless of your race, ethnicity, national origin, religion, sex,
age, mental or physical disability, sexual orientation, genetic information or source of
payment.
2. Receive information about us and our services, affiliated doctors, health care professionals
and providers, and patients’ rights and responsibilities, as well as information about your
health plan’s coverage for services you may need or are considering.
3. Be treated with respect and recognition of your dignity and right to privacy.
4. Be represented by parents, guardians, family members or other conservators if you are
unable to fully participate in treatment decisions.
5. Have information about our contracting physician and provider payments agreements, as well
as explanations for any bills you receive for services not covered by us or your health plan.
6. Receive health care services without requiring you to sign an authorization, release, consent
or waiver that would permit us to disclose your medical information. We will treat information
about you, including information about services and treatment we provide, as confidential
according to all current privacy and confidentiality laws.
7. Have round-the-clock access, seven days a week, to your primary care physician or on-call
physician when your primary care physician is unavailable.
8. Know the name and qualifications of the physician who has primary responsibility for
coordinating your care, and the names, qualifications, and specialties of other physicians,
and non-physicians who are involved your care.
9. Have a candid discussion of medically appropriate or necessary treatment options for your
condition, regardless of the cost, the extent of benefit coverage or the lack of benefit
coverage. To the extent permitted by law, this includes the right to refuse any procedure or
Page 38
treatment. If you refuse a recommended procedure or treatment, we will explain the effect
that may have your health.
10. Actively participate in decisions regarding your health care and treatment plan and receive
services at your own expense if we deny coverage. The decision to receive a particular
service or treatment rests with you and your treating physician or health care professional.
11. Receive complete information, before receiving care and in terms you can understand, about
an illness, proposed course of treatment or procedure, and prospects for recovery, so that
you may be well informed when consenting to refusing a course of treatment. This includes

being able to request and receive information about how medical treatment decisions
are made by physicians, health care professionals or providers and our
administrators, and

the criteria or guidelines applied when making such decisions

an explanation of the cost of the care you will receive and what you will be expected
to pay out of your own pocket
Except in emergencies, this information will include a description of the procedure or
treatment, the medically significant risks involved, any alternate course of treatment or nontreatment and the risks involved in each, and the name of the person who will carry out the
procedure or treatment.
12. Receive information about your medications – what they are, how to take them, and possible
side effects.
13. Reasonable continuity of care and to know the time, location of appointment, the name of the
physician providing care and to be informed of continuing health care requirements following
discharge from inpatient or outpatient facilities
14. Be advised if a physician proposes to engage in experimental or investigational procedures
affecting their health care or treatment. Patients have the right to refuse to participate in such
research projects.
15. Obtain upon request a copy or summary of the Utilization Management Program Description
and the Quality Improvement Program Description that we publish annually.
16. Voice complaints or appeals about us or the care we provide.
17. Be informed of rules regarding patient conduct in any of the various settings where you
receive health care services as our patient.
18. Complete an advance directive, living will or other instructions concerning your care in the
event that in the future you become unable to make those decisions while receiving care
through our physicians, health care professionals and providers.
19. Make recommendations about these patients’ rights and responsibilities policies.
Our patients share responsibility for their care. In keeping with honoring our patients’ rights, we
have expectations of our patients. You have a responsibility to:
Page 39
1. Be familiar with the benefits, limitations and exclusions of your health plan coverage.
2. Supply your health care provider with complete and accurate information which is necessary
for your care (to the extent possible).
3. Be familiar and comply with our rules for receiving routine, urgent, and emergency care.
4. Contact your primary care physician (or covering physician) for any care that you may
needed after that physician’s normal office hours, including on weekends and holidays.
5. Be on time for all appointments and notify the physician’s or other provider’s office as far in
advance as possible for appointment cancellation or rescheduling.
6. Obtain an authorized referral form from your primary care physician before making an
appointment with a specialist and/or receive any specialty care.
7. Understand their health problems and participate in developing mutually agreed upon
treatment goals to the degree possible, and inform your physicians and health care providers
if you do not understand the information they give you.
8. Follow treatment plans and instructions for care you have agreed on with your physicians
and health care professionals, and report changes in your.
9. Accept your share of financial responsibility for services received while under the care of a
physician or while a patient at a facility.
10. Treat your physicians and health care providers and their office staff with respect.
11. Contact our Member Relations Department or your health plan’s Member Services
Department if you have questions or need assistance.
12. Respect the rights, property and environment of your physicians and health care providers,
their staff and other patients.
PATIENT ACCESS STANDARDS
Patients have a right to timely access to care and service. Access standards for HMO
patients have been standardized by contracting health plans and regulatory agencies.
The Department of Managed Health Care (DMHC) recently enacted new regulations concerning
time-elapsed access standards for Commercial members that went into effect January 17, 2011. The
DMHC is implementing these changes to ensure the health plans provider networks are sufficient to
provide accessibility and continuity of covered health care services. The key components of these
new DMHC time-elapsed access regulations for providers are summarized on the following page.
The prior authorization process is included in the time-elapsed standards. If the appointment
type requires prior authorization, obtaining authorization must be completed within the time
frame for that visit or service. For example, the time elapsed standard of 15 days for nonurgent referral to a specialist will be measured from the time the PCP requests the
authorization to the first appointment date offered to that patient by the specialist. For urgent
Page 40
appointments that require authorization, the appointment scheduling must be done in
concurrence with the prior authorization process.
It is expected that plans will monitor compliance with these new access standards via appointment
access surveys, after-hours surveys, member and provider satisfaction surveys as well as
monitoring member complaints in regards to access.
Effective January 17, 2011, California health plans are required to demonstrate compliance with
specific standards for scheduling appointments for non-emergency health care services, including
health plan and provider standards. The key provisions of these new DMHC time-elapsed access
regulations for participating providers are summarized below.
APPOINTMENT ACCESS STANDARDS
Contracting health plans set patient appointment access standards. Practitioners are monitored for
compliance with the following standards:
Commercial HMO Programs
Appointment Access Standards - Medical
ACCESS TYPE
STANDARD
Access to non-urgent appointments for
primary care – regular and routine care
(with a PCP)
Access to urgent care services (with a PCP)
that do not require prior authorization
Access to urgent care (specialist and other)
services that require prior authorization
Within 10 business days of request
Access to after-hours care (with a PCP)
Ability to contact on-call physician after hours
within 30 minutes for urgent issues
Appropriate after-hours emergency instructions
Access to non-urgent appointments with a
specialist
In-office wait time for scheduled appointments
(PCP and specialist)
Access to preventive health services
Non-urgent appointments for ancillary
services for the diagnosis or treatment of
injury, illness or other health condition
Wait time not to exceed 48 hours of request
Within 96 hours of request
Not to exceed 15 minutes
Within 30 business days of initial request
Appointment Access Standards – Behavioral Health
ACCESS TYPE
STANDARD
Access to non-urgent appointment with
physician for routine care
Non-urgent appointments with a nonphysician behavioral health care provider
Access to urgent care
Page 41
Access to non-life-threatening emergency care
Access to life-threatening emergency care
Access to follow-up care after hospitalization for
mental illness
Immediately
Within 7 business days of request (initial visit)
Within 30 business days of request (second
visit)
Also see Part 7 for additional information about monitoring of patient access to appointments.
Telephone Response Standard. The telephone call response standard for practitioners’ offices is
30 seconds. 1 Spanish-speaking callers are expected to be directed to an office staff person within
no more than an additional 30 seconds.
EXCEPTIONS
According to the new DMHC regulations, exceptions may be made to these standards as
follows:

Extending Appointment Waiting Time – The applicable waiting time for a particular
appointment may be extended if the referring, treating or triage screening licensed
health care provider, acting within the scope of his or her practice and consistent with
professionally recognized standards of practice, has determined and noted in the
relevant record that a longer waiting time will not have a detrimental impact on the
health of the member.

Advance Access – A PCP may demonstrate compliance with the established primary
care time-elapsed access standards through implementation of standards, processes
and systems providing same or next business day appointments from the time an
appointment is requested.

Advance Scheduling – Preventive care services and periodic follow-up care,
including, but not limited to, standing referrals to specialists for chronic conditions,
periodic office visits to monitor and treat pregnancy, cardiac or mental health
conditions, and laboratory and radiological monitoring for recurrence of disease, may
be scheduled in advance consistent with professionally recognized standards of
practice as determined by the treating licensed health care provider acting within the
scope of his or her practice.
APPOINTMENT RESCHEDULING
When it is necessary for a provider or a member to reschedule an appointment, the
participating provider must promptly reschedule the appointment in a manner that is
appropriate for the member’s health care needs, and ensures continuity of care consistent
with good professional practice.
ASSESSMENT OF COMPLIANCE
1
Behavioral health practitioners are not held to a telephone response standard, because they often are in session
when calls are received.
Page 42
To comply with existing and new regulations, health plans may use several methods to
ensure that members have adequate access to providers, including, but not limited to:

Conducting provider appointment access surveys to determine the waiting time for
appointments, and after-hours surveys to determine the accessibility of emergency
and urgently needed services after regular office hours

Administering member satisfaction surveys to determine whether members are
satisfied with the accessibility of health care services

Conducting provider satisfaction surveys

Monitoring member grievances about access to care to identify potential trends or problems
AFTER-HOURS ACCESS REQUIREMENTS
Anyone calling your office after normal office hours must be given appropriate emergency
instructions, regardless of whether the caller reaches a live person at your office or a recorded
message.

The only acceptable instructions are to call 911 or go to the nearest hospital emergency
room if the caller believes it is an emergency.

The information must be given at the very first opportunity after initial office identification
information is given.

If the caller does not know if it is an emergency or wishes to speak to the on-call physician,
they may be given further instructions following the directions to call 911 or go to the nearest
hospital emergency room. The time frame for the physician to contact the member must be
less than 4 hours from the initial call.

Recorded messages and live attendant responses must accommodate non-English speaking
callers.

A PCP or covering physician must be available to accept calls from or about their patients 24
hours a day, seven days a week. Recorded messages and live attendants must state the
time frame when the physician will return the call. The timeframe must be less than 30
minutes from the patient’s call.
PRACTITIONER-PATIENT RELATIONSHIPS
We support mutually satisfactory practitioner-patient relationships through the availability of culturally
and linguistically appropriate practitioners, equitable balancing of practitioners’ patient caseloads,
patients’ continuing care needs, and setting expectations for their relationships with patients.
Patients’ Rights to Appropriate Practitioners. As evidenced above, every effort is made to
provide HMO patients with practitioners in an array of specialties appropriate for the unique and
current composition of both the medical and cultural needs of patients.
Page 43
Interpreter Services. We encourage physicians to have the ability, either personally or through their
office staff, to communicate in many different languages and serve as interpreters when needed,
including American Sign Language (ASL). Anyone performing such services should be sufficiently
proficient in the patient’s language to properly interpret medical terms and information. You may not
charge for any interpreter services, including the use of professionals. If they wish, patients must be
permitted to use their own interpreters, including professionals.
MED3OOO holds a contract with Life Signs for onsite interpreter services and Language Line
Services for linguistic services, but they must be authorized in advance through the UM Department.
Once authorized, your office may make the arrangements with Life Signs by calling (213) 550-4210.
Their fax number is (213) 550-4205.
Language Assistance Program (LAP). For linguistic assistance, we offer the Language Assistance
Program (LAP). The following page has the health plan telephone contact information to assist you
as needed. MED3OOO also has the ability if need to access the Language Line Services if
needed. To utilize this service call the provider services department for assistance. Once authorized,
a customer service representative will assist with placing the call to access an interpreter.
For the hearing impaired, MED3OOO also uses the California Relay Service available through all
telephone companies for patients who wish to contact our offices. The toll-free number is 800-7352929 (TTY) or 888-877-5378 (TTY). Your office also should use the service when needed.
Health
Plan Name
Aetna
Anthem
Blue Cross
Blue Shield
of
California
Plan LAP
Threshold
Languages
(Other than
English)
English,
Spanish
Plan Interpreter Access
Plan
Translation
Access (Vital
Non-Standard
Documents)
1-800-525-3148
1-877-287-0117
Plan Contact For
Questions
related to
Interpreter/Transl
ation
Nicki Theodorou
at 415-645-8264
Megan Rooney at
650-279-6091
Spanish,
Chinese
(traditional),
Vietnamese,
Tagalog,
Korean
1-888 254-2721
1-888 254-2721
1-800-677-6669
Spanish,
Chinese
(Traditional),
Vietnamese
Providers: Over-thephone interpretation 800541-6652, follow IVR
menu;On-site
interpretation services
call 800-541-6652, dial
"0" and speak to a
Provider Services Agent
to arrange for an
interpreter.
Please fax
Language
Services
Request Form &
and document
requiring
translation to
209-371-5838
email:LanguageAs
sistance@
blueshieldca.com
or call your
Provider Relations
representative
Additional
Resources
N/A
www.anthem.com/ca
Note: Cultural &
Linguistic resources
are available on the
Provider Home
Page, under
Provider Services
blueshieldca.com/pr
oviders
Page 44
CIGNA
Health
Plan Name
Spanish,
Traditional
Chinese
Plan LAP
Threshold
Languages
(Other than
English)
Oral translations
in all languages,
print
translations
Spanish and
Chinese
Health Net
of
California,
Inc
PacifiCare
Spanish,
Chinese
Call 1-800-806-2059.
You will need the
member’s CIGNA ID
number, mbr date of birth
and your TAX ID number
(or NCPDP for
pharmacies) to confirm
eligibility and access
interpretation services. It
is not necessary to
arrange for these
services in advance.
Plan Interpreter Access
Call the number on the
member's ID card or
HMO, PPO, POS,
Medicare Supplemental
members - (800)-5220088, After hours and
weekends- (800)-5464570. The following are
24/7 access numbers:
Individual and Family
Plan (IFP) members(800)-839-2172.
Healthy Families,
Healthy Kids or AIM
members please call
(888)-231-9473. MediCal members- (800) 6756110
1-800-730-7270 Spanish
; 1-800-938-2300
Chinese 1-800-6248822 English (and All
Other Languages)
Send Word
document to
translate to
Culturalandlingu
isticsunit@cigna
.com. Protect
PHI by
encrypting emails.
Plan
Translation
Access (Vital
Non-Standard
Documents)
Translation
access
questions
contact Diana
M. Carr,
Manager C&L
services at 626683-6307
1-800-730-7270
Spanish 1-800938-2300
Chinese 1-800624-8822
English (and All
Other
Languages)
Culturalandlinguist
icsunit3@
cigna.com
Plan Contact For
Questions
related to
Interpreter/Transl
ation
(800)-522-0088
Customer Contact
Center, after
hours and
weekends 800546-4570
1-800-730-7270
Spanish 1-800938-2300 Chinese
1-800-624-8822
English (and All
Other Languages)
Provider Reference
Manual
Additional
Resources
www.pacificare.com
www.pacificarelatino.
com
www.pacificareasia.c
om
Practice Closures. PCP practices are not limited to a set number of HMO patients. In order for a
PCP to close his or her practice to new patients, the PCP must complete a special form for review by
the Board of Directors of your PO. The Board evaluates whether an increase in patient census and
or a significant imbalance in the type of patients customarily seen by that practitioner exists. (Does
not apply to SBSIPA)
Once a PCP’s practice is closed to new HMO patients, the MED3OOO Contracting Department
periodically monitors the PCP’s HMO case load to determine whether the practice should again
welcome new patients.
Continued Care Following Practitioner Termination. Contracting specialists are required to notify
the Contracting Department at least 90 days in advance when terminating their contracts.
Page 45
This requirement is governed by state and federal law. It is very important you provide that advance
notice so that patients who have been under your care can be notified well in advance of the
termination effective date of their right to continue to receive care from you.
HMO patients whose specialist’s employment or contractual arrangement terminates 2 are entitled by
law to continue care with that practitioner after the termination date, provided the terminating
practitioner agrees to continue such care under the same contractual terms of the terminating
agreement or other terms that may be negotiated for an agreed upon period. The patient must meet
specific criteria to qualify for the continuation, which differ somewhat depending upon whether the
patient is enrolled in a commercial HMO plan or a senior HMO plan. The duration of the continued
care varies.
Generally speaking, the continuation may be provided under the following circumstances:

Patients who are in active treatment for a serious chronic or acute medical condition

Patients who are pregnant

Children between birth and 36 months whose care was initiated with the terminating
practitioner

Patients for whom surgery or another procedure has been authorized prior to the
practitioner’s termination in connection with a documented course of treatment and
recommended by the terminating practitioner

Patients being treated for a terminal illness
Patient Requests to Change PCPs and Voluntary Transfers from a PO. HMO patients’ requests
to change their chosen PCP are honored in most instances. Exception to this policy may be made if
there is evidence that the patient’s request is an attempt to subvert acceptable medical practices,
such as compliance with treatment recommendations and plans or prescription-seekers. In such
instances, the patient’s health plan is requested to disenroll the patient from the medical group/IPA
entirely.
Requests from HMO patients for voluntary departures from your PO are directed to the patient’s
health plan. Reports of such transfers provided by the health plans are reviewed to identify
underlying issues with practitioners or the organization as a whole.
Terminating a Physician-Patient Relationship. Practitioners are entitled to set expectations for
their relationships with patients, and MED3OOO has the right to maintain viable business
relationships with their practitioners’ patients. Patients who do not collaborate with their practitioners
or MED3OOO in maintaining a mutually satisfactory relationship are subject to transfer of their
affiliation to another practitioner or, in extreme cases, another medical group/IPA. Under certain
circumstances, physicians may terminate their relationship with a patient due to behaviors that affect
or interfere with treatment objectives.
2
This policy does not apply to specialists whose contractual arrangements are involuntarily terminated for
cause, nor to those (a) relocating out of the area and no longer available within a reasonable distance to
members or (b) leaving practice.
Page 46
Consistent with health plan policies, three levels of severity have been established to quantify the
degree of the patient’s offenses so that any action taken is appropriate for the offense. For details of
the circumstances when disciplinary action may be taken against an HMO patient, please contact
the MED3OOO Provider Relations Department (see Part 8).
Page 47
Management Services
Administrator
Administrators
forfor
Contracting
Physician
Organizations
Buenaventura
Medical
Group
and Care IPA
Part 5. Credentialing Program
We ensure that HMO patients have access to practitioners who meet high standards and stringent
qualifications requirements.
CREDENTIALING MANDATES
Credentialing requirements for practitioners are governed by state regulations and national
accreditation standards. Through MED3OOO’s credentialing and privileging program, patients
seeking care through affiliated POs are ensured that they are being treated by practitioners who are
highly qualified and meet criteria established for medical professionals in their community.
The Credentialing Department ensures reviews each practitioner’s qualifications when he or she first
joins the panel of your PO, and every 36 months after that. The Credentialing Department initiates
the credentialing and recredentialing process, subject to stringent, mandated time frames. The
Credentialing Committee for your PO meets regularly to evaluate the information collected and
verified by the Credentialing Department and makes the final decision whether to accept a new
practitioner on the panel or continue a practitioner’s privileges for the next 36-month recredentialing
period.
The credentialing program is mandated and governed by federal and state regulations and
accrediting organizations. It is the practitioner’s responsibility to

comply with credentialing program requirements

provide timely response to requests for information

inform the Credentialing Department of any changes in the information previously supplied to
the Credentialing Department
Failure to notify the Credentialing Department may be grounds for suspension or termination of the
practitioner’s privileges and employment or contract.
Nondiscrimination. In making decisions about practitioners’ panel privileges, the Credentialing
Committee will not consider and shall ensure nondiscrimination of practitioners based on their age,
race, ethnic/national identity, gender, sexual orientation or other personal factors not relevant to the
practitioner’s professional credentials, or the types of procedures (e.g., abortions) or patients (e.g.,
Medicaid) in which the practitioner specializes.
Practitioner Considerations. Practitioners are entitled to the following considerations in the
credentialing/ recredentialing process:

You may review information submitted to us by primary sources in support of your
application.

You may correct erroneous information. Corrections will be reviewed by the Credentialing
Department in a timely manner. You must request the correction prior to your records being
reviewed by the Credentialing Committee if the information may affect the Committee’s
decision regarding your privileges.

Upon request, we will inform you of the status of your application prior to the process being
finalized.
Page 48
Management Services
Administrator
Administrators
forfor
Contracting
Physician
Organizations
Buenaventura
Medical
Group
and Care IPA
LICENSURE AND DRUG ENFORCEMENT ADMINISTRATION (DEA)/CONTROLLED DANGEROUS
SUBSTANCES (CDS) CERTIFICATION
Practitioners are responsible for maintaining a current physician and surgeon’s license to practice in
the State of California. If the practitioner is required to have a DEA or CDS certificate, it also must
be continuously current. Failure to maintain a current license and DEA/CDS certificate is grounds for
automatic termination of your contract.
You must provide a copy of your current license and DEA certificate after each renewal.
BOARD CERTIFICATION
Practitioners whose specialties are subject to board certification are required to obtain their
certification at the earliest possible opportunity if not certified prior to joining the practitioner panel.
Board certification will be temporarily waived to permit the practitioner time to attain certification.
It is your responsibility to notify the Credentialing Department when certification has been awarded.
MALPRACTICE LIABILITY COVERAGE
At all times, practitioners must have current malpractice insurance in amounts established for the
practitioner’s specialty. Opened, pending or finalized malpractice actions must be disclosed on the
application and fall within current guidelines established by the Credentialing Committee for allowing
panel privileges. Any new cases, judgments or settlements occurring after initially credentialed or
between any recredentialing review period must be reported to the Credentialing Department within
fourteen (14) calendar days.
OTHER CREDENTIALING REQUIREMENTS
Other requirements for practitioners include the following:

Certification by the specialty board applicable for the practitioner’s primary practice type, if
such certification is available

Local hospital privileges if the practitioner will see or treat hospitalized patients and is not
exempt from that requirement due to the nature of his or her practice

Complete and submit a signed, approved application, meet the credentialing and privileging
criteria established by the Credentialing Committee and be granted panel privileges by the
Credentialing Committee

Sign and agree to comply with the provisions of their employment or contracting agreement,
which specify
»
adherence to MED3OOO policies and procedures
»
abiding by MED3OOO’s utilization management program and quality improvement
program requirements, including patient rights and access, referral authorization
processes, standards for practice sites, medical record-keeping practices and as
described in this document
Page 49
Management Services
Administrator
Administrators
forfor
Contracting
Physician
Organizations
Buenaventura
Medical
Group
and Care IPA
AVAILABILITY OF CREDENTIALING PROGRAM DESCRIPTION
The scope of the credentialing program is described in the complete Credentialing Program
Description. It is available upon request by calling the Provider Relations Department (see Part 8).
The policies and procedures established to support the UM program are viewable on the network
shared server.
CREDENTIALING INFORMATION CONTACT
Questions about the credentialing requirements and related credentialing/recredentialing policies
and time frames should be directed to the Credentialing Department (see Part 8).
Page 50
Part 6. Utilization Management Program
In its capacity as administrator for contracting
POs, MED3OOO conducts a comprehensive
utilization management (UM) program for patients enrolled in HMO health plans. PO panel
practitioners are contractually required to participate in and comply with UM program activities.
UM PROGRAM RESPONSIBILITY
Your PO delegates responsibility for meeting UM program requirements specified by contracting
health plans to MED3OOO. Our UM Department is responsible for UM program activities, the scope
of which currently extends to the customary array of utilization management/utilization review and
health management services now accepted as integral to managed health care in the United States.
The Utilization Management Committees, which report to the respective Boards of Directors of
contracting PO, are the governing bodies for the UM program.
DECISION-MAKING POLICIES
The UM program is consistent with the administration requirements and clinical standards
established by managed care organizations in the State of California to ensure compliance with state
and federal regulations. It is designed to ensure that HMO patients receive the quality health care
they deserve and expect while preserving the financial integrity of our contracting POs.
The cornerstones of our UM program are uniformity, consistency and timeliness. The program relies
on established standardized decision-making criteria and guidelines that are based on sound
medical evidence. UM Department clinical staff reviews them regularly to be certain that they reflect
the needs of our patients. We also make sure that our clinical decision-makers — physicians, nurses
and other health professionals — consistently apply the criteria for all patients. Contracting health
plans routinely monitor our UM review activities for compliance with established requirements.
Failure to comply with requirements may jeopardize your PO’s contractual arrangements with HMO
health plans.
The UM Department makes these promises to you and your patients when it comes to making
utilization management decisions about health care services:

Only board certified physicians and qualified health professionals are permitted to make
utilization management decisions about the health care services our patients receive.

Utilization management decisions are based solely on the appropriateness of care and
service and each patient’s own health plan benefits. We do not reward our decision-makers
for denials of coverage, services or care.

We do not offer our decision-makers any financial incentives to limit, restrict or discourage
use of health care services.
Case reviews are conducted to determine

whether the services are covered by the member’s plan of benefits

if covered, the services meet the criteria and guidelines for medical necessity and/or
appropriateness of clinical or medical services and meet any applicable conditions of
coverage
Page 51
Review requests are screened to verify the patient’s eligibility for HMO health plan benefits and
identify the UM requirements applicable for that patient. Then, depending upon the applicable
requirements for the services being reviewed, the request is either authorized, if further review is not
required, or it is directed to a senior clinician for evaluation. Any case having the potential for denial
is forwarded to the Medical Director for your PO or a specialty-specific practitioner designee for final
determination.
AVAILABILITY OF UTILIZATION MANAGEMENT PROGRAM DESCRIPTION
The scope of the UM program is described in the complete Utilization Management Program
Description. It is available upon request by calling the Provider Relations Department (see Part 8).
The policies and procedures established to support the UM program are viewable on the network
shared server. The following information summarizes the UM program.
UM DEPARTMENT BUSINESS HOURS
The UM Department is your primary source for UM program information and requirements.

Daily UM Department business hours are 8:00 a.m. – 5:00 p.m., Monday through Friday.
We observe the customary national holidays, when our offices are closed for business. The
UM Department staff makes outbound calls and receives incoming calls regarding UM
activities only during those hours. If you have a hospital, skilled nursing facility, rehabilitation
or home health care case, a Case Manager may provide you with a number for direct
contact.

After normal business hours, on weekends and holidays, you may fax
UM-related inquiries issues to the Provider Relations Department (see Part 8). 1
Practitioners who are connected to MED3OOO’s computer system may also submit
authorization requests and view the status of a request electronically. Inquiries will be
responded to at the earliest opportunity on the next business day.
REQUIREMENTS FOR SPECIALTY CARE, ANCILLARY SERVICE AND INPATIENT REFERRALS
HMO members must meet their health plan’s UM requirements in order for the services to be eligible
for coverage. As their physician, you are responsible for initiating the UM process on your HMO
patients’ behalf.
Services Subject to Review. The UM Department is delegated the authority by contracting health
plans to review and authorize their HMO patient referrals for elective inpatient (acute, skilled nursing
and rehab facility) care, most specialty care (including behavioral health services, but only for
members of senior HMO health plans), and most ancillary services. The requirements extend to
services to be provided by contracting and affiliated practitioners/providers, as well as by noncontracting practitioners/providers when the needed services are not available from within
MED3OOO’s contracting PO practitioner panels or affiliated practitioners/ providers.
PCPs must obtain authorization prior to referring their patients to contracting specialists for elective
services. Contracting specialists are required to obtain authorization for continuing care prior to
services beyond those originally authorized being rendered.
1
Patients may call the Member Services Department (see Part 8). SeaView IPA practitioners may email
their UM inquiries to the Member Services Department (see Part 8).
Page 52
Services Not Subject to Review. Certain services are not subject to review, depending upon the
type of HMO health plan in which the patient is enrolled. As a general rule, treating physicians may
order the services listed below directly from the designated provider for their HMO patients. Services
received by HMO plan members under conditions other than those indicated below that have not
been authorized in advance usually are not eligible for coverage, regardless of whether they are
received from a practitioner, provider or vendor having a contractual arrangement with your PO.

Primary Care Services. Services rendered for HMO patients within the primary care practice
setting are not subject to review. The PCP determines when services are required outside
the primary care setting and requests the necessary authorizations from the UM Department.

Emergency Services. Emergency services generally do not require prior authorization;
however, emergency facility services that do not conform to emergency services/conditions
guidelines established by the State of California Health and Safety Code (for commercial and
state-funded health plan members) or by the Center for Medicare-Medicaid Services (for
senior health plan members), as applicable for the patient’s age group, are evaluated in the
claims payment process. They must be forwarded to the UM Department for postservice
review by the Medical Director. Emergency medical and behavioral health services that are
necessary to screen and stabilize a member will not be denied. Any services not authorized
by the patient’s PCP/treating physician that do not meet emergency criteria are subject to
denial of the claim. Decisions are made after obtaining all necessary information, such as an
ER summary or medical record, regarding the presenting symptoms and the discharge
diagnosis.

Diagnostic and Routine Preventive Screening Lab Tests. Prior authorization is not
required for lab services ordered by an authorized practitioner to (1) diagnose or monitor an
HMO member patient’s condition, or (2) when ordered in connection with age-appropriate
routine preventive screening services, such as FDA-approved cervical cancer screening tests
(i.e., Pap smears and thin prep tests). Coverage for lab services is subject to the patient’s
plan of benefits, and MCO's are responsible for complying with any legislation or regulations
pertaining to such services.

Radiology/Imaging Services. Requests for advanced imagings are directed by the
treating/ordering practitioner to the contracting imaging vendor.
(SVIPA & VCIPA Only) The vendor/facility evaluates the request against agreed upon
preservice review guidelines. Those falling outside the guidelines for authorization by the
vendor are forwarded to the UM Department. If the request is for imaging services not
subject to preservice review by the UM Department, the vendor proceeds with scheduling
and providing the requested imaging.

Exception: Requests for use of non-contracting imaging vendors and facilities must be
submitted to the UM Department for review.

OB/G Gyn and Well-Woman Services. HMO patients are not required to obtain
authorization for routine office-based OB/Gyn care, including annual well-woman preventive
care exams. However, they must receive the services from an OB/Gyn specialist on the
practitioner panel for your PO. Surgical procedures, hospital admission, or other complex
services require prior authorization.
Page 53

Behavioral Health Services. Behavioral health services for commercial HMO health plan
members typically are not included in the range of services for which your PO is financially
responsible, as they are provided under separate “carve-out” arrangements with behavioral
health provider organizations.

Direct Referral Specialists. Selected PCPs may refer their patients to some contracting
specialists without prior authorization. PCPs eligible for direct referrals are selected based on
their history of compliance with review requirements and protocols. The specialties to which
they may refer must be approved by the UM Committee and Board of Directors and/or have
capitation agreements.
Direct referral utilization is monitored through post service review.
Members of Blue Cross of California HMO health plan who reside in Santa Barbara County
are entitled to be directly referred to specialists contracting with SBSIPA without prior
authorization.
Services Coordinated Through Patients’ Health Plans. A range of services are coordinated by
the UM Department through the affected patient’s health plan, which is responsible for determining a
member’s eligibility for the services and interfacing with the UM Department, based on the outcome
of the health plan’s evaluations. When you submit an authorization request for such services, the
UM Department must await the health plan’s determination, so please allow ample time for the
request to be processed. The following types of services are subject to health plan review of your
authorization request:

Cancer clinical trials

Experimental or investigational treatments

Organ transplantations
The patient’s health plan also may become involved in the following types of cases:

Requests for second opinions from specialists who are not affiliated with your PO (the patient
has the option of selecting one who has a contract with the patient’s health plan)

Services of practitioners and providers outside the local service area that are medically
necessary due to an emergency

Healthy Families programs — The UM Department does not review some services for HMO
patients from birth to age 21 who are enrolled in a contracting health plan’s Healthy Families
HMO benefit plan. Requests for medical services for children enrolled in a Healthy Families
HMO due to conditions falling into these general categories are referred to and managed by
the State of California Children’s Services (CCS) Department:
Infectious diseases
Neoplasms
Endocrine, nutritional and metabolic diseases and
immune disorders
Medical therapy program conditions
Mental disorders and mental retardation
Diseases of:
» nervous system
» blood and blood-forming organs
» circulatory system
» eye
» ear and mastoid process
» respiratory system
Page 54
» digestive system
» genitourinary system
» musculoskeletal system and connective
tissue
Congenital anomalies
Accidents, poisonings and immunization reactions
Specific referral criteria are issued by CCS and maintained in the UM Department.
INFORMATION REQUIRED FOR CASE REVIEWS
Requests for review must be submitted to the UM Department by the patient’s PCP or treating
practitioner on the appropriate form. The forms can be found starting on page 68 or you may call
providers services for assistance in getting the form.
Request forms must be fully completed to include the following minimum data elements or be
accompanied by a supplemental sheet with relevant information, as applicable for the case
submitted for review:
Minimum Information Required for Case Reviews
Category
Patient Information
Minimum Data Elements
Name
Sex
Date of birth
Health plan
Primary diagnosis
Surgical assistant requirements
Secondary diagnosis
Anesthesia requirements
Tertiary diagnosis
Proposed admission or service date(s)
Multiaxial diagnosis
Proposed procedure/service date(s)
Proposed procedure(s),
treatment(s) or service(s)
Proposed length of stay and frequency/
duration of services
Clinical Information
Sufficient to support the
medical necessity/
appropriateness and level of
service proposed
Contact person for detailed clinical information
Facility Information
Name
Type (inpatient, outpatient, special unit, SNF,
rehab, office/clinic, home health agency, etc.)
Diagnosis/Treatment
Information
Location
Minimum Information Required for Case Reviews
Category
Concurrent
(Continuing Care)
Information)
For Admissions to
Facilities Other Than
Additional
days/services/procedures
proposed, with frequency and
duration of services
Reasons for extension, including clinical
information sufficient to support medical
necessity/appropriateness and level of service
proposed
Diagnosis (same/changed)
Discharge plans
History of present illness
Prognosis
Page 55
Category
Acute Medical/Surgical
Hospitals, Include
Current special assessment
reports
For Special Situations:
Additional information sufficient to support health insurance carrier/plan
requirements, such as:
Patient treatment plan and goals
• Second opinion information
• Information in support of the need for a procedure, drug, device or other
therapy
Treatment plans must be appropriate, time-specific and updated periodically.
INITIATING A CASE REVIEW
1. Fax review requests directly to the MED3OOO UM Department (see Part 8. UM-related
inquiries, including referral requests, are received and outbound responses provided only
during normal business hours of 8:00 a.m. – 5:00 p.m., weekdays and non-holidays only. If
the services are beyond the scope of those customarily screened and authorized by UM
Department non-clinical staff, Review Nurse will further evaluate the request. If additional
information is needed, the Review Nurse will contact you and provide a direct phone or fax
number. See Part 8 for phone and fax numbers.
2. Allow the UM Department sufficient time to perform a fair review of the requested
services. Federal and state regulations mandate the time frames for completing a review.
Referral review requirements and response time frames are mandated by federal and state
regulations and accreditation regulations. The UM Department strives to exceed those
standards and makes every effort to complete reviews in advance of the required timeframe.
3. Submit complete records supporting the need for the referral and promptly respond to
requests from the UM Department for additional information when needed. If requested
information is not supplied, the request is at risk for being denied and may need to be
resubmitted to be given further consideration.
Page 56
REPORTING EMERGENCY INPATIENT ADMISSIONS
SeaView IPA patient hospital admissions following emergency room treatment must be coordinated
through the inpatient physician (hospitalist) on duty at the admitting facility.
Valley Care IPA patient hospital admissions may be coordinated through the hospitalist or managed
directly by the PCP. The facility will notify the UM Department on the next business day.
Santa Barbara Select IPA patient hospital admissions may be coordinated through the hospitalist or
managed directly by the PCP. The facility will notify the UM Department on the next business day.
Leisure World Managed Care patient hospital admissions should be coordinated by the hospitalist or
managed directly by the PCP.
Pioneer Provider Network patient hospital admissions must be coordinated by the hospitalist at the
primary admitting hospital(s).
The UM Department will follow up on the admission on the next business day. At the beginning of
the next business day, the Case Manager checks with the facility’s admitting office to identify any
patients admitted in the off-hour period and performs an evaluation of the patient’s need for
continuing inpatient care. If the patient can be discharged, the Case Manager issues the appropriate
denial notifications. You will be contacted if additional information is needed.
When a patient is admitted to a facility following emergency treatment, continued care will be
authorized until the treating practitioner believes that the member may be safely discharged, a
treatment plan has been agreed upon with the treating practitioner, and both the treating practitioner
and the member (or member’s representative) have been given 24 hours’ advance notice that
coverage will be discontinued. For senior HMO health plan members, the authorization will be
provided within one hour of receiving a request from a non-contracting facility.
Out-of-Area Emergency Admissions. To accommodate post-stabilization care needs subsequent
to emergency treatment by out-of-area/non-contracting hospitals, the facilities customarily attempt to
contact the patient’s PCP/treating physician or behavioral health practitioner, as applicable.
Post-Emergency Stabilization Services Following Discharge. PCPs and treating physicians have
the authority to order post-emergency stabilization services from contracting ancillary
providers/suppliers, such as skilled nursing facilities, home health agencies and medical suppliers.
Such services ordered by the PCP/treating practitioner will be authorized by the Case Manager on
the next business day, and the patient’s need for continuing services will be evaluated.
AUTHORIZED REFERRAL PROVIDERS
As a matter of policy, referrals are authorized only to practitioners and providers affiliated with
your PO.
Your PO’s contracting provider network also extends to tertiary facilities and major medical centers
designated by contracting health plans for use by their members when needed services are not
available locally.
Page 57
Use of Non-Contracting Providers. Your PO accommodates the need for services not available
within their networks of affiliated practitioners and providers.

For commercial members, medically necessary use of non-contracting providers is
permitted when a contracting practitioner or provider capable of providing the needed
services is not available through a contracting practitioner/provider. These services must be
authorized and a special agreement will be executed with the practitioner/provider.

For senior members, a special agreement is not required if the practitioner/provider is
Medicare certified. However, authorization may be required.
If the needed services are not available in-network, the Review Nurse or Case Manager will locate a
non-contracting practitioner/provider appropriate for the patient.
AUTHORIZATION PROBLEMS
Practitioners are entitled to the following considerations in the review process:
1. If you have not received a response within the time frames indicated above, you may call the
Provider Relations Department (see Part 8) to request a status. 1 If you are connected to
MED3OOO’s computerized referral system, you may obtain status information online.
2. You may discuss a case submitted for review and denial decisions with your PO’s Medical
Director or other physician who made the determination. If you can provide information that
you believe was not considered at the time a denied request was reviewed, and an appeal
has not yet been filed, the case will be given immediate reconsideration.
3. All denials are subject to appeal. Appeals must be directed to the patient’s health plan, as
required by our contractual arrangements with them. You may file the appeal on behalf of
your patient and encourage you to do so if your input will help with the decision. The health
plan will notify us and direct a response within a time frame appropriate for the patient’s
medical needs.
UM DECISION-MAKING CRITERIA AND GUIDELINES
The UM Department does not conduct a scripted clinical screening. When evaluating a case, UM
Review Nurses, Case Managers and Physician Reviewers are required to consider information
pertinent to the individual’s clinical/medical needs, including the treating/ordering
practitioner/provider’s recommendation. They also must observe the terms of coverage under the
patient’s specific benefit plan. They further must base their review determinations on established
clinical criteria recognized within the medical community-at-large as appropriate for the medical
specialty or other clinical discipline relevant to the services subject to the review.
The standardized decision-making guidelines and criteria currently in use include the following
resources, as applicable for the requested services:

Standard reference compendia, including but not limited to
»
1
InterQual Level of Care Acute Criteria®
This number is dedicated to practitioner and provider inquiries. Patients may call the Member Services
Department for information and assistance (see Part 8).
Page 58
»
InterQual Care Planning Specialty Referral Criteria®
»
InterQual Care Planning Procedures Criteria®
»
Complete Guide to Medicare Coverage Issues

Medical policy or conditions of coverage guidelines issued by the patient’s health plan

Other established clinical practice guidelines and criteria that are
»
evidence-based
»
commonly applied by the medical specialty or other clinical discipline appropriate for
the services subject to review
Examples include

»
practice guidelines or criteria from the federal government
»
practice guidelines or criteria from nationally recognized professional associations or
societies that have been developed by a peer review or consensus process
»
the American Hospital Formulary Service-Drug Information
»
American Medical Association Clinical Practice Guidelines
»
the American Medical Association Drug Evaluation
»
American Psychiatric Association Practice Guidelines
»
American Psychological Association Practice Guidelines
»
the American Dental Association Accepted Dental Therapeutics
»
the United States Pharmacopoeia-Drug Information
»
American Physical Therapy Association Guide to Physical Therapist Practice
»
Guidelines for Chiropractic Quality Assurance and Practice Parameters, Proceedings
of the Mercy Center Consensus Conference
»
Clinical Practice Guideline No. 1, Vertebral Subluxation in Chiropractic Practice
Criteria and guidelines developed and approved by your based on current standards of
practice within our medical community for the requested services
In the absence of consistent guidelines, a Reviewer’s medical judgment based on professional
experience may be considered as definitive.
Standardized guidelines are evaluated annually to ensure that the most current versions appropriate
for PO patients are used in the UM process.
Application of Criteria and Guidelines by Reviewers. Information sources for review decisionmaking are monitored and evaluated annually by your PO’s UM Committee. Reviewers are informed
Page 59
of requirements for considering appropriate information and applying relevant medical and scientific
evidence in their case evaluations and are supplied with information and documents pertinent to the
individual’s medical needs. Their written opinions are evaluated to ensure that that they include
citation of the specific clinical criteria applied in the review.
Review clinicians receive training in requirements for applying pertinent clinical criteria and providing
appropriately documented written opinions. Your PO’s Medical Director also assists individuals
needing access to the latest medical research findings, studies, practice, guidelines and other
clinical reference materials when requested in order to complete their reviews.
CASE MANAGEMENT PROGRAMS
The UM Department also offers a spectrum of specialized health management services tailored to
our patients’ medical needs. The case management program is geared to patients who have
complex or specialized treatment needs. Whether for a long-term chronic condition or for an illness
patients will recover from, these programs focus on the best possible health outcome for patients.
The Case Manager coordinates multiple health care services, sees that patients have the
information they need to effectively manage their illness or condition, and through telephone contact
follows their progress to be sure that their treatment plan is working for them. They also work with
the patient’s health plan so that their benefits are used efficiently and to the patients’ best
advantage.
Contact the Provider Relations Department if you wish to refer a patient who may benefit from
individualized case management of their services. If you already have a patient being actively case
managed, you may contact the Case Manager.
Page 60
Part 7. Quality Improvement Program
The quality improvement (QI) program is an ongoing, comprehensive and integrated program.
It
objectively and systematically monitors and continuously evaluates all aspects of the delivery of
health care services. Its purpose is to identify opportunities to improve care and service, as well as
resolve identified problems in the delivery of care and service in all departments. Assessment of
standards, objectives and outcomes provide an ongoing basis upon which patient care related
issues are evaluated, upgraded and improved for the benefit of the member, practitioners and staff.
The PO I Committees, which report to their respective Board of Directors, are the governing body for
the QI program.
PO practitioners are contractually required to participate in and cooperate with QI program activities.
Many of those activities focus on improving the operational aspects of delivering health care
services. Operations activities are monitored continuously and systematically to assess corporatewide and individual performance and to identify areas for focal performance improvement.
AVAILABILITY OF QUALITY IMPROVEMENT PROGRAM DESCRIPTION
The scope of the QI program is described in your PO’s Quality Improvement Program Description. It
is available upon request. If you are connected to MED3OOO’s computer system, the policies and
procedures established to support the QI program are viewable on the network shared server. For
further information, contact the Provider Relations Department (see Part 8). 1 The following
summarizes the QI program.
PHYSICIAN SUPERVISION OF NON-PHYSICIAN PRACTITIONERS
California state law assigns physicians responsibility for direct oversight of the following nonphysician practitioners in their practice sites:

Physician assistants (PAs)

Nurse practitioners (NPs, RNPs, CRNPs)
The Credentialing Department monitors the licenses of physician assistants and nurse practitioners
practicing in contracting physicians’ offices. Contracting physicians who permit physician assistants
or nurse practitioners to treat their managed care patients are responsible for ensuring that the
practitioner’s license is current.
Physicians must ensure that non-physician practitioners confine their treatment of your PO patients
to services that fall within the scope of their license. Medical records documentation must reflect
that all services falling outside the scope of a non-physician practitioner’s license were performed by
a physician. For example, if the report of a physician’s services is prepared by a non-physician
practitioner, it must be initialed by the physician. Accurate documentation ensures that the procedure
is reimbursable and protects practitioners from claims that provided services are outside the scope
of the practitioner’s license.
Other supervision requirements for non-physician practitioners include the following:
1
This number is dedicated to practitioner and provider inquiries. Patients may call the Member Services
Department (see Part 8).
Page 61

The supervising physician has continuing responsibility for all medical services provided by
the health professional under his or her supervision. Note: Effective 7/1/01, Californialicensed physicians can supervise a PA without MBC approval. The exception is those
physicians who are expressly prohibited by the Medical Board of California (MBC) from
supervising a PA. [CCR, Title 16-Division 13.8-Physician Assistant Practice Act-Section
3502; Board of Registered Nursing, Nursing Practice Act, Rules and Regulations, Article 8]

PAs may perform medical services set forth by the regulations of the MBC when the services
are rendered under the appropriate supervision of a licensed physician. [CCR Title 16:
Division 13.8-Physician Assistant Practice Act-Section 3502]

»
At all times, the supervising physician must be physically or electronically available to
the PA for consultation, except in emergency situations.
»
The supervising physician must not supervise more than two PAs at one time.
Prescribing of drugs and/or devices by NPs must be in accordance with standardized
procedures or protocols developed by the NP and supervising physician. [Board of
Registered Nursing, Nursing Practice Act, Rules and Regulations, Article 8]
»
The supervising physician is not required to be physically present; availability by
telephone is adequate.
»
The supervising
one time.
physician
must
not
supervise
more
than
four
NPs
at
MEDICAL RECORDS REQUIREMENTS AND AUDITS
Accurate medical record documentation is essential to your PO’s ongoing success, from both quality
of care and financial perspectives. QI program activities in connection with medical recordkeeping
that require practitioner participation or cooperation include the following:
1

Compliance with standardized recordkeeping protocols ensures the safety of patients,
and data supporting such compliance are tied to financial incentives proffered by contracting
health plans, as well as the stability of contractual arrangements with those health plans. The
QI Department periodically audits individual practitioner’s recordkeeping practices. Any
deficiencies are reported to the practitioner and the applicable PO’s QI Committee. Serious
deficiencies require the practitioner to submit a corrective action plan, and compliance with
the protocols will be re-evaluated at later date.

For a copy of the medical record audit standards, call the Provider Relations Department
(see Part 8).

Timely response to health plan inquiries and patient complaints/grievances or appeals
is critical. When the QI Department requests a medical record for such purposes, response
time is closely monitored by the requesting health plan. If a patient’s medical record is in
your office when it is needed, it must be promptly forwarded to the QI Department 1. The QI
Department will return the record as soon as possible.
Only a copy of the portion of the record relevant to the issue of the case will be required. The copy will
not be returned.
Page 62

Data for key statewide quality of care/quality of service measurements are collected
annually by contracting health plans and reported to an external vendor for analysis and
ranking of your PO’s performance in comparison to other medical groups and IPAs
throughout the state. In some cases, the results may be published for public inspection as a
guide for health plan purchasers. Consequently, favorable data have a direct positive impact
on your PO’s financial standing. The underlying principles for these measurements are (1)
timely delivery of preventive services, (2) appropriate management of high-risk conditions,
and (3) appropriate documentation of services rendered.
You PO’s QI Committee reviews the results of the above activities and determines ways to improve
overall PO and individual practitioner performance.
FACILITY OPERATIONS REQUIREMENTS AND AUDITS
The QI Department assesses primary care, OB/GYN and some behavioral health practitioners’
facilities to ensure compliance with essential premises safety, staff supervision, equipment and
patient access protocols. Contracts with health plans require that such assessments be performed
at regular intervals. Any deficiencies at practice sites are reported to the practitioner and the PO’s
QI Committee. Serious deficiencies require the site manager or practitioner to submit a corrective
action plan, and compliance with the protocols will be re-evaluated at later date.
For a copy of the facility audit standards, call the Provider Relations Department (see Part 8 How
to Contact Us).
ACCESS AUDIT
Appointment access standards are set by contracting health plans (see Part 4 Patient Access to
Care and Service). Timely access to needed medical services is monitored through various
mechanisms, including appointment access data, facility operations audits, patient complaints and
grievances, quality issue reports, patient satisfaction surveys and patient access audits. Results are
used to identify individual practitioner or panel-wide access issues and develop ways to improve
performance. The PO QI Committees determine any needed actions.
Page 63
Part 8. How to Contact Us
If you have questions about requirements or procedures, or need assistance, please contact the
appropriate MED3OOO department, as indicated below:
SeaView IPA
(805) 604-3325
(877) 311-5411
Valley Care IPA
(805) 604-3308
(877) 299-5599
(805) 604-3308
(877) 299-5599
(805) 278-6823
(800) 705-0831
Leisure World MCMG
(805) 604-3317
(800) 415-4455
(805) 988-5164
(800) 720-2323
Member Services Email:
[email protected]
Provider Relations Email:
[email protected]
Page 64
Part 9. Appendix
WAIVER FORM
I have enrolled in
____________
health plan.
(Health plan name)
I understand my eligibility status does not appear on the current eligibility list provided to
_____________________________.
(Provider name)
If eligibility is not established in the next 60 days, I assume full responsibility for all charges incurred
by dependents and myself.
______________
Date
Patient Full Name
Patient’s signature
Subscriber’s Full Name
Employer
Date of Birth
Employer Telephone Number
Subscriber’s Social Security Number
Witness
Verification of Eligibility was requested by:
Provider
Verification given on:
(Date)
Name of health plan representative
Dependents covered:
Temporary Authorization Number
Effective Date
$
Co-Payment Amount
Page 65
Part 9. Appendix
Sample Member Introduction Letter for PCPs
Dear Member,
We welcome you to our office and are pleased you have chosen us as your PCP.
Because health plans (managed care organizations) are different from other forms of health
insurance, we have found it helpful to provide some guides as to the best use of your plan.
We are members of a Provider Group, which contracts with health plans to provide Provider
services within the plan benefits. As such, we act as the "PCP".
There are some basic rules governing the care, which will prevent any misunderstanding of
how this system works for you.
We operate on an appointment system, so please call if you need medical care. You should
be able to be seen in a timely manner. Please call in advance for routine appointments. If
you are ill, we may be able to advise you over the telephone, or we may need to see you.
Please be prepared to come to the office whenever we can schedule you. It may also be
that you may have to wait a day unless your illness is severe and/or quite acute. We will do
our best to accommodate you promptly when you call. Be sure to make it clear to the nurse
or receptionist you have an acute problem if you think your need for medical care is urgent.
There are Providers on call 24 hours a day, every day of the year. It may not be your own
doctor, but it will be one of` your doctor's associates. If you should require medical services
when the office is closed, please call our office immediately, and the doctor on call will
advise you on the best course of action. It is of utmost importance you call before going to
the emergency room, whenever possible.
We provide primary care services, which include all basic medical care, including well
woman examinations. Specialty care, such as surgery requires a referral from your PCP
when medically indicated. If a member decides to go to a specialist without an approved
referral, it may be the member’s responsibility to pay the Provider for the service.
If your plan has a co-payment requirement, you must pay this fee at the time service is
provided.
Specialty Providers must obtain authorization for additional services by contacting your PCP
(this could include, but is not limited to, services such as laboratory, x-ray, surgical
procedures, follow-up visits, etc.). Failure to obtain an authorization could result in a denial
of reimbursement to the provider of service.
We understand many of our members have seen Specialty Providers in the past as a
regular source of care. However, unless it is medically indicated and authorized, routine
visits to those Specialty Providers may not be covered by your plan.
Page 66
Part 9. Appendix
We also understand this is a change for many people who have been accustomed to
choosing their own doctor for a particular problem. However, in order to provide cost
effective coverage without large out of pocket costs to you, your plan requires your PCP
direct your care. We encourage you to discuss these matters with us so we may address
your expectations. Additionally, please remember the decision making is based only on
appropriateness of care and service and the providers in our group or other individuals
conducting utilization review for denials of coverage or services are not compensated to
encourage barriers to care or service. Also, financial incentives for the decision makers do
not encourage denials of coverage or service, nor are incentives used to reward
inappropriate restriction of care as special concern must be kept in mind regarding the risk
associated with under-utilization. According to your health plan agreement, if you have other
insurance coverage, you are obligated to inform us so we may coordinate the benefits.
We feel this is an excellent plan, which provides you with high quality, affordable medical
care. Should you require such services, we have available to you the finest specialty and
sub-specialty Providers in our community.
We encourage your participation in making decisions regarding your medical care, and your
active participation in disease prevention and wellness. It is your right and responsibility to
access regular physical examinations and preventive services such as health screening
tests and immunizations, and to participate in health education and health maintenance
activities. With your cooperation, we are committed to provide you with quality health care.
If you have any questions regarding the benefits to which you are entitled, please refer to
your plan benefits booklet, or call your health plan directly.
Sincerely,
Practitioner Organization (SeaView IPA, Valley Care IPA, Santa Barbara Select IPA, Leisure
World Managed Care Medical Group, or Pioneer Provider Network)
Page 67
DATE REC’D STAMP
URGENT
ROUTINE
REFERRAL AUTHORIZATION FORM
SeaView IPA
Oxnard, CA 93036
Provider Services: (805) 604-3325
Member Services: (805) 988-5188
Fax: (805) 988-5162
PATIENT INFORMATION
Patient Name (Last, First, MI):
Sex
M
Address:
Health Plan Name:
PRIOR AUTHORIZATION REQUEST
AND/OR DIRECT REFERRAL FOR SPECIALIST
ICD-9 Code(s): __________
CPT Code(s): __________
Zip Code:
PCP Phone Number:
PCP:
Member Phone Number:
Plan Code:
Other Insurance?
Name:
Yes
Date Last Seen:
No
Diagnosis:
__________
__________
__________
__________
__________
Specify Proc/Svc:
__________
Frequency/Duration Requested: ________________________________________
(Chronic/exacerbated acute conditions can be >2 visits/60 days with treatment plan)
Prior Treatment/Relevant Diagnostic Testing:
Hospital/Facility:
Expected Date of Admission:
Assistant Surgeon:
Inpatient/Outpatient:
____________________________________________
Physician Name (please print)
Requested Service (s):
DIRECT REFERRAL
(FOR PCP USE ONLY)
Member ID#:
City / ST:
Service to be provided by:
____________________________________________
_
Physician Signature
ICD9 Code (s):
CPT Code (s):
Facility
__________________________
Date
ALLERGY
ENDOCRINE
GENERAL
SURGERY
ORTHOPEDICS
NEUROLOGY
RHEUMATOLOGY
CARDIOLOGY
ENT
HEM/ONC
PODIATRY
OB/GYN
UROLOGY
DERMATOLOGY
GE/GI
NEPHROLOGY
PULMONOLOGY
PLEASE ATTACH CLINICAL DOCUMENTATION / LABS / IMAGING / CONSULTS
____________________________________________
SPEC
ONLY
DOB:
F
OPHTHALMOLOGY
OON
(PAGES _________________)
__________________________________
_Physician Signature
__________________________________
Date
Reason for referral adequately communicated?
Yes
No
Adequate information received prior to the patient’s visit?
Yes
No
Clinical guidelines followed?
Yes
No
STANDING
REFERRAL
STANDING SPECIALIST REFERRAL:
Yes
No, IF YES, PLEASE COMPLETE BELOW
Prior Standing Referral
EXTENDED ______________# VISITS (>5)x _________ MONTHS
MEDICAL
GROUP ONLY
Yes
No
STANDARD ______________# VISITS (<4)x _________ MONTHS
[ ] APPROVED
Treatment Plan agreed by Specialists/PCP
Yes
Accompanying this request
Yes
No
[ ] CANCELLED
No
[ ] DENIED
AUTHORIZATION #:
______________________________________________________________________________________________
Signature of Utilization Department
________________________
Date
*NOTICE: This is not a guarantee of payment. Charges for non-covered service or services rendered to patients whose coverage is no longer in effect are the patients responsibility. This authorization
is valid only for services specified for 60 days.
**CONFIDENTIAL: Information protected under Federal and State law, and intended only for the use of the individual or entity named. If the reader of this form is not the intended recipient, employer, or
agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited.
SANTA BARBARA SELECT IPA
ROUTINE
URGENT
REFERRAL AUTHORIZATION FORM
SB Select IPA
Oxnard, CA 93036
Provider Services: (800) 705-0831
Member Services: (800) 705-0831
Fax: (877) 216-4218
PATIENT INFORMATION
Patient Name (Last, First, MI):
Sex
M
Address:
DOB:
Co-Pay:
F
City / ST:
Member ID#:
Member Phone Number:
Health Plan Name:
Plan Code:
Zip Code:
PCP:
Other Insurance?
Name:
PCP Fax Number:
Yes
No
PRIOR AUTHORIZATION REQUEST
AND/OR DIRECT REFERRAL FOR SPECIALIST
ICD-9 Code(s): __________
CPT Code(s): __________
__________
__________
__________
__________
__________
__________
Description:
Specify Proc/Svc:
Frequency/Duration Requested: ________________________________________
(Chronic/exacerbated acute conditions can be >2 visits/60 days with treatment plan)
Treatment Plan:
Hospital/Facility:
Expected Date of Admission:
Assistant Surgeon:
Inpatient/Outpatient:
____________________________________________
____________________________________________
Physician Signature
________________________
Date
DIRECT REFERRAL
(FOR PCP USE ONLY)
ICD-9 Code(s): __________
CPT Code(s): __________
__________
__________
__________
__________
SPEC
ONLY
__________
Description:
Specify Proc/Svc:
Studies Completed/Comments:
____________________________________________
MEDICAL
GROUP ONLY
__________
___________________________________
Physician Signature
________________________
Date
Reason for referral adequately communicated?
Yes
No
Adequate information received by the time of the patient’s visit?
Yes
No
Clinical guidelines followed?
Yes
No
[ ] APPROVED
[ ] CANCELLED
[ ] DENIED
AUTHORIZATION #:
______________________________________________________________________________________________
Signature of Utilization Department
________________________
Date
*NOTICE: This is not a guarantee of payment. Charges for non-covered service or services rendered to patients whose coverage is no longer in effect are the patients responsibility. This authorization is valid only for
services specified for 60 days.
**CONFIDENTIAL: Information protected under Federal and State law, and intended only for the use of the individual or entity named. If the reader of this form is not the intended recipient, employer, or agent responsible
for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited.
Patient Referral Form
PH: 805-604-3308
Fax: 805-278-6815
Date____________________
Patient Name__________________________________ Patient DOB ______________ HP ID#____________________
Referring Physician __________________________ Primary Care Physician ___________________________________
STAT/Urgent: Call UM for approval (once approved fax this completed form to UM for tracking)
Must complete for STAT/Urgent: Specialist appointment Date: _______________ Time:________
Routine
Retro (all retro referrals must be sent with claim for retro claim review)
Refer to: __________________________________________________________________________________________
ICD-9/Diagnosis: ___________________________________________________________________________________
ICD-9/Diagnosis:___________________________________________________________________________________
CPT/Service: ______________________________________________________________________________________
CPT/Service: ______________________________________________________________________________________
Prior Treatment/Testing: _____________________________________________________________________________
__________________________________________________________________________________________________
Reason for Referral:_________________________________________________________________________________
__________________________________________________________________________________________________
Place of Service (name): _______________________________
Inpatient
Outpatient
PCP Signature: ___________________________________________________________________________________
Eligibility Checked by: ______________________________ Effective Date:____________
Aetna
Aetna Senior
Blue Cross
Blue Shield
Health Net
Pacificare
Secure Horizons
SCAN
Cigna
TO BE COMPLETED BY UTILIZATION MANAGEMENT
APPROVED___________________ DENIED ______________________ MODIFIED___________________________
Referral # _________________________________________________________________________________________
U.M. Physician Comment ____________________________________________________________________________
Fax Completed Referral Form to: 805/278-6815
Patient Referral Form:
Request for Additional Services
PH: 805-604-3308
Fax: 805-278-6815
STAT/Urgent: Call UM for approval (once approved fax this completed form to UM for tracking)
Routine
Retro (all retro referrals must be sent with claim for retro claim review)
Date:
Patient Name:
Last Seen:
Member ID #:
DOB:
Primary Care Physician:
Reason for Referral:
ICD-9 Code
Diagnosis:
ICD-9 Code
Diagnosis:
ICD-9 Code
Diagnosis:
Aetna
Blue
Shield
Health Net
Aetna SR.
Cigna
Scan
PacifiCare
Blue
Cross
Secure
Horizons
Authorization is being requested for the following Procedures/tests and/or future visits:
CPT / Service:
CPT / Service:
CPT / Service:
CPT / Service:
Place of Service
(name):
Inpatient
Outpatient
List of potential consultants, (i.e., anesthesia, assistants):
Consultant’s Signature
Print Last Name
Fax to Primary Care Physician: For routine referrals only
VCIPA Primary Care Physicians Only – fax to VCIPA UM at 805/278-6815
PCP Recommendations:
PCP Initials:
Eligibility Checked:
Effective Date:
To be completed by VCIPA Utilization Management
APPROVED:
DENIED:
MODIFIED:
Referral #: _________________________________________________________________________________________
UM Comment:
Part 10. Glossary
Benefit Plan - refers to the specific services available to an enrollee under the HMO agreement with
the employer.
Capitated Services - those services listed in the Covered Services of the I.P.A./Medical Group and
hospital contracts which the I.P.A./Medical Group and hospital are each responsible for providing for
a fixed amount of reimbursement per member per month.
Capitation - a prepaid monthly fee made to the I.P.A./ Medical Group and hospital for each enrollee
in exchange for the provision of comprehensive health care services to enrolled members.
Concurrent Review - review of a patient's chart, including verification of necessity of treatment and
need for continued treatment, conducted during the course of treatment.
Conversion Factor - the dollar amount to be applied to each relative value unit in a relative value
scale to determine the payment amount for physician services.
Co-Payment - a charge to a patient receiving medical care which is required by the health plan to be
collected by the Provider of care.
Coordination of Benefits (COB) - When a patient is covered by two or more group health plans,
coordination of benefits divides the responsibility of payment between the health plans so that the
coverage combined will pay up to 100% of hospital and professional services within the limits of all
contracts.
Dependent - includes spouse and children of the subscriber who receive coverage through the
subscriber's health plan.
Eligibility - a determination of whether a member is covered by the health plan for medical services.
Enrollee - any person, or eligible dependent, who is enrolled in the health plan.
E.O.B. - explanation of benefits.
Evidence of Coverage - description of health insurance benefits as well as limitations and
exclusions provided to each member by the health plan.
Fee for Service – a method of payment to physicians for all services authorized based on a specific
dollar amount for each service.
Health Care Financing Administration (HCFA) – the federal agency responsible for administering
Medicare and overseeing states’ administration of Medicaid.
Health Maintenance Organization (HMO) - a prepaid health plan licensed by the appropriate state
agency (for example, in California HMOs are regulated through the Department of Corporations).
Individual Plan - a benefit plan available to individual members who chose their eligibility for
coverage through their employer.
Independent Physicians Association "IPA" - a network of private practice physicians and allied
health professionals established to facilitate referrals and to contract with HMO's and other third
party payors.
Page 74
Part 10. Glossary
Medical Assistant (MA) – an individual trained to perform a minimal amount of nursing duties and
laboratory procedures, as well as front-office duties.
Member - a subscriber or dependent entitled to receive medical services from Providers.
National Committee for Quality Assurance (NCQA) – a Washington D.C. group that develops
HMO accreditation standards.
Non-Covered Services - health care services which are not benefits under the subscriber's
evidence of coverage.
Nurse Practitioner (NP) – a nurse with additional extensive training who is licensed to perform
duties beyond the scope of the nursing profession.
Open Enrollment - the annual period during which employees of a company may change their
health insurance coverage.
Out of Area - the area outside a 30 air-mile radius of the primary hospital. Outside this boundary
the Provider Group and hospital are not directly responsible for the provision of care, according to
their contractual agreement with the health plan.
Participating Physician - a legally qualified physician who has entered into an agreement with the
HMO or with one of the hospitals or physician groups to provide physician services to enrollees of
the HMO.
Per Diem Rates - cost figures negotiated with Providers to cover specific services rendered in a 24
hour period beginning at 12:00 midnight or for a one day admission.
Pre-Admission Review Program - a process by which the Provider Group will arrange for the
admission of enrollees to the primary hospital or referral to other hospitals.
Premium - refers to the fee paid by an employer to the health plan as compensation for the
provision of health care services.
(PCP) Primary Care Provider - is the Provider Group physician selected by an enrollee to render
first-contact medical care and may include physicians whose training is in family practice, internal
medicine, pediatrics, and obstetrics/gynecology.
Primary Hospital - is that hospital selected by the HMO and the Provider Group where the majority
of enrollees’ inpatient care is to be provided.
Provider - physicians, hospitals and other health care professionals providing health care related
services to health plan enrollees.
Quality Management - the process established to ensure that the quality of medical services
rendered meets or exceeds objective standards developed by knowledgeable health professionals
and that services provided are "medically necessary" and provided in a timely manner.
Referral - the process by which the PCP directs an enrollee to seek and obtain covered services
from other contracted health professionals.
Retrospective Review - review conducted following the patient's treatment.
Page 75
Part 10. Glossary
Service Area - the geographic area that is within a 30 air mile radius of the primary hospital.
Shared Risk Services - the in-patient and other patient care services which are subject to a formula
for determining the amount and distribution of risk sharing incentives between the I.P.A./Medical
Group, primary hospital and HMO.
Stop Loss – an insurance program limiting the financial liability of a Provider Group for any given
member.
Subscriber - the adult who selects coverage by HMO through his/her employer.
Subscriber Group - is the organization, firm or other entity contracting with HMO's to arrange health
care services for employees and their dependents.
Subrogation - the assumption by a third party (as a second creditor) of another's legal right to
collect a debt or damages.
Utilization Management - the process established to assure that services rendered are medically
necessary and provided in the most cost-effective manner, consistent with the maintenance of high
quality standards of practice.
Page 76

Provider Manual

Transcription

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