Univera Community Health Participating Provider Manual

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Univera Community Health Participating Provider Manual 1.0 Introduction 1.1 About the Manual The Univera Community Health Participating Provider Manual is a reference and source document for physicians and other providers who participate with Univera Community Health (UCH). The manual clarifies and supplements various provisions of a provider s participation agreement. In the event of a conflict between the provisions of this manual and a specific provider s agreement with Univera Community Health, the agreement controls. The Univera Community Health Participating Provider Manual contains relevant program policies and procedures with accompanying explanations and exhibits. Since Univera Healthcare is the manager for Univera Community Health, many of the processes the manual describes will refer to Univera Healthcare procedures, departments, and staff. UCH encourages providers to give this document to staff who perform the administrative, billing, and quality assurance functions in their organizations. It is essential that they understand the UCH programs and the procedures UCH has established for effective implementation and operation. UCH updates this manual as needed. Representatives of the Provider Relations Department are also available to provide on-site training at provider offices. For information, call Provider Service. (See the Contact List in Section 2 of this manual for addresses and telephone numbers.) 1.2 About Univera Community Health 1.2.1 Univera Community Health Description Univera Community Health is a not-for-profit company that provides health insurance to the uninsured, is regulated by New York State and is a partnership of the Erie County Medical Center Healthcare Network, Kaleida Health and Univera Healthcare. For more information about Univera Community Health, visit the UCH Web site at www.univeracommunityhealth.org. August 2006 1 1

1.0 Introduction Univera Community Health Univera Community Health s Mission Univera Community Health s mission is to serve the needs of the underserved and uninsured in Western New York by: Providing affordable health insurance options Increasing access to health care Improving the quality of care These services are provided through the cooperative efforts of Erie County Medical Center, Kaleida Health and Univera Healthcare. Program Manager Univera Healthcare is the manager for Univera Community Health. Most processes for handling eligibility verifications, referrals, customer service, and claims inquiries are the same as those for other programs of, or administered by, Univera Healthcare. 1.2.2 Univera Community Health s Responsibilities In dealing with participating providers, Univera Community Health has responsibilities set forth in individual provider contracts. Below are some of Univera Community Health s responsibilities: Determining enrollment status and eligibility for covered services. Arranging for utilization management decision-making that: - Is based only on appropriateness of care and service - Does not specifically reward participating physicians, providers, or employees for issuing denials - Does not offer incentives to encourage inappropriate underutilization. Providing and administering grievance and appeal processes for members and providers, and offering information on how to access the process. Prompt payment of clean and uncontested claims for covered services to eligible members in accordance with the time frames required by law and provider agreements. Compensating UCH physicians and other providers directly, consistent with the reimbursement methodologies described in participation agreements. Implementing policies and procedures to maintain quality functioning and improvement of UCH processes. Contracting with primary care physicians and specialists for 24-hour telephone coverage to advise members of procedures for emergency and urgent health care services. 1 2 August 2006

Participating Provider Manual 1.0 Introduction 1.2.3 Code of Conduct In the management of Univera Community Health, Univera Healthcare follows the Code of Business Conduct established by its parent company for itself and its wholly-owned subsidiaries (collectively the "Corporation"). The Code was prepared with the advice and assistance of legal counsel and has been approved by the Board of Directors. The Code is a formal statement of the corporation s commitment to the standards and rules of ethical business conduct. It applies to employees, directors, officers, contractors and others with whom UCH does business. In addition to being committed to upholding the rules set forth in the Code, UCH is committed to conducting all activities in accordance with applicable laws and regulations. Copies of the Code of Business Conduct are available upon request from Provider Service. (See the Contact List in Section 2 for addresses and telephone numbers.) 1.2.4 Prohibition on Restricting Provider Discussion with Members As mandated by New York State Public Health Law, UCH will not by contract, written policy or written procedure prohibit or restrict any provider from: Disclosing to any subscriber, enrollee, patient, designated representative or, where appropriate, prospective enrollee, any information that such practitioner/provider deems appropriate regarding a condition or a course of treatment with an enrollee including the availability of other therapies, consultations, or tests, or the provisions, terms, or requirements of UCH products as they relate to the enrollee, where applicable. Filing a complaint or making a report or comment to an appropriate governmental body regarding UCH policies or practices when the practitioner/provider believes that the policies or practices have a negative impact on the quality of, or access to, patient care. Advocating to UCH on behalf of the enrollee for approval or coverage of a particular treatment or for the provision of health care services. In addition, no contract or agreement between UCH and a health care provider, or between the delivery system network and a health care provider, shall contain any clause purporting to transfer to the health care provider, other than a medical group or one of the three partners of UCH, by indemnification or otherwise, any liability relating to activities, actions or omissions of UCH as opposed to those of the health care provider. 1.3 Univera Community Health s Programs UCH provides health benefits coverage via one of three government programs. These are PlusMed (the UCH Medicaid managed care program), Family Health Plus and Child Health Plus. Covered benefits vary by program and are primarily determined by New York State. In addition to every provision of this Participating Provider Manual, the following provisions apply with regard to the government programs Child Health Plus, Family Health Plus and Medicaid managed care. August 2006 1 3

1.0 Introduction Univera Community Health 1.3.1 Applying for CHP, FHP or PlusMed Prospective members may contact Univera Community Health for information about enrollment in any of these programs. Enrollment in PlusMed or Family Health Plus occurs through a facilitated enroller. Univera Community Health staff can schedule an appointment with an enroller. Applicants for each of the programs must meet certain income guidelines. Income guidelines vary by program and may change from year to year. 1.3.2 Restrictions Members of these HMO government programs must follow all the rules and guidelines of a typical HMO. This includes selecting a primary care physician (PCP) who coordinates all their care, including obtaining referrals to specialists and obtaining prior authorization for specified services. Information regarding referral and prior authorization requirements is included in Section 4, Benefits Management. For services to be covered, members must use providers who participate in the Univera Community Health provider network, or by approval to an out-of-network provider. 1.3.3 How to Select or Change PCP Members should select a PCP at the time of enrollment. The UCH Web site includes a Find a Doctor option. In addition, printed provider directories are available. Members may change their PCPs by: Calling the customer service numbers on their ID cards Faxing a PCP Selection Form to UCH. For the convenience of providers, there is a copy of the form at the end of Section 2 of this manual. Providers may have the member complete it in the office and fax it to UCH at the fax number listed on the form. (The fax number is also included in the Contact List in Section 2 of this manual.) 1.3.4 PlusMed (Medicaid Managed Care) PlusMed is an HMO health benefit program for residents of Allegany, Cattaraugus, Chautauqua, Erie and Niagara counties who are eligible for Medicaid. The program maintains the benefit structure of Medicaid, but requires members to follow all of the HMO rules and guidelines. Some services, such as prescription drugs, are not part of the benefit package but rather are covered under the Medicaid fee-for-service program. There is no cost to PlusMed members. There are no premiums, deductibles, copays or coinsurance. (Limited copays apply to the prescription drug benefit that is covered under Medicaid fee-for-service.) A member s eligibility in PlusMed is always month-to-month, from the first of the month through the last day of the month. Members must recertify their eligibility annually. 1 4 August 2006

Participating Provider Manual 1.0 Introduction 1.3.5 Family Health Plus New York State's Family Health Plus program is for adults between the ages of 19 and 64 who have no health insurance coverage and are not eligible for Medicaid. Univera Community Health offers Family Health Plus insurance coverage in Allegany, Cattaraugus, Chautauqua, Erie and Niagara counties. There are no premiums or deductibles for members who participate in Family Health Plus. However, there are copayments for selected services. These copayments and selected services are determined by New York State and may be subject to change. Eligibility is always the first day of the month following enrollment. Members must recertify their eligibility annually. 1.3.6 Child Health Plus New York s Child Health Plus program is designed to cover children and adolescents (under age 19) whose families have no comparable insurance coverage, and who are ineligible for Medicaid. To enroll in Child Health Plus with Univera Community Health, an individual must be a resident of Allegany, Cattaraugus, Chautauqua, Erie or Niagara County. There is a monthly premium for the program, but the amount of it is based on income and family size. There are no deductibles, copayments or coinsurance. Parents or guardians of prospective enrollees may contact UCH to request an application, or they may download one from the UCH Web site by selecting Child Health Plus and then How do I enroll? http://www.univeracommunityhealth.org/ Eligibility is always the first day of the month following enrollment. Members must recertify their eligibility annually. 1.4 Commitment to Members 1.4.1 Customer Service Providers may tell members who have any questions or concerns about their coverage to contact Customer Service. (The telephone number for Customer Service is listed on the member s ID card.) Providers may also contact UCH with questions and concerns. (See Section 2 of this manual for UCH requirements for confirming an established relationship with the member.) Univera Community Health also encourages members of PlusMed, Child Health Plus and Family Health Plus to contact Customer Service if they are dissatisfied with any aspect of their care or coverage. If a complaint cannot be resolved immediately on the telephone, a Customer Service representative will assist the member, his/her designee, or his/her provider in initiating an appeal or grievance. For information about the grievance and appeals process, see Section 4 of this manual. August 2006 1 5

1.0 Introduction Univera Community Health 1.4.2 Privacy and Confidentiality Univera Community Health and Univera Healthcare have established procedures for compliance with all federal and state statutes, regulations and accreditation standards governing the use, protection and dissemination of medical records and protected health information, including medical records, claims, benefits, surveys and administrative data. Both organizations utilize protected health information and data to assist in the delivery of health care, to compensate providers, and to measure and improve care. UCH recognizes that an individual who submits, or authorizes his or her health care provider to submit, medical and dental claims information for processing and payment has an expectation that such information, to the extent it identifies the individual, will not be disclosed in any manner that violates federal or state law or regulation. UCH affords members the opportunity to authorize or deny the release of identifiable medical information. By law, a member must provide a special authorization for UCH to release protected health information, including mental health, alcohol and substance abuse, abortion, sexually transmitted diseases, genetic testing and HIV/AIDS-related information. Members may authorize the release of some or all of their protected health information by completing an authorization form. For those members who lack the ability to give authorization, UCH will obtain authorization from a legally designated, qualified person, such as the member s legal guardian or person with the member s power of attorney. A copy of the UCH policy on protected health information is available upon request from Provider Service, as is the UCH overall privacy policy. 1.4.3 Member Rights and Responsibilities Members of Univera Community Health programs have certain rights and responsibilities, as outlined below. Many of them involve responsibilities, as well as rights, of the practitioners providing service. A member has the right to: Receive all the benefits to which he/she is entitled under his/her contract. Receive quality health care through his/her providers in a timely manner and medically appropriate setting. Receive considerate, courteous and respectful care. Be treated with respect and recognition of his/her dignity and right to privacy. Information about services, staff, hours of operation and his/her benefits, including access to routine services as well as after-hours and emergency services and members rights and responsibilities. Participate in decision-making with his/her physician about his/her health care. Obtain complete, current information concerning a diagnosis, treatment and prognosis from a provider in terms that he/she can reasonably be expected to understand. 1 6 August 2006

Participating Provider Manual 1.0 Introduction Refuse treatment as allowed by law, and be informed by his/her physician of the medical consequences. Refuse to participate in research. Confidentiality of medical records and information, with the authority to approve or refuse UCH's disclosure of such information, to the extent protected by law. Receive all information needed to give informed consent for any procedure or treatment. Access to his/her medical records as permitted by New York State law. Express concerns and complaints about the care and services provided by physicians and other providers, and have UCH investigate and respond to these concerns and complaints. Candid discussion of appropriate or medically necessary treatment options for his/her condition, regardless of cost or benefit coverage. Care and treatment without regard to age, race, color, sex or sexual orientation, religion, marital status, national origin, economic status or source of payment. Voice complaints and recommend changes in benefits and services to staff, administration and/or the New York State Insurance Department or Department of Health, without fear of reprisal. Formulate advance care directives regarding his/her care. To obtain a Health Care Proxy form, contact UCH. Contact the UCH service department to obtain the names, qualifications and titles of providers who are responsible for his/her care. All information about his/her health benefit program, its services and its providers and procedures. Make recommendations regarding the UCH member rights and responsibilities. A member has the responsibility to: Be an active partner in the effort to promote and restore health by: - openly sharing information about his/her symptoms and health history with his/her physician; - listening; - asking questions; - becoming informed about his/her diagnosis, recommended treatment and anticipated or possible outcomes; - following the plans of care he/she has agreed to (such as taking medicine and making and keeping appointments); - returning for further care, if any problem fails to improve; and - accepting responsibility for the outcomes of his/her decisions. Participate in understanding his/her health problems and developing mutually agreed-upon treatment goals. Have all care provided, arranged or authorized by his/her primary care physician (PCP). Inform his/her PCP if there are changes in his/her health status. Obtain services authorized by his/her PCP. August 2006 1 7

1.0 Introduction Univera Community Health Share with his/her PCP any concerns about the medical care or services that he/she receives. Permit UCH to review his/her medical records in order to comply with federal, state and local government regulations regarding quality assurance, and to verify the nature of services provided. Respect time set aside for his/her appointments with providers, and give as much notice as possible when an appointment must be rescheduled or cancelled. Understand that emergencies arise for his/her providers and that his/her appointments may be unavoidably delayed as a result. Respect staff and providers. Follow the instructions and guidelines given by his/her providers. Show his/her ID card and pay his/her visit fees to the provider at the time the service is rendered. Become informed about UCH policies and procedures, as well as the office policies and procedures of his/her providers, so that he/she can make the best use of the services that are available under his/her contract. Abide by the conditions set forth in his/her contract. 1.4.4 Member Surveys UCH conducts member satisfaction surveys at least annually. The surveys assess member satisfaction with the care and services members receive. The surveys are used to identify opportunities for improvement. They may also be used to measure the success of any actions that are taken to improve the care and services members receive. 1 8 August 2006

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