Provider Procedural Manual

This manual provides physicians, hospitals, and other healthcare practitioners in The Health Plan network with an easy-to-use guide to our business and medical management practices. You can navigate to specific sections of the manual below.

FULL MANUAL

SECTION 1 | WELCOME

SECTION 2 | PHYSICIAN AVAILABILITY

SECTION 3 | MEMBER BENEFITS

SECTION 5 | MEDICAID

SECTION 6 | OFFICE COPAYS, MEDICAL COPAYS, COINSURANCE, DEDUCTIBLES

SECTION 7 | MEDICAL MANAGEMENT PROGRAM

SECTION 8 | QUALITY MANAGEMENT PROGRAM

SECTION 9 | BEHAVIORAL HEALTH

SECTION 10 | PHARMACY SERVICES

SECTION 11 | BILLING PROCEDURES

SECTION 12 | ELECTRONIC DATA INTERCHANGE

SECTION 13 | COORDINATION OF BENEFITS

  • Coordination of Benefits (COB)
    • Order of Benefit Determination Rules
    • Procedures Regarding COB
    • Medicare Crossover Notice
    • Medicare Primary
    • Commercial Credit Adjustment Example
    • Medicare Primary Payment Example
    • Helpful Hints
    • COB Denial Codes

SECTION 14 | PAYMENT VOUCHER

SECTION 15 | CREDENTIALING/RECREDENTIALING

SECTION 16 | PHONE DIRECTORY

SECTION 17 | FRAUD AND ABUSE