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
- Full 2018 Manual *Note - This is a large file (22.5 MB).
- Provider Quick Reference Guide
SECTION 1 | WELCOME
SECTION 2 | PHYSICIAN AVAILABILITY
- Physician Availability
- Primary Care Physician Guidelines
- Secondary Care Physician Guidelines
- Specialist Guidelines
- Physician Care of Self or Family
SECTION 3 | MEMBER BENEFITS
- Member Benefit Information
- Product Matrix
- Fully-Insured HMO Plans
- SecureCare HMO - Medicare Advantage Plan
- Appeals Overview
- Appointment of Representative Statement
- SecureChoice PPO - Medicare Advantage Plan
- Appeals Overview
- Appointment of Representative Statement
- D-SNP - Medicare Advantage Special Needs Plan
- Appeals Overview
- Appointment of Representative Statement
- Administrative Services Only (ASO) Self-Funded Employer Groups
- Mountain Health Trust | West Virginia Health Bridge (WV Medicaid Program)
- Fully-Insured Point-of-Service (POS) Plans
- Noncovered Service Guidelines
- Fully-Insured Preferred Provider Organization (PPO) Plans
- Prescription Drug Riders
- Vision Service Benefit
- THP Members' Rights and Responsibilities Statement
- SecureCare/SecureChoice Rights and Responsibilities Statement
- Anti-Discrimination Notice
SECTION 4 | MEDICARE
- SecureCare HMO Medicare Advantage Plan
- SecureChoice PPO Medicare Advantage Plan
- DSNP Program Medicare Special Needs Plan
- Coordination of Benefits Medicare Advantage Secondary Payer
- THP Insurance Company Medicare Supplemental Plans
- SecureCare/SecureChoice Rights and Responsibilities Statement
- Medicare Provider Rights and Responsibilities
- Medicare Noncovered Service Guidelines
- CMS Quality Measures
- Appointment of Representative Statement
- Notice of Medicare Noncoverage (NOMNC)
- Medicare Outpatient Observation Notice
- Medicare Appeals Overview
- Low Income Medicare Beneficiaries
SECTION 5 | MEDICAID
- Mountain Health Trust and West Virginia Health Bridge (WVHB) (WV Medicaid Programs)
- Mountain Health Trust ID Cards
- WV Health Bridge ID Cards
- Benefits Tables
- EPSDT
- Copays
- Payment to Out-of-Network
- Prescription Benefit
- Family Planning
- Local Health Departments
- Staffing
- Surgical Consent Forms
- Pregnancy and Newborn Enrollment
- WV Prenatal Risk Screening Form
- Women's Access to Health Care
- Smoking Cessation
- Diabetes
- Adult Dental
- Children's Dental
- Immunization Registry
- Appeals and Grievances
- MHT/WVHB Members' Rights and Responsibilities
- Provider Responsibilities
- Marketing Guidelines
- Miscellaneous Items
- Changes in Provider Fee Schedule
- WV Medicaid Provider Required Provisions
SECTION 6 | OFFICE COPAYS, MEDICAL COPAYS, COINSURANCE, DEDUCTIBLES
- Office Visit Copays, Medical Copays, Co-insurance, and Deductibles
- Preventive Guideline Sheet
- Quick Reference Guide of CPT Codes for Office Encounters
SECTION 7 | MEDICAL MANAGEMENT PROGRAM
- Introduction
- Pre-Authorization/Pre-Notification Requirements
- Medical Management Telephone Directory
- Nurse Information Line
- Admissions/Concurrent Review Process
- Pre-Authorization/Referral Management
- Requests for a Second Opinion
- Provider Analytics Program
- Standing Referrals
- Specialist Coordination of Health Care Services
- Review Criteria
- Interqual Review
- Chiropractic Care
- Care Navigation
- Complex Case Navigation
- Social Work Services
- Chronic Disease Navigation Programs
- Diabetes Program
- Chronic Cardiac Conditions Programs
- Chronic Obstructive Pulmonary Disease Program
- Perinatal Care Program
- Medical Department Staff and Committee Overview
- Annual Program Evaluation
- Forms, Tools, and Worksheets
SECTION 8 | QUALITY MANAGEMENT PROGRAM
- Introduction
- Quality of Clinical Care Indicators
- Customer Satisfaction
- Review Process for Clinical and Customer Service Quality Indicators
- HEDIS
- Clinical Practice Guidelines
- Continuity and Coordination of Care
- Standards for Access to Care and Service
- Advance Care Planning
- Member Health and Wellness Promotion
- Member Empowerment Projects
SECTION 9 | BEHAVIORAL HEALTH
- Introduction
- Pre-Authorization/Pre-Notification Requirements
- Review Criteria
- Interqual Review
- Review of Inpatient, Detoxification, Substance Abuse Rehab, Partial Hospitalization, Intensive Outpatient, Chemical Dependency, Intensive Outpatient, Eating Disorder and Observation
- Outpatient Pre-Authorization Referral Management
- Crisis Encounters
- Care Navigation
- Complex Case Navigation
- Social Work Services
- Chronic Disease Navigation - Depression Program
- Depression Disease Navigation Program
- Management Programs
- Annual Program Evaluation
- Behavioral Health Advisory Committee
- Access to Care
- Continuity and Coordination of Care
- Behavioral Health Services Forms
- Admission Review Information Form
- Authorization to Disclose Health Information to PCP
- Behavioral Health Fax Cover Sheet
- Concurrent Authorization for ABA
- Concurrent or Discharge Review Information Form
- Continuity of Care Consultation Sheet
- Crisis Encounters Report Form
- Initial Authorization for ABA
- Intensive Outpatient Partial Hospitalization Form
- Pre-authorization for Drug Screening Form
- Psychological Testing Pre-authorization Form
- Request for ACT Programming
- Request for CFT Programming
- Substance Abuse Admission Review
- Substance Abuse Concurrent or Discharge Review Information Form
- Treatment Continuation Request Form
- Request for Outpatient ECT/TMS
- Telehealth Services
- Follow-up Care After Behavioral Health Admissions
- Standards and Guidelines of Care
- Autism and Member Advocates
- Substance Use Disorder Care Navigation
SECTION 10 | PHARMACY SERVICES
- Pharmacy Services
- Introduction
- Obtaining a Prescription
- Formulary
- Prior Authorizations
- Prior Authorization Forms
SECTION 11 | BILLING PROCEDURES
- Billing Procedures
- Provider Reimbursement Voucher
- Never Events and Avoidable Hospital Conditions
- Electronic Billing - Documentation Submission
- Credit Vouchers Explained
- 30 Day Readmission Policy
- Fax Cover Sheet
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
- Payment Voucher Example
- Claim Numbers
- Age of Claim Determination
- Claims in Process
- Resubmission of Claims Denied for Documentation
- Process to Resubmit a Denied Claim
- Claim Resubmission Form
- Julian Calendars
SECTION 15 | CREDENTIALING/RECREDENTIALING
- Credentialing
- Recredentialing
- Practitioner's Credentialing/Recredentialing Rights
- Standards of Participation
- Initial Certification
- Practitioner's Rights
- Site Survey of Standards (Audit) Form
- Office Orientation Form
- Standards for Patient Records
- Medical Record Audit Form
- Medical Records and Confidentiality Statement
- Signature Log
- Telephone Messages
SECTION 16 | PHONE DIRECTORY
SECTION 17 | FRAUD AND ABUSE