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

• Introduction
• The Health Plan Mission Statement
• About The Health Plan
• Network Services Contacts

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
• Coordination of Benefits Medicare Advantage Secondary Payer
• THP Insurance Company Medicare Supplemental Plans
• 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
  • Provider Reimbursement Voucher
• THP Members' Rights and Responsibilities Statement
• SecureCare/SecureChoice Rights and Responsibilities Statement
  • Low Income Medicare Beneficiaries
• Anti-Discrimination Notice

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
• Podiatric Services
• 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
  • Medical Pre-Authorization Request Form
  • Molecular Pathology Request Form
  • PET/CT Review Tool
  • Pre-certification Fax Form for Durable Medical Equipment

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
• Clinics/Health Fairs/Wellness Programs
• 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
• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
• 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

• 30 Day Readmission Policy
• Billing Procedures
  • Never Events and Avoidable Hospital Conditions
  • Electronic Billing - Documentation Submission
  • Credit Vouchers Explained
• Fax Cover Sheet

SECTION 12 | ELECTRONIC DATA INTERCHANGE

• Introduction

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 Procedure Review
• Office Orientation Form
• Standards for Patient Records
• Medical Record Audit Form
• Medical Records and Confidentiality Statement
• Signature Log
  • Signature Log Form
• Telephone Messages
  • Telephone Message Form

SECTION 16 | PHONE DIRECTORY

• Phone List

SECTION 17 | FRAUD AND ABUSE

• Fraud, Waste and Abuse Regulations and Guidelines
• Compliance Thorugh Training
• HIPAA Privacy and Security
• Fraud, Waste and Abuse Poster