forms â€” all providers

Section VIII 1

SECTION VIII — Forms and Publications Forms — All Providers

Traditional

To locate an Ohio network doctor or hospital, visit MedMutual.com or call 800/232-7400.

To locate a network doctor or hospital outside of Ohio:

888/225-8932

800/672-2140

To order a network doctor or hospitaldirectory call 888/241-2583.

Electronic Claims Emdeon [WebMD]Payer ID: 29076

PROVIDERSMEMBERS

Claim Submission:Drug Information: 800/417-1961

Medical MutualP.O. Box 6018Cleveland, Ohio 44101-1018

Visit at MedMutual.com.Precertification: In Ohio, precertification must be obtained for thefollowing inpatient services: - Medical / Surgical: 800/338-4114 - Behavioral Health: 800/258-3186Outside Ohio, members must obtain precertification prior toinpatient services.

Provider Service: Visit or call 800/362-1279.

Medical MuTual ProducT id cards

Section VIII


2

superMed classic



888/225-8932

800/672-2140



PROVIDERSMEMBERS





Medical MuTual ProducT id cards continued

Section VIII


3


superMed Plus


PROVIDERSMEMBERS





Section VIII


4

superMed select


Section VIII


5

superMed Professional



888/225-8932

800/672-2140



PROVIDERSMEMBERS






Section VIII


6

superMed one



888/225-8932

800/889-0277



PROVIDERS MEMBERSClaim Submission: Medical Mutual

P.O. Box 6018Cleveland, Ohio 44101-1018

Visit at MedMutual.com.

Precertification: In Ohio, precertification must be obtained for thefollowing inpatient services: - Medical / Surgical: 800/258-2873 - Behavioral Health: 800/258-3186Outside Ohio, members must obtain precertification prior toinpatient services.



Section VIII


7

superMed Preferred


Section VIII


8


superMed HMo

HMo Health ohio

Section VIII


9

consumers life Plan – Georgia

consumers life – indiana

consuMers life Plan ProducT id cards

WWW.CONSUMERSLIFE.COM

800/889-0277

800/982-3116 800/511-4442

800/982-3116

800/982-3116

WWW.CONSUMERSLIFE.COM

Section VIII


10

carolina care Plan

WWW.CAROLINACAREPLAN.COM

Electronic Claims Payer ID: 57105

carolina care Plan ProducT id cards

Submit pharmacy claims to: Express Scripts, Inc. P.O. Box 66583 St. Louis, MO 63166 www.Express-Scripts.com Customer Srv: 800/879-9080

Rx Bin #: 003858Rx PCN: A4Rx Grp: BWEAPharmacist Use Only: 800/824-0898

Rx Bin #: 003858

800/511-4442

800/232-2821

800/530-0621

Section VIII


11

culTural coMPeTence of neTworks and HealTH Plan inforMaTion forM

3. ___________________________________

Other needs/preferences that arise out of cultural, ethnic or social beliefs that you are comfortable addressing with patients:

______________________________________________________________________________________________________________________________________________________________________________________________

In creating and maintaining the Company’s (Medical Mutual) network delivery system of practitioners and providers and related health plan information, the Company will consider and provide, to the extent possible, culturally sensitive services to help ensure access of both clinical and non-clinical services to Covered Persons. In counties or regions where there is a large population who speak a primary language other than English, the Company will seek to provide health plan information in that language and strive to have health plan information available in alternative forms for the visually and hearing impaired. For other special and cultural needs and preferences of which the Company is aware, we will attempt to provide both clinical and non-clinical services to Covered Persons on an as needed basis.

The Company will attempt to link members with practitioners who can address their special cultural needs and preferences by developing and maintaining a network appropriate to the population. To achieve this goal, practitioners who speak a language other than English, or who are able to meet other special needs and preferences of a group, are asked to notify the Company. This information will be placed into a database and be available upon a Covered Person’s request. Please submit the information on the Language and Other Cultural Needs Information Form found under Tools and Resources in the Provider section of our Web sites located at MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com, or copy this page and mail or fax the completed form to:

Medical Mutual of ohio Mail Zone: 01-5B-3983 2060 east 9th street cleveland, oH 44115-1355

or

fax to: 216/687-6558

Name:

_____________________________________________________________

Social Security Number: __________________________

Languages spoken fluently, other than English:

1. ___________________________________

2. ___________________________________

http://www.MedMutual.com

http://www.ConsumersLife.com

http://www.CarolinaCarePlan.com

Section VIII


12

saMPle cMs-1500 claiM forM (Providers must use the standard red ink form)

1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

front

Section VIII


13

saMPle cMs-1500 claiM forM continued

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BYAPPLICABLE PROGRAMS.

NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information maybe guilty of a criminal act punishable under law and may be subject to civil penalties.

REFERS TO GOVERNMENT PROGRAMS ONLYMEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to processthe claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signatureauthorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group healthinsurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned orCHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge,and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the chargedetermination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program butmakes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor should be provided in thoseitems captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.

BLACK LUNG AND FECA CLAIMSThe provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure anddiagnosis coding systems.

SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnishedincident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUSregulations.

For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervisionby his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’soffices, and 4) the services of nonphysicians must be included on the physician’s bills.

For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employeeof the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lung claims,I further certify that the services performed were for a Black Lung-related disorder.

No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32).

NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subjectto fine and imprisonment under applicable Federal laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION(PRIVACY ACT STATEMENT)

We are authorized by CMS, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lungprograms. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.

The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the servicesand supplies you received are covered by these programs and to insure that proper payment is made.

The information may also be given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federalagencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessaryto administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosuresare made through routine uses for information contained in systems of records.

FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished.

FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, “Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28,1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished.

FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishmentof eligibility and determination that the services/supplies received are authorized by law.

ROUTINE USE(S): Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/orthe Dept. of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation ofthe Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupmentclaims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be madeto other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claimsadjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil andcriminal litigation related to the operation of CHAMPUS.

DISCLOSURES: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussedbelow, there are no penalties under these programs for refusing to supply information. However, failure to furnish information regarding the medical services renderedor the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delaypayment of the claim. Failure to provide medical information under FECA could be deemed an obstruction.

It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801-3812 provide penalties for withholding this information.

You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches.

MEDICAID PAYMENTS (PROVIDER CERTIFICATION)I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnishinformation regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.

I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exceptionof authorized deductible, coinsurance, co-payment or similar cost-sharing charge.

SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and werepersonally furnished by me or my employee under my personal direction.

NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and Statefunds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMBcontrol number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including thetime to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning theaccuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS.

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Section VIII


14

saMPle uB-04 claiM forM (Providers must use the standard red ink form)

front1 2 4 TYPE

OF BILL

FROM THROUGH5 FED. TAX NO.

a

b

c

d

DX

ECI

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

A

B

C

A B C D E F G HI J K L M N O P Q

a b c a b c

a

b c d

ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURE NPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

7

10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 2522 26 2823 27

CODE FROM

DATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.INFO

BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 36 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 67 68

69 ADMIT 70 PATIENT 72 73

74 75 76 ATTENDING

80 REMARKS

OTHER PROCEDURE

a

77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

3a PAT.CNTL #

24

b. MED.REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

e

a8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

6 STATEMENT COVERS PERIOD

9 PATIENT ADDRESS

17 STAT STATE

DX REASON DX 71 PPS

CODE

QUAL

LAST

LAST

National UniformBilling CommitteeNUBC

™

OCCURRENCE

QUAL

QUAL

QUAL

CODE DATE

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

a

b

a

b

Section VIII


15

saMPle uB-04 claiM forM continued

Submission of this claim constitutes certification that the billinginformation as shown on the face hereof is true, accurate and complete.That the submitter did not knowingly or recklessly disregard ormisrepresent or conceal material facts. The following certifications orverifications apply where pertinent to this Bill:

1. If third party benefits are indicated, the appropriate assignments bythe insured /beneficiary and signature of the patient or parent or alegal guardian covering authorization to release information are on file.Determinations as to the release of medical and financial informationshould be guided by the patient or the patient’s legal representative.

2. If patient occupied a private room or required private nursing formedical necessity, any required certifications are on file.

3. Physician’s certifications and re-certifications, if required by contractor Federal regulations, are on file.

4. For Religious Non-Medical facilities, verifications and if necessary re-certifications of the patient’s need for services are on file.

5. Signature of patient or his representative on certifications,authorization to release information, and payment request, asrequired by Federal Law and Regulations (42 USC 1935f, 42 CFR424.36, 10 USC 1071 through 1086, 32 CFR 199) and any otherapplicable contract regulations, is on file.

6. The provider of care submitter acknowledges that the bill is inconformance with the Civil Rights Act of 1964 as amended. Recordsadequately describing services will be maintained and necessaryinformation will be furnished to such governmental agencies asrequired by applicable law.

7. For Medicare Purposes: If the patient has indicated that other healthinsurance or a state medical assistance agency will pay part ofhis/her medical expenses and he/she wants information abouthis/her claim released to them upon request, necessary authorizationis on file. The patient’s signature on the provider’s request to billMedicare medical and non-medical information, includingemployment status, and whether the person has employer grouphealth insurance which is responsible to pay for the services forwhich this Medicare claim is made.

8. For Medicaid purposes: The submitter understands that becausepayment and satisfaction of this claim will be from Federal and Statefunds, any false statements, documents, or concealment of amaterial fact are subject to prosecution under applicable Federal orState Laws.

9. For TRICARE Purposes:

(a) The information on the face of this claim is true, accurate andcomplete to the best of the submitter’s knowledge and belief, andservices were medically necessary and appropriate for the healthof the patient;

(b) The patient has represented that by a reported residential addressoutside a military medical treatment facility catchment area he orshe does not live within the catchment area of a U.S. militarymedical treatment facility, or if the patient resides within acatchment area of such a facility, a copy of Non-AvailabilityStatement (DD Form 1251) is on file, or the physician has certifiedto a medical emergency in any instance where a copy of a Non-Availability Statement is not on file;

(c) The patient or the patient’s parent or guardian has respondeddirectly to the provider’s request to identify all health insurancecoverage, and that all such coverage is identified on the face ofthe claim except that coverage which is exclusively supplementalpayments to TRICARE-determined benefits;

(d) The amount billed to TRICARE has been billed after all suchcoverage have been billed and paid excluding Medicaid, and theamount billed to TRICARE is that remaining claimed againstTRICARE benefits;

(e) The beneficiary’s cost share has not been waived by consent orfailure to exercise generally accepted billing and collection efforts;and,

(f) Any hospital-based physician under contract, the cost of whoseservices are allocated in the charges included in this bill, is not anemployee or member of the Uniformed Services. For purposes ofthis certification, an employee of the Uniformed Services is anemployee, appointed in civil service (refer to 5 USC 2105),including part-time or intermittent employees, but excludingcontract surgeons or other personal service contracts. Similarly,member of the Uniformed Services does not apply to reservemembers of the Uniformed Services not on active duty.

(g) Based on 42 United States Code 1395cc(a)(1)(j) all providersparticipating in Medicare must also participate in TRICARE forinpatient hospital services provided pursuant to admissions tohospitals occurring on or after January 1, 1987; and

(h) If TRICARE benefits are to be paid in a participating status, thesubmitter of this claim agrees to submit this claim to theappropriate TRICARE claims processor. The provider of caresubmitter also agrees to accept the TRICARE determinedreasonable charge as the total charge for the medical services orsupplies listed on the claim form. The provider of care will acceptthe TRICARE-determined reasonable charge even if it is lessthan the billed amount, and also agrees to accept the amountpaid by TRICARE combined with the cost-share amount anddeductible amount, if any, paid by or on behalf of the patient asfull payment for the listed medical services or supplies. Theprovider of care submitter will not attempt to collect from thepatient (or his or her parent or guardian) amounts over theTRICARE determined reasonable charge. TRICARE will makeany benefits payable directly to the provider of care, if theprovider of care is a participating provider.

UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATIONOF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FORCIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDEFINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).

SEE http: / /www.nubc.org/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS





























































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Section VIII


16

Providing Necessary Information

Is Prior Authorization Necessary?

Some managed care products require

an authorization prior to rendering the

service. If you are unsure whether prior

authorization is necessary, please check

with our Care Management department at

800/258-2873.

Before the consultation takes place, please

be sure the consulting physician has all

necessary clinical information:

1. Reason for the consultation

2. Pertinent clinical data

3. Intended scope of the consultant’s role• Should the consultant provide follow-up care

or “consultation only?”

4. Desired method(s) of communicationback to you

• Do you want a preliminary report or a finalwritten report only?

• Did you indicate the method of communicationyou prefer? (e.g., fax, phone, mail)

Communication Form

Need a form for sending along necessary

information? We can provide you with our

Patient Summary Physician Communication

Form (Z5417) to complete and send to the

consultant. Obtain a copy of the form in

one of three ways:

� InternetVisit MedMutual.com, ConsumersLife.comor CarolinaCarePlan.com and then underthe Providers tab, click Forms and thenClinical Supply Form.

� PhoneCall 800/586-4523.

� FaxFax a request to 216/687-7787.

Responsibilities of the Referring ProviderWhen Requesting a Consultation

Date:

Patient SummaryPhysician Communication Form

Name: Name:

Address: Address:

Telephone: Telephone:

Fax: Fax:

Referring Physician Information Consulting Physician Information

Diagnosis

Clinical findings and diagnostic tests

Current treatment plan, includingmedications

Allergies

Other

Reason for Consultation

Patient Name: Date of Birth:

Patient Information

Preferred Method of Communication

Fax Mail Phone

Medical Mutual of Ohio 2060 East Ninth Street Cleveland, Ohio 44115-1355 Visit MedMutual.com.

X7059 Continuity of Care R11_07 11/8/07 1:48 PM Page 2

conTinuiTy of care forMsfront

Section VIII


17

conTinuiTy of care forMs continued

Back

� Keeping Your Preventive Care Flowsheet Current

Record when the preventive service is

rendered (e.g., immunizations, preventive

testing, health screenings and anticipatory

guidance counseling).

� Medication List

Include over-the-counter medications

and those prescribed by other physicians.

� Laboratory and Diagnostic Test Results

Document that results were reviewed

(initial and date each page) and record

subsequent actions, as appropriate.

Track pending test to ensure that all

reports are received.

Responsibilities of the Consulting PhysicianWhen Reporting Results to the Referring Provider

A written summary of the consultation and

findings should be sent to the referring

provider within 14 days following the

initial visit.

Note: Any preliminary report should stillbe followed by a final report.

� Allergy List

Drug allergy list should be updated

regularly.

� Additional Medical Record Documentation Information

Access more medical record documentation

information on our Web sites, by visiting

MedMutual.com, ConsumersLife.com

and CarolinaCarePlan.com, under the

Providers tab, then click Resources and

Clinical Credentialing.

We maintain strict privacy and confidentiality

policies that state our commitment to treating

members in a manner that respects their rights

and protects the confidentiality of personal health

information and records.

Medical Record Keeping

A Key Component of Quality Care

X7059 Continuity of Care R11_07 11/8/07 1:48 PM Page 3

Section VIII


18

Medical Record ManagementMedical Record Keeping is a Key Component of Quality Care

Use Preventive Care Flowsheet and Keep it CurrentRecord when the care was rendered (e.g., vaccines, screenings includingdepression, anticipatory guidance counseling)

MedicationCurrent medication list, including over-the counter and prescribed medicationsby other physicians

Laboratory and Diagnostic Test ResultsOutpatient lab and diagnostic testing results ordered (e.g., via hospital orfree-standing facility) are received and reviewed in a timely manner

The ordering physician should document the date lab and diagnostic tests werereviewed (i.e. initial each page) and record subsequent actions, as needed

Utilize a system to track pending tests and be sure to initial and date allreceived reports

Medical Mutual maintains strict privacy and confidentiality policies that state our commit-ment to treating members in a manner that respects their rights and protects the confidentiality of personal health information and records.

Medical record ManageMenT

Section VIII


19

Patient SummaryPhysician Communication Form

Diagnosis


Current treatment plan, includingmedications

Allergies

Other

Reason for Consultation


Patient Information

Preferred Method of Communication

Fax Mail Phone

Medical Mutual of Ohio 2060 East Ninth Street Cleveland, Ohio 44115-1355 Visit MedMutual.com.

Date:

Referring Physician Information Consulting Physician Information

Name: Name:

Address: Address:

Telephone: Telephone:

Fax: Fax:

Z5417 R11/07

PaTienT suMMary PHysician coMMunicaTion forMfront

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20

Patient SummaryBehavioral Health Communication Form

Presenting Problem


Clinical Impression

Treatment and follow-uprecommendations

Consultation Findings


Patient Information

Date:

Referring Physician Consulting Physician

Name: _______________________________________________

Address: _____________________________________________

_____________________________________________________

Phone:_____________________ Fax: _____________________

Name: _______________________________________________

Address: _____________________________________________

_____________________________________________________

Phone:_____________________ Fax: _____________________

Z5443 R9/08

I, _____________________, hereby expressly authorize the release and disclosure of all medical and counselingrecords, including but not limited to the types of information referenced above, to Dr. ______________________,for the purpose of coordinating my healthcare. I understand that my records are confidential and cannot bedisclosed without my written consent unless otherwise provided for in state or federal regulations.

___________________________________ _______________Patient Signature Date

___________________________________ ___________________________________ _________________Legal Guardian Signature Print Name of Legal Guardian Date

*This consent is valid for one year from the date of signature unless revoked in writing by the patient or legal guardian.

Patient Consent to Disclose Medical Information

PaTienT suMMary BeHavioral HealTH coMMunicaTion forMfront

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21

Adult Patient Care Summary Sheet

Patient Name: Address:Home Telephone: DOB:Sex: Marital Status: Employer: Work Telephone: EmergencyContact:

EmergencyTelephone:

Allergies: Pharmacy:

PharmacyTelephone:

Past Medical History/Surgery Family Medical History

Date Problem List Date Medications (Includes OTC and Herbal Remedies)

12/21/07

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22

Patient Name: DOB:

Immunization Record Date:Td booster Hepatitis B vaccine Rubella vaccine Influenza vaccine Pneumococcal vaccine

Preventive Screenings Date: Blood pressure Cholesterol Rectal exams Stool for occult blood Sigmoidoscopy/ColonoscopyBreast exam Mammograms Pap smear Testicular exam PSA Glaucoma Vision Hearing

Habits Query Yes No Advance Directives Yes No Smoking Inquiry Alcohol use Education Illicit drug use Living will on file

Education Date Ed. Materials Provided Date Nutrition Nutrition Exercise Exercise Dental health Dental health STDí s/HIV STDí s/HIV Smoking Smoking Alcohol Alcohol Drug abuse Drug abuse Injury prevention Injury prevention Breast/ testes self exam Breast/ testes self exam Birth control Birth control Osteoporosis Osteoporosis Immunizations Immunizations

12/21/07

Adult Patient Care Summary Sheet

adulT PaTienT care suMMary sHeeT continued

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Section VIII


23

Pediatric Patient Care Summary Sheet

Patient Name: Address: Home Telephone: DOB:Sex: Marital Status: Parent/Guardian: Parent/Guardian

Telephone: Emergency Contact: Emergency Telephone:

Allergies: Pharmacy:

Pharmacy Telephone:

Past Medical History/Surgery Prenatal Care/Birth History

Family Medical History

Date Problem List Date Medications (includes OTC and Herbal Remedies)

12/21/07

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24

Pediatric Patient Care Summary Sheet Patient Name: DOB:

Immunization Record Date DTaP or DPT IPV or OPV MMR Hib VZV Hepatitis B Td Pneumococcal vaccine Meningitis vaccine

Preventive Screenings Date Blood pressure Mantoux testing Hemoglobin/Hematocrit Blood lead screening Sickle cell screening Hearing history/inquiry Hearing testing Eye screening Pap smear Testicular exam Chlamydia screening Gonorrhea screening

Habits Query Yes No Environment Yes No Smoking Passive smoking Alcohol use Pets in home Illicit drug use Day care/babysitter

Education Date Ed. Materials Provided Date Nutrition Nutrition Exercise Exercise Development/behavior Development/behavior Dental health Dental health STDí s/HIV STDí s/HIV Smoking Smoking Alcohol Alcohol Drug abuse Drug abuse Injury prevention Injury prevention Breast/ testes self exam Breast/ testes self exam Birth control Birth control Immunizations Immunizations UV exposure UV exposure Seat belts Seat belts

12/21/07

PediaTric PaTienT care suMMary sHeeT continued

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25

DEMOGRAPHICS ALLERGIES:

Client Name: ____________________________________ Date: Date of Birth: ______/______/______ Age: ____ Gender: ____ Grade: School: __________ Address: __________________________________________________________________________ Phone: ___________________________ Responsible Party: Occupation: _______________________ Employer: ______________________________________ Emergency Contact: ______________________________________ Phone: ___________________

Insurance: Policy Number: Group: Phone: ___________________ Primary Physician: Phone: ___________________

Chief Complaint:

Medical History:

Medications: (Prescription/over the counter/herbal supplements):

________________________________________________________________________________ Current Medications:

Previous Treatment Psychiatric:

________________________________________________________________________________ Alcohol/Drug:

Family History Medical:

_________________________________________________________________________________ Mental Health:

Social History Single:_____ Married:_____ Divorced:_____ Widowed:_____ Pertinent Factors:______________

Legal History

12/21/07

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26

Substance Assessment History of Use: Current Use: Alcohol _____________________ Alcohol ___________________ Drug _______________________ Drug ______________________ Tobacco ____________________ Tobacco ____________________

Mental Status Exam: Dress: unusual unclean unkempt normal other _____________________ Hygiene: poor fair normal other_______________________________ Orientation: person place time Memory: recent (impaired/intact) remote (impaired/intact)

Sensorium: Vision: intact impaired corrected Hearing: intact impaired corrected

Mood: depressed blunted manic angry anxious appropriate inappropriate

Perception: Hallucinations: visual auditory none other __________________________________

Thought Processes: logical loose tangential rigid flight of ideas scattered other delusional (type) obsessional phobic ambivalent hopeless narcissistic persecutory other ________________________

Insight: poor fair good Judgement: poor fair good Motor Behavior: slowed hyperactive normal other ____________________________ Speech: quiet pressured affected normal other _____________________

Risk Assessment:Suicidality: minimal____ low____ moderate____ high____ plan____ prior attempt____________________________________________________________________________________

Homicidality: minimal____ low____ moderate____ high____ plan____ prior attempt____________________________________________________________________________________

Strengths: Weaknesses:

12/21/07

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Section VIII


27

DSM IV Diagnosis Axis I: __________________________________________ Axis II: __________________________________________ Axis III: __________________________________________ Axis IV: __________________________________________ Axis V: ________________________ current___________ highest in last year___________

Treatment Plan for Psychotherapy

#1 Problem ______________________________________________________________________

Goal Objective: ________________________________________________________________

Time frame for goal ____________________________________________________________

Intervention __________________________________________________________________

#2 Problem ______________________________________________________________________

Goal Objective ________________________________________________________


Intervention __________________________________________________________________

#3 Problem ______________________________________________________________________

Goal Objective: ________________________________________________________________


Intervention __________________________________________________________________

yes Discussed treatment plan with client no

yes Client understands and agrees to treatment plan no

_______________________________ Provider signature/credentials

12/21/07

PaTienT deMograPHics forM continued

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Section VIII


28

INSTITUTION/PROVIDER NAME: _________________________________________ DEPARTMENT:_______________________

SEND TO THE ATTENTION OF: ___________________________________________________________________

PHONE NO: ___________________________________________________________________________________

ADDRESS: _______________________________CITY:____________________STATE/ZIP:___________________Note: Printer friendly versions of our guidelines are also available on our website www.MedMutual.com. Please mail or fax back this form to # 216.687.7787.

Category Physician Form Description Form# Quantity

ANTIBIOTIC Pediatric Antibiotic Pamphlet Z6130 _________RESISTANCE Patient educational handout describing appropriate antibiotic use for children

Adult Antibiotic Pamphlet Z6628 _________Patient educational handout describing appropriate antibiotic use for adults

Viral Infection Checklist Z6249 _________Patient educational handout with suggested home treatments for viral infections

CARDIOVASCULAR Cholesterol Guidelines Z5352 _________Coronary Artery Disease Guidelines X7085 _________Heart Failure Guidelines Z5328 _________High Blood Pressure Guidelines Z6350 _________

CHRONIC PAIN Musculoskeletal & Chronic Pain Guidelines X6195 _________

CONTINUITY Continuity and Coordination of Medical Care X7059 _________Standards for timely written communication between referring and consulting physicians

Behavioral Health Continuity of Care Guidelines X5825 _________Standards for timely written communications from consulting behavioral health cliniciansto referring providers

Patient Summary Physician Communication Form Z5417 _________Form for documenting necessary clinical information when requesting a consultation

Behavioral Health Summary Communication Form Z5443 _________Form to send referring providers a written summary of behavioral health consultations

DEPRESSION Specialist Major Depression Guidelines Z4741 _________Primary Care Physician Major Depression Guidelines Z4819 _________Antidepressant Card Z5361 _________Educational card mailed to patients starting on an antidepressant to promote complianceand proper follow-up

Depression and Alcohol Screening Z6591 _________Provider educational handout regarding standardized depression and alcohol screening tools

DIABETES Diabetes Mellitus Guidelines Z4744 _________Diabetic Eye Examination Report Z7075 _________Form for provider to provider communication regarding diabetic eye exam requests and results

HEALTH MANAGEMENT BabyLink Program Brochure Z4048 _________BROCHURES Balanced Outlook Program Brochure Z5472 _________

Breathe Easy Program Brochure Z4286 _________Diabetes Advantage Program Brochure Z5340 _________Heart Sense Program Brochure Z3868 _________Pain Solutions Program Brochure Z5473 _________

PREVENTIVE Preventive Guidelines Z4765 _________

RESPIRATORY Asthma Guidelines Z4690 _________Asthma Diary Z4763 _________Patient educational handout for tracking symptoms, medication usage and peak flows

Asthma Self Management Plan Z4742 _________Patient educational handout providing suggested actions based upon symptoms and peak flows

COPD Guidelines Z4837 _________COPD Self Management Plan Z5286 _________Patient educational handout providing suggested actions based upon symptoms

Tobacco Dependence Guidelines Z5331 _________Tobacco Dependence Information SheetPatient educational handout with facts about tobacco Z5509 _________

Tobacco Dependence Rx Pad Z5480 _________Patient educational handout recommending smoking cessation with a list of available resources

Tobacco Use Chart Stick-ons Z5315 _________Office identification stickers for medical recordsX6193 R3/08

Clinical Quality Supply Requisition Form

clinical suPPly requisiTion forMfront

Section VIII


29

AffixFirst Class

PostageHere

MZ: 01-5B-7501ATTN: CQI DEPARTMENTMEDICAL MUTUAL2060 E 9TH STCLEVELAND OH 44115-1355

(Tape Here — Do Not Staple)

___________________________

___________________________

___________________________

clinical suPPly requisiTion forM continued

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Section VIII


30

addiTional PracTice locaTions for aBove PracTice affiliaTion:Practice Name, if different than above Medicare Number Medicaid Number List Location in Directory?

Street Address

City State County Zip + 4

Office Phone/Appointment Fax Office Days and Hours

Practice Name, if different than above Medicare Number Medicaid Number List Location in Directory?

Street Address

City State County Zip + 4


PracTice affiliaTion inforMaTion:Practice Federal Tax Identification No. Practice Name

Medicare Number Medicaid Number List Location in Directory?

Street Address Correspondence Address?

City State County Zip + 4 accepting new Patients?


Correspondence Address

reiMBurseMenT address inforMaTion for aBove PracTices suBsTiTuTe forM w-9Reimbursement Name (Legal name): Reimbursement Entity’s Federal Tax ID Number

TYPE OF ENTITY Please check the appropriate box □ Individual/Sole Proprietor □ Corporation □ Partnership □ Other

I certify under penalty of perjury that the Tax Identification Number I have provided is correct.

_____________________________________________________________________ ______________________Signature Date

Street Address / P.O. Box City

County State Zip + 4 Phone Fax

Office Manager or Administrator (Please Print) / Phone Signature of Individual Completing This Form Date

idenTificaTion inforMaTion:Last Name First Name Initial Suffix Title (M.D., etc.) Medical License Number

Social Security Number NPI Number Primary Specialty Secondary Specialty PHO Affiliation Info Effec Date

individual ProviderinforMaTion forM

check one: □ add □ delete check one: □ PcP □ specialist If deleting a PCP, move members to: ________________

identify insurer: □ Medical Mutual □ 1st Medical network □ carolina care Plan □ consumers life

□ Yes □ No

□ Yes □ No

□ Yes □ No

□ Yes □ No

□ yes □ no

( ) ( )

( ) ( )

( ) ( )

( ) ( )

Please use additional forms for each Tax id number. (additional instructions on the back of this form). Page _____ of _____

Z4153 R1/08

Par □ PPo □ Pos □ sMH □ Man □ HMo □ sMPr □ oHio only sMwk □ MaP □

If no, indicate address below

COMMENTS CAQH Number

individual Provider inforMaTion (Pif) forMfront

Section VIII


31

individual Provider inforMaTion forM – insTrucTions

1. This form must be completed when becoming a new provider or when changing provider information. Providers who wish to apply for membership in any managed care network should contact their contracting representative (see number 6 below) for the appropriate forms.

2. Please fill out the form completely, and legibly.

3. Please complete one form per transaction. For example, if you are adding a physician to an existinggroup, or adding a new office to an existing practice, indicate “add” by checking the add box. Ifyou are moving from one location to another, complete one form to indicate the “add” to the newaddress, and complete a “delete” form to end the old address information. When deleting a PcP,please be sure to indicate to which provider members/patients should be moved.

4. If you are closing your practice to new members (or reopening a closed practice), please completethe form and mark the correct “yes” or “no” box in the block marked “Accepting New Patients?”.

5. Incomplete forms will be returned to the provider unprocessed.

6. Please return completed forms to your appropriate regional office.

Medical Mutual of ohio Professional contracting offices

cincinnati region (sw ohio)300 E Business WaySuite 370Cincinnati, Ohio 45241-2369Fax: 513/684-8121Phone: 800/589-2583

cleveland region (ne ohio)2060 East 9th StreetMZ 01-5B-7509Cleveland, Ohio 44115-1355Fax: 216/687-7994Phone: 800/625-2583

columbus region (central/se ohio)9961 Brewster LanePowell, Ohio 43065-7571Fax: 614/932-7254Phone: 800/235-4026

dayton region (sw ohio)6450 Poe AvenueSuite 111Dayton, Ohio 45414-2647Fax: 937/898-3401Phone: 800/422-8339

Toledo region (nw ohio)3737 Sylvania AvenueToledo, Ohio 43623-4482Fax: 419/473-7024Phone: 888/258-3482

1st Medical network1899 Powers Ferry RoadSuite 400Atlanta, GA 30339Fax: 877/376-9260Phone: 888/980-6676

carolina care Plan networkManagement department201 Executive Center DriveColumbia, SC 29210-8434Fax: 803/216-6291Phone: 803/750-7400

7. For large groups interested in submitting this information electronically, please contact yourProfessional Contracting Representative, for file specifications.

individual Provider inforMaTion (Pif) forM continued

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Section VIII


32

Provider ActionRequest

Instructions

Z529 R2/08

NOTE: Fill in the form completely. Be sure to print clearly, using black or blue ink only. Any blanks or incomplete informationcould delay or cause your request to be returned unprocessed. Submit only one inquiry per form. Use a separatePAR form for each patient.

Street or P.O. Box City State Zip Code

Services provided in: Pennsylvania Ohio Georgia South Carolina State

Mailing Address:

Provider’s

Telephone Number:

Pro

vid

er In

form

atio

n

Provider’s e-mail address:

Legacy ID

Fax Number:

Provider Name:

NPI Number:Number:

Requester/Contact Name:

PatientIdentification

Service Date(s) Questioned:

For Internal Use Only

MCR Record No Yes

Pat

ien

t In

form

atio

n

Reject Code:

Number: Name:

Claim Number:The Company

DRG/APG/Outlier

Explanation required for all the following, except Medical review.

Claim review

COB

Duplicate payment or denial

Requested information attached

Pricing

Timely filing

Medical review (records attached)

Corrected billing

Typ

e o

f R

equ

est

Exp

lan

atio

n

Date:

Provider acTion requesT (Par) forM

Section VIII


33

Required InformationThe PAR Form is used to help process provider inquiries in a more timely manner. All data fields must becompleted. Forms not completed properly or provider inquiries not submitted with a form will be returned.Original submissions should have only one inquiry per form. Use a separate PAR Form for each patient.

Provider Information

Fill in the defined fields: the provider and tax identification number; contact person and telephone number;and the mailing address, including zip code. Provide e-mail address when available.

Patient Information

The PAR Form is used for all provider inquiries and provider appeals related to reimbursement. Check oneType of Request that best describes your request.

Medical Review: When questioning reimbursement due to medical necessity, claim copies are not neededunless the original claim form data is being changed as a part of the request. Medical records must beattached. The needed records have been grouped by services.

• Allergy: All office notes for the services in question and a description of all medications given, includingdosage

• Ambulance — emergency room reports: Air — flight records, including a breakdown of charges that identifythe number of air miles and a letter of medical necessity that substantiates the need for transfer; the place ororigin of flight; and the destination; Ground — the run report from the ambulance company

• Anesthesia: Hospital anesthesia records and operative reports

• Behavioral Health: Inpatient medical records. For the medical care cases, physician’s signed written progressnotes for the services in question

• Cardiology: Medical history and test results

All patient data must be given. If you are questioning an entire remittance or voucher, write multiple in thePatient’s Name field. Always list the The Company claim number as well as dates of service. The Explanationfield must clearly state the outcome or action being requested. The remittance or voucher must be attached.Please check the box indicating where services were rendered.

Type of Request

Providers may request corrective adjustments to any previous payment, using the Provider Action RequestForm (PAR), and Medical Mutual of Ohio/Consumers Life Insurance Company/Carolina Care Plan (together knownas The Company) may make such adjustments as necessary and appropriate. Please note, however, that TheCompany has no obligation to make any adjustment after 12 months from the date the initial claim was pro-cessed.

Provider ActionRequest

Instructions

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Page 1

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34

Type of Request continuedpage 2

• Complex Surgery: When questioning the level of reimbursement due to performance of additional servicesor services with a high level of difficulty, claim copies are not needed if the modifiers appear on the originalclaim submittal. It you are adding a modifying reason, you must submit a new claim form. Operative reportsare required for Modifier 22. Incidental procedure denials require operative reports and/or office notes.

• Concurrent Medical Care: All physician’s signed progress notes for the date of service in question

• Cosmetic: Operative notes and pre-op photos and clinical notes

• Institutional Outpatient and Professional Dental: Entire medical records, including operative notes, proce-dure notes, anesthesia records and/or the physician’s office notes, and preoperative panorex x-rays. Forlesion removals, the pathology reports (required)

• Emergency Room: Complete ER records with readable copies of physician’s and nurse’s notes

• Durable Medical Equipment: Complete description of the equipment and a valid HCPCS code, form orletter of medical necessity, detailed medical history, and approximate cost of the equipment

• Ear, Nose and Throat: Office notes, operative notes, medical history, and the test results

• Home Health Care: Physician notes, physician-signed treatment plan, and all notes for any services beingperformed by the agency

• Institutional Inpatient: All documentation related to the service in question (Also, refer to When Not to Usethe PAR Form on page 3)

• Laboratory: Patient history and lab results

• Medical Care Issues: All office notes for the service in question. For cases involving denial of an officevisit/consultation and for any case involving the submission of Modifier 25: office notes, a patient history,reason for testing, and testing outcomes. If the case involves medication or administration of medication:office notes, and a detailed description of the medication, including dosage

• MRI: The MRI report and a detailed patient history (Also, refer to When Not to Use the PAR Form on page 3)

• Maternity: Detailed patient medical history, antenatal records, test results, labor and delivery records

• Private Duty Nursing: Physician’s orders and all hourly nursing documentation

• Podiatry: Operative reports and office notes for surgical cases, and lab/pathology reports

• Radiology: The radiology report; medical history for PET scans

• Skilled Nursing: All physician orders and progress notes, nursing notes, treatments, medication documen-tation, all therapy modalities, and any other relevant data (Also, refer to When Not to Use the PAR Formon page 3)

• Surgery: Operative/procedure notes, and pathology reports (required) for cases involving the removal oflesions

• Therapy: Progress notes; x-ray reports; re-exam findings; objective data, such as flow charts for anychiropractic, speech or occupational therapy service beyond the 10 treatments within a calendar year; anda completed Request Authorization Therapy form (Z3233) (required)

• Transplant: In the Explanation field, a comprehensive problem statement

• Vascular Services: Medical history and test results

• Vision: Office notes, test results (if appropriate), and medical necessity information

Claim Review: When the claim outcome varies from the benefits expected, for denial of services, for aclaim payment error, or reconsideration of a payment recovery (take back) or interest calculation. Claimform copies are not needed unless there is a change from the original claim submitted.

COB: Requests related to the incorrect processing of COB or Medicare claims. (Note: If the original claimdenied for another carrier’s EOB (E22) or Medicare’s EOB (MIM), it is not necessary to complete a PARform. Submit a new claim attaching the needed EOB.)


Page 2

Section VIII


35

Type of Request continuedPage 3

Corrected Billing: Adjustment requests require a revised claim form. Examples of when to use this type ofrequest: changing number of units or date of service. The Company claim number is required to enable TheCompany to access the original claim payment information.

Duplicate Payment or Denial: When a duplicate claim payment was made or claims were erroneouslydenied as a duplicate in error.

Requested Information Attached: Used for all claim denials related to the absence of data The Companyneeds for final adjudication. If the denial letter is attached to the medical records and attached to the PARForm, there is no need to complete the Explanation field.

Timely Filing: Documentation that clearly shows The Company was in receipt of the claim (required).Acceptable documentation includes a Company professional or hospital electronic claims Detail Accept/Reject Report, or fax receipt from The Company.

Pricing/UCR: When questioning the level of reimbursement. Examples include fee too low, not my agreed-to reimbursement rate. Claim copies are not needed.

DRG/APG/Outlier: When questioning the level of reimbursement related to DRGs, APGs or Outliers.

When NOT to Use the PAR Form:

• Do not use the PAR Form if you are attempting to verify the status of a claim. Use Claims Connect. Claims Connect maybe accessed through The Company Web site at medmutual.com, consumerslife.com, carolinacareplan.com.

• Do not use the PAR Form if the claim has been returned unprocessed for additional data. Simply com-plete the claim form with the additional or corrected data and resubmit the claim as a new claim by mailingit to:

• Do not use a PAR Form when requesting the review/appeal of a service that requires precertification andwas denied for incomplete certification or lack of medical necessity. Those inquiries should be addressedto Care Management, 2060 East Ninth Street, MZ 01-5B-3984, Cleveland, Ohio 44115-1355.

• Do not use a PAR Form to submit a late charge. Submit late charges electronically.

Additional Information

You may obtain a PAR Form in one of three ways:

• You may electronically submit or print out a copy of the PAR from The Company Web sites,MedMutual.com, ConsumersLife.com, or CarolinaCarePlan.com.

• You may print out a copy of the PAR from the Professional Provider Manual.• You may order printed copies. The PAR comes padded in quantities of 100 (Form number Z529). Fill out a

Supply Requisition Form (PC103). (A copy of the Supply Requisition Form is located in the ProfessionalProvider Manual.) Use pads as your quantity unit instead of individual forms when filling out your order.

Then either mail or fax the Supply Requisition Form to:

Inventory Control, 18-5570Medical Mutual of Ohio, Consumers Life Insurance Company, Carolina Care Plan4601 Hinckley Industrial Parkway, Cleveland, Ohio 44109-6020Fax: 216/749-8074 or 800/577-8026

Consumers Life Insurance CompanyP.O. Box 94875Cleveland, Ohio 44101-4875

Medical Mutual of OhioP.O. Box 94917Cleveland, Ohio 44101-4917

Carolina Care PlanP.O. Box 100234Columbia, South Carolina 29202-3234


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Section VIII


36

Medical Mutual of Ohio®

Supply Requisition Form

INSTITUTION/PROVIDER NAME _________________________________________________ DEPARTMENT ________________________________________

SEND TO THE ATTENTION OF______________________________________________________________________________________________

ADDRESS ______________________________________________________________________________________________________________

CITY ______________________________________________________ STATE / ZIP _________________________________________________

(Please be sure to complete all identifying information requested above to ensure the delivery of your order to the correct location.)

Quantity FormRequested Number MMO Form Description_____________ ________ ______________________________________________________

_____________ E342 Medical Review Envelope

_____________ MED83 Patient Transfer Information

_____________ MM886 Dental (Claim Form) Cleveland

_____________ PC103 MMO Supply Requisition Form

_____________ SC37 Medical/Surgical Claim Form (HCFA 1500)

_____________ SCM9 Major Medical/Catastrophic Claim Form

_____________ Z529 Provider Action Request Form

_____________ Z3233 Request for Authorization for Speech and Physical/Occupational Medicine

_____________ Z3323 Predetermination Request Form

PC103 R7/03 USE REVERSE SIDE FOR ORDERING FORMS NOT LISTED ABOVE

PC103 Supply Req form R7_03:PC103 Supply Req form 1/12/09 10:58 AM Page 1

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37

QUANTITY FORMREQUESTED NUMBER FORM DESCRIPTION

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

____________ ________________ _____________________________________________________

_____________________

_____________________

_____________________

AffixFirst Class

PostageHere

ATTN INVENTORY CONTROLMEDICAL MUTUAL OF OHIO®

4601 HINCKLEY INDUSTRIAL PKWYCLEVELAND OH 44109-6020

(Tape Here — Do Not Staple)

PC103 Supply Req form R7_03:PC103 Supply Req form 1/12/09 10:58 AM Page 2

suPPly requisiTion forM continued

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Section VIII

SECTION VIII — Forms and Publications Publications — All Providers

38

Provider coMMunicaTions and oTHer inforMaTion sources inTroducTioninTroducTionThe Company publications are designed to give providers the information necessary to work effectively with us.

If you have not received one or more of the publications listed in this section, please contact your local Contracting Representative. Sample layouts of each printed Company provider communication are provided as attachments at the end of this section. The publications are also used to update this Manual and are considered part of it.

Provider PuBlicaTionsThe following are the major Company publications relevant to Professional and Institutional Providers. The Company also produces brochures, fact sheets, and other communications of use to providers as needed.

n•• The Provider Manual (Manual)

The Manual identifies Company administrative and medical policies, procedures, guidelines, and forms. The Manual is referenced in the Provider Agreement and is considered part of it.

The Manual is updated as necessary and appropriate at least annually, and is available on CD ROM or on MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com.

Questions or comments regarding information contained in the Manual should be directed to your local Contracting Representative, or the Company department referenced in the Manual.

n•• Mutual news

Mutual News is a newsletter published to keep providers current on Company products, policies and procedures. It is also used to address issues and questions identified through provider contacts with the Company’s Provider Contracting Department and Provider Inquiry Unit, as well as to inform providers about any new and/or unique policies and procedures related to existing and new group accounts. (See Attachment 1 of this section for a sample.)

••

n•• Mutual news Bulletin

Mutual News Bulletins are published on an as-needed basis to inform providers about items that, due to their importance and/or immediacy, need to be distributed quickly. (For a sample, see Attachment 2 of this section.)

Questions about the Provider Manual, Mutual News, and Mutual News Bulletin should be directed to your local Contracting Representative. See Section I, Introduction, for a list of the offices by region, along with phone numbers.

n•• eye on quality

Eye On Quality is a newsletter created to inform providers about the Company’s practice standards, improve the quality of care rendered to Covered Persons, and provide information on current Quality Improvement (QI) projects, national quality standards, Clinical Quality Improvement (CQI) policies and procedures, and the Company QI initiatives. (For a sample, see Attachment 3 at the end of this section.)

n•• quality connection

Quality Connection is a hospital newsletter that is published twice a year. The newsletter is designed to address issues that specifically impact the Company’s network facilities. Quality Connection primarily focuses on subjects of interest to hospital departments involved with quality improvement, patient safety, case management, discharge planning, utilization management and coding. (For a sample, see Attachment 4 at the end of this section.)




Section VIII


39

Provider coMMunicaTions and oTHer inforMaTion sources inTroducTion continued

coMPany weB siTesIn 2008, the Company launched the secure provider ePortal, designed to give providers quick access to important and individualized information. Via the ePortal, providers can view contracted fee schedules, review and update demographic information, enroll in Electronic Funds Transfer (EFT), and subscribe to have publications, such as newsletters and bulletins, delivered via e-mail. Future functionality available in 2009 includes Electronic Remittance Advice (eRA) and historical claims remittance look up.

The Company Web sites are frequently updated to meet the information needs of providers and Covered Persons. Tools & Resources in the Provider section of the Company’s Web sites includes all of our newsletters and the Provider Manual in a searchable format. Visit MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com to learn more.

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attachment 1: Mutual News layout sampleattachment 2: Mutual News Bulletin layout sampleattachment 3: Eye on Quality layout sampleattachment 4: Quality Connection layout sample




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attachment 1 Mutual News layout

MUTUALNEWS

This material is considered part of the Provider ManualMedical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

VVVVVolume 1/Issue 1 • July 2008olume 1/Issue 1 • July 2008olume 1/Issue 1 • July 2008olume 1/Issue 1 • July 2008olume 1/Issue 1 • July 2008

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Mutual News Premiers New LookMutual News Premiers New LookMutual News Premiers New LookMutual News Premiers New LookMutual News Premiers New Look

Update

Hospital

HOSPITALHOSPITALHOSPITALHOSPITALHOSPITAL

ANCILLARYANCILLARYANCILLARYANCILLARYANCILLARY

CAQH Universal Credentialing Data Source BeginsCAQH Universal Credentialing Data Source BeginsCAQH Universal Credentialing Data Source BeginsCAQH Universal Credentialing Data Source BeginsCAQH Universal Credentialing Data Source Beginsto Unroll Service Improvementsto Unroll Service Improvementsto Unroll Service Improvementsto Unroll Service Improvementsto Unroll Service Improvements

Mutual News is premiering a redesigned look to compliment an all-inclusive audience.Beginning with this issue Mutual News will be updating all provider groups—professional, hospital and ancillary — with news relevant to Medical Mutual of Ohioand our Family of Companies.

This move to a new look is to help you identify information that is important to you, sono matter what provider specialty — professional, hospital or ancillary — you will beable to locate the news that is specific to you.

To help identify updates that pertain only to a single provider type, such as for hospitalsonly, icons will be used in association with the headline within these various sections(see sample icons to right).

We hope this will make reading Mutual News an easier process and welcome yourcomments. Comments can be shared with your contracting representative or mailed toProvider Communications at Medical Mutual’s address (see mailing cover). E-mails arealso welcome to [email protected].

Over 600,000 providers nationwide already enjoy thebenefits of CAQH Universal Credentialing Data Source(UCD), the industry standard for provider datacollection and dissemination.

The UCD enables healthcare providers to enter requiredcredentialing information one time, either online or byfax, to satisfy the credentialing and recredentialing of allof the over 350 participating health plans andhealthcare organizations.

Beginning late summer, the CAQH UniversalCredentialing Data source (UCD) will introduceenhanced security features and increased functionality.These will be the first in a series of service improvementsexpected to roll out over the next several years.

All network professional providers are eligible to participatein the UCD and are encouraged to do so. Please visitwww.caqh.org for more information. Any questions relatedto participating in the UCD should be directed to your localcontracting representative (see page 7).

IndexIndexIndexIndexIndexClaims Submission Reminder ....................................... 2Prior Approval List ........................................................ 2Premier Health Systems Acquired ................................. 2Provider Satisfaction Survey Results ............................. 3Prior Approval Additions .............................................. 3Have You Submitted Your NPI Number? ...................... 4

NPI Claims Submission Chart ....................................... 5Pass-Through Billing Policies ........................................ 5SuperWell Disease and Maternity ManagementPrograms: Providing Education and Support ............... 6E-Business Coming Soon .............................................. 7Consider Your In-Network Provider Advantages ......... 7Provider Contracting Offices ......................................... 7

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aTTacHMenT 2 Mutual News Bulletin layouT

Volume 1, Issue 2 •September 2008

This material is considered part of the Provider Manual Medical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

MEDICAL MUTUALMUTUAL NEWS BULLETIN

On April 1, 2008, the Centers for Medicare and Medicaid Services (CMS) implemented their program Hospital Acquired Conditions and Present on Admission Indicator Reporting (HAC & POA). Hospitals submitting inpatient claims to CMS for payment must report accurate POA data or the claims will be returned for correct submission of POA data.

Accurate POA coding is necessary to assure correct MedicareSeverity Diagnosis Related Group (MS-DRG) assignment. A valid POA indicator needs to be recorded for each ICD-9-CM diagnosis or external cause of injury (other diagnosis) code transmitted on an inpatient claim unless the diagnosis code is exempt from POA reporting, per the ICD -9-CM Of cial Guidelines for Coding and Reporting.

CMS POA indicators are: Y = Diagnosis was present at time of inpatient admission

N = Diagnosis was not present at time of inpatient admission

U = Documentation insuf cient to determine if condition was present at the time of inpatient admission

W = Clinically undetermined; unable to clinically determine whether condition was present at the time of inpatient admission

1 = When billing electronically, diagnosis code is exempt from POA reporting. This is the equivalent of a blank on a paper claim.

In conformance with CMS, all claims with discharge dates on or after October 1, 2008, for Private Fee-for-Service (PFFS) and HMO/POS Medicare Advantage Products will be rejected by our Company if theyhave missing or invalid POA data. This does not affect hospitals exempt from CMS required POAreporting. Moreover, POA logic will be incorporated into the MS-DRG assignment for these claims. Thismay affect reimbursement for Hospital Acquired Conditions.

Commercial claims with admit dates of October 1, 2008, and after will be rejected if submitted with invalid POA data. Hospitals exempt from CMS required POA reporting will not be impacted. Our Company will continue to evaluate its approach to POA coding and will notify providers of any potential changes prior to their implementation.

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aTTacHMenT 3 Eye On Quality layouT

Eye on Quality Provider Newsletter Volume 12, Issue 4 � 2008

Going Green � Cervical Cancer Prevention � Comorbid Conditions

Family of Companies


Consumers Life insurance company®

carolina care plan®

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PQRI and Category IICPT

Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Cervical Cancer Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4O

bstetrical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5M

edical Policy Update

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Contacting Care M

anagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Prior Approval Requirem

ent Update

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Shingles Education

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9O

nline Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

1

Thank You for Your Input Our 2008 Healthcare Effectiveness Data Information Set (HEDIS)audit required us to request nearly 3,000 member medical records.We greatly appreciate you and your staff for the time and effort ittook to provide us with these records in a timely manner.

As part of the data collection, we also asked providers to completeand return a survey. We received multiple responses on the followingtwo items:

� Having a nurse reviewer visit the office to collect necessary medicalrecord information. In the past, we performed an on-site visit if a total of 10or more medical record reviews were required. Now, requests for on-site datacollection for offices with less than 10 required records are considered on acase-by-case basis.

� Scheduling our HEDIS audit at a different time of year. We understand youroffice is busy and is complying with HEDIS information requests from otherinsurers; however, the National Committee for Quality Assurance (NCQA)identifies the date by which HEDIS data must be submitted and this date isthe same for all insurers. Due to the challenge of obtaining all requiredinformation and pursuing additional data when needed, we begin gatheringdata in February and the effort continues into May.

Consolidation of Effort for 2009 HEDIS SeasonIn addition to our annual HEDIS audit, we often use your office recordsfor quality improvement initiatives pertaining to medical recorddocumentation. To minimize the frequency of medical record requests,we may ask for some additional information beyond that requiredfor the HEDIS measure. The additional information allows us to limitthe impact of multiple requests for office records during the rest of theyear. Every effort will be made to utilize the additional informationsubmitted to minimize record requests for the 2009 HEDIS audit.

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aTTacHMenT 4 Quality Connection layouT

Making M

amm

ography Easier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2Com

bating Post-Discharge N

oncompliance

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Continuity of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4Coding Corner

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Promoting Sm

oking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8M

aximize Your InFLU

ence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9Preventable A

dverse Events Policy under Developm

ent . . . . . . . . . . . . . . . . . . . . . . . . . . .10Flu/Pneum

onia Resource Packets Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Smoking Cessation � COPD Coding � Combating Noncompliance

1

Newborn Hepatitis B Vaccine – Priorto DischargeA survey conducted by the Center for Disease Control andPrevention (CDC) revealed that only 50 percent of newbornsreceive a dose of the hepatitis B (HepB) vaccine prior todischarge. The current recommendation for administering HepB isto give the first dose to medically stable infants weighing at least2,000 grams (4 pounds 6.5 ounces) prior to hospital discharge.

When infants become infected with the HepB virus they have a90 percent chance of becoming chronically infected, which caneventually lead to cirrhosis and liver cancer.

The CDC believes that delivery hospitals play a key role in thenational strategy to prevent HepB transmission and recommendsthat hospitals have policies and procedures in place to ensurethat HepB vaccination is administered to all newborns beforethey are discharged.

Many parents fear possible vaccine side effects and refuse thevaccine due to misguided and false information from family,friends and medically unsound Web sites. We encourage ournetwork hospitals to be compliant with the Advisory Committeeon Immunization Practices and CDC current recommendations.Providing education and discussion of the benefits ofvaccinations can help allay parental fears about possible sideeffects and help increase the number of infants receiving theprotection of the HepB virus vaccine in a timely manner.

Source: CDC. Morbidity and Mortality Weekly Report, August 1, 2008.

Quality Connection Provider Newsletter Volume 7, Issue 2 � 2008

Family of Companies


Consumers Life insurance company®

carolina care plan®

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forms â€” all providers

Documents