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PROVIDER MANUAL

Dean Health Plan Provider Manual | Revised 12/2017 2

TABLE OF CONTENTS

HEALTH PLAN OVERVIEW .......................................................................................................... 3

PRODUCTS ................................................................................................................................11

PROVIDER PORTAL ....................................................................................................................15

CREDENTIALING PROCESS .........................................................................................................17

CLAIMS, TIMELY FILING, AND EOPS...........................................................................................25

CLAIMS CODING PROCESS ........................................................................................................31

EDI TRANSACTION PROCESS .....................................................................................................32

AUTHORIZATION PROCESS ........................................................................................................33

SKILLED NURSING FACILITY (SNF) AUTHORIZATION GUIDELINES ..............................................54

CHIROPRACTIC CARE OVERVIEW ..............................................................................................58

ADMISSIONS AND CONCURRENT REVIEW PROCESS .................................................................65

CARE MANAGEMENT ................................................................................................................69

CASE AND DISEASE MANAGEMENT ..........................................................................................79

MEMBER GRIEVANCE AND APPEALS PROCESS ..........................................................................83

PROVIDER APPEALS ..................................................................................................................85

PHARMACY ...............................................................................................................................87

QUALITY IMPROVEMENT ..........................................................................................................91

PUBLICATIONS ..........................................................................................................................95

Changes are periodically made to the information in this manual. This manual was last updated 12/2017.


HEALTH PLAN OVERVIEW Dean Health Plan, a subsidiary of Dean Health Insurance, Inc. (DHI), would like to take this opportunity to welcome you into our provider network! The Dean Health Plan Provider Manual serves as a resource for policies and procedures that affect claim submission. If you have questions relating to this information, or are unable to find information that you are looking for, please refer to the phone directory below or access deancare.com to contact the appropriate department for assistance.

CUSTOMER CARE CENTER Customer Care Center Monday – Thursday 7:30 am to 5:00 pm Friday 8:00 am to 4:30 pm

(608) 828-1301 | (800) 279-1301

Operator (608) 836-1400 | (608) 356-7344

Dean On Call (608) 250-1393 | (800) 57-NURSE (800) 576-8773

CARE MANAGEMENT Utilization Management (608) 827-4455 | (800) 356-7344 ext. 4455 Point of Service Prior Authorizations (608) 836-1400 | (800) 356-7344 ext. 4455 Case & Disease Management (608) 827-4132 Care Management Fax Number (608) 836-6516

CLAIMS

Claims Manager (608) 827-4432 (800) 356-7344, ext. 4432

Information Systems for Electronic Claims Transmission [email protected]

DRUG PRIOR AUTHORIZATIONS Dean Health Plan Drug Prior Authorizations (608) 828-1301 | (800) 279-1301 Drug Prior Authorization Fax (920) 735-5350 Navitus Health Solutions (866) 333-2757 (toll free)

Dean Health Systems Website deancare.com

Address

Dean Health Plan P.O. Box 56099 Madison, WI 53705

WHO IS DEAN HEALTH PLAN? Dean Health Plan, a member of SSM Health, is headquartered in Madison, Wis. Dean Health Plan provides unsurpassed quality and compassionate care through a network of clinics, hospitals and health care partners. Dean Health Plan was established in 1983, and joined the SSM Health system in September 2013. SSM Health is a St. Louis-based order which also owns several hospitals nationwide, including SSM Health St. Mary’s Hospital – Madison, SSM Health St. Mary’s Hospital – Janesville, and SSM Health St. Clare Hospital – Baraboo. SSM Health Dean Medical Group is a for-profit, integrated health care organization based in Madison, Wisconsin. The network consists of more than 60 clinics in south-central Wisconsin, SSM Health Davis Duehr Dean Eye Care, insurance provider Dean Health Plan, and pharmacy benefits company Navitus Health Solutions. Approximately 500 physicians provide primary, specialty and tertiary care in the clinics. The system serves more than 400,000 health plan members.

http://www.deancare.com/

mailto:[email protected]



As a member of SSM Health, Dean Health Plan follows the SSM mission statement “through our exceptional health care services, we reveal the healing presence of God.”

VISIT OUR WEBSITE Dean Health Plan offers a wealth of information through the Dean Health Systems website. Dean Health Systems’ affiliates can access information by visiting deancare.com\providers

http://www.deancare.com/providers


PROVIDER NETWORK SERVICES The Provider Network Services department includes our Provider Network Consultants (PNCs), who are responsible for educating all existing and new plan providers within the Dean Health Plan provider network. Provider education includes: Updating our providers on new policies and procedures via provider newsletter, provider mailings, or workshops Orientations for new practitioners and facilities Ongoing education for network providers (i.e. Quality Improvement, Utilization Management, and Customer

Relations processes, authorization training, etc.)

Provider Network Services maintains the provider files, the administration of the provider contracting process, and the provider manual. Additionally, our provider newsletters are coordinated and distributed by Provider Network Services to keep providers up to date on any changed health plan procedures, benefits, or other areas of interest involving the health plan. Provider News is now available at deancare.com/providers/newsletter.

Who can I contact for questions and assistance? To determine your designated Provider Network Consultant, please visit deancare.com/providers for the most up-to-date service area listing of our territory assignments.

PROVIDER UPDATES AND CHANGES To ensure that Dean Health Plan has the most current demographic information for our network providers, contact your Provider Network Consultant for any of the following situations: New Physicians: When multi-specialty or independent clinic physicians add to their staff; requests to consider this physician for

plan provider status should be directed, in writing, to Provider Network Services. Approval by Dean Health Plan Senior Administration is required before a credentialing application will be sent for completion/review.

All applications must be the original, a photocopy, or faxed copy. Furthermore, Dean Health Plan does not allow practitioners to see Dean Health Plan members until they have completed the credentialing process. No retroactive effective dates are granted.

Providers who do not have to be credentialed will have the same effective date as the notification date. Providers need to be responsible for notifications to us regarding their effective dates.

Physician Extenders & Locum Tenens: Dean Health Plan welcomes physician extenders (Physician Assistants or Nurse Practitioners) to participate in the

plan provider network. All mid-level practitioners are required to complete the credentialing process. Dean Health Plan requires our plan providers notify us in advance of the need for a locum tenens. The plan

provider utilizing a locum tenens should inform their Provider Network Consultant with the name of the locum tenens and the expected coverage time involved.

A physician extender form should be completed and returned to your designated Provider Network Consultant to ensure proper claims payments before any services are rendered to Dean Health Plan members. deancare.com/app/files/public/3709/pdf-providers-Extender-Form.pdf

ADDING A NEW PRACTITIONER TO YOUR PRACTICE Dean Health Plan is a closely managed HMO and our contracts may restrict by practitioner. If you are requesting to add a new practitioner to your practice, Dean Health Plan will first need to approve the addition prior to starting the credentialing process. Once Dean Health Plan has approved your request, we will contact you to submit a credentialing application; if already provided, Dean Health Plan will pass the application to the Credentialing Department. If Dean Health Plan denies your request to add a new practitioner to your practice, you will be notified. Any questions regarding this process can be directed to your assigned Provider Network Consultant.

http://www.deancare.com/providers/newsletter


http://www.deancare.com/app/files/public/3709/pdf-providers-Extender-Form.pdf


A written request with the following information is needed in order for Dean Health Plan to consider adding a new practitioner to your practice: Practitioner name and degree Location(s) where they will practice (if multiple locations, note their primary location) Primary specialty, board certification status, and secondary specialty (if applicable) License number and state issued Status (full time, part time, fill-in, or outreach – if not full-time, please provide the practitioner’s expected hours) If the practitioner is an addition or a replacement (if a replacement, note the name of the practitioner they are

replacing and their termination date) Billing information (i.e. NPI 2, TIN, and whether the clinic or hospital will be doing the billing) If the practitioner is a PA/PA-C, APNP, NP, or CNM, note their supervising physician’s name, specialty, and practice

location

HOSPITAL UPDATES AND CHANGES All of the following requests need to be submitted in writing to the attention of your Provider Network Consultant. Please provide as much advance notice as possible to avoid any disruption to your patient’s authorization submission, or claim payments. The following are examples of facility demographic changes that should be communicated to your Provider Network Consultant: Facility name Location and/or address Phone number Accreditation NPI or TIN additions/changes

Requests for the following are required to have prior approval through the Provider Network Services department. Please communicate these requests in advance to your designated Provider Network Consultant: To expand or add new clinics and/or office locations To add additional services and/or programs

PRACTITIONER UPDATES AND CHANGES All of the below requests need to be submitted in writing to the attention of your Provider Network Consultant. Please provide as much advance notice and information regarding the new practitioner and/or change to the practitioner’s status, as soon as possible, to avoid any disruption to your patients or claim payments. Provider Demographic Information:

o Name o Specialty o Office locations o Gender o Hospital Affiliations o Tax ID changes o Medical Group Affiliations o Website URL o Facility handicap accessibility o Medicare Certification Number

Professionals must have Medicare Certification Number listed on credentialing application No retro claims payment (if Medicare certification numbers is pending, provider is required to

update us once received) Providers need to notify their patients in writing in advance for practitioner terminations, clinic closures, etc.


TERMINATIONS Practitioner Terminations Please communicate any contracted practitioner terminations in writing to your Provider Network Consultant with as much advance notice as possible (minimum of 30 days prior to the termination). Include the following information in your notification: Practitioner name and degree Practice location(s) Termination date Reason for termination (i.e. moving to a new practice, retirement, etc.) Where the practitioner will be providing services (if still actively practicing) A copy of your member notification letter communicating the practitioner’s termination

Clinic/Facility Terminations Please communicate any contracted clinic terminations in writing to your Provider Network Consultant with as much advance notice as possible (minimum of 60 days prior to the termination). This information is necessary as Dean Health Plan adheres to the state statute for Continuity of Care. Include the following information in your notification: Location name Address Termination date If applicable, which practitioners at the terminating location will be moving to another contracted location A copy of your member notification letter communicating the clinic termination

OTHER SITUATIONS Please communicate the following situations to your Provider Network Consultant in writing: Leave of Absence/Vacation: when a practitioner will be out of the office, vacationing, or on extended leave, and

another facility or location will be covering his/her practice. Dean Health Plan requires written notification to include:

o Name o Location o Duration of the covering practitioner or facility

The covering practitioner must be a plan provider and have completed the credentialing process.

Panel Status: when a practitioner finds it necessary to discontinue accepting new patients or limit his/her practice (following this page is a Patient Acceptance Form that is required to be completed to communicate this information – see below for template). This does not apply to practitioners who are with a Dean Medical Group site.

PROVIDER SERVICE OBJECTIONS Providers in the Dean Health Plan network that refuse to provide a service to members based on moral or religious objections must notify their Provider Network Consultant in writing of the objection and its basis in a timely manner. Dean Health Plan will notify the member so that the member can seek another like network provider that is available to provide the service in question.


DEAN HEALTH PLAN TERMINATION OF PATIENT/PRACTITIONER RELATIONSHIP POLICY & PROCEDURE Contracted providers are required by Dean Health Plan (DHP) to send copies of member termination of care notification letters to their assigned Provider Network Consultant.

Practitioners may terminate a member’s care only with good cause. The following are examples of good cause, in which a member: Physically injured or threatened a practitioner or other member of the clinic staff. Repeatedly and materially refused to pay coinsurance, copayments, or deductibles associated with DHP claims

after all reasonable collection efforts have been exhausted. Displayed verbally abusive behavior or harassment towards a practitioner or other member of the clinic staff. Repeatedly refused to cooperate with the practitioner, was non-compliant with medical care, or there was a

breakdown in the practitioner-patient relationship. Failed to attend or late cancel 3 or more scheduled appointments after having received a written warning. Communicated to the practitioner that they would like to select a different practitioner.

NOTE: this process applies to members with commercial policies, including State of Wisconsin and federal employees. If the member is a recipient of Medicaid or Badgercare, please contact the DHP Medicaid Member Advocate.

The following should be included in the termination of care letter, per DHP guidelines: 1. Member’s full name, including middle name (not just initial) 2. Member’s date of birth (optional) 3. Member’s address, which can be in address line 4. Clinic/facility name 5. Practitioner name 6. Notice in the body of the letter stating that the member may see the practitioner for 30 days from the date the

member received the termination notice if the member presents for urgent or emergent care 7. Reason for the termination

a. If reason is due to the member missing or late-canceling appointments, include when their initial warning letter was sent to them

b. If reason was due to non-payment, include proof of attempts to collect payment 8. Dean Health Plan’s Customer Care Center phone number (800) 279-1301 or (608) 828-1301

a. If the member is under the Dean Advantage MAPD plan, use the Dean Health Plan Member Services phone number (877) 232-7566 or (608) 828-1978 instead

9. Copy of a patient authorization form, as the member may want to transfer care to a different clinic/facility

Practitioner-Member Communication Dean Health Plan shall ensure that Dean Health Plan allows open practitioner-member communication regarding appropriate treatment alternatives and shall not penalize practitioners for discussing medically necessary or appropriate care with members.

MEMBER INTERPRETATION SERVICES It is Dean Health Plan’s philosophy to help each and every member regardless of any language barriers that might exist. To that end, Dean Health Plan employs the services of translation and interpretation professionals to assist with in-person and telephonic encounters at Dean Health Plan, as well as written documentation upon request, when the member has limited English proficiency or is hard of hearing. These services are available through the Customer Care Center at (800) 279-1301.


Providers shall use best efforts to provide their own interpreter services for Dean Health Plan members with limited English proficiency upon request.

DEAN ON CALL Dean on Call is a free telephone service that's available to Wisconsin residents 24 hours a day, 365 days a year. If members are not sure they need to see a doctor, or they’re wondering if they have a problem, they can call the line. Dean on Call is staffed by experienced, registered nurses who are able to answer member questions and concerns. Dean on Call can be reached at (608) 250-1393 or Toll Free (800) 57-NURSE (800-576-8773).


PRODUCTS

DEAN HEALTH PLAN’S PRODUCTS Dean Health Plan offers a variety of products for members; each designated to serve specific needs. Below is an overview of the products that are available to Dean Health Plan members.

• Dean HMO is a group plan based on the philosophy of a managed care organization – a primary care provider (PCP) oversees all aspects of an individual's health care needs, both for regular check-ups and for emergency or extended care needs. Members will be expected to visit physicians listed in our extensive provider directory. Specialty care is also coordinated through the PCP, thus leaving members virtually free from paperwork and claims to file.

• Dean POS not only offers HMO coverage, but also a more flexible benefit package to members that chose not to select a primary care provider. This gives members the option to see any Dean Health Plan contracted practitioner as well as the freedom to see non-Dean Health Plan providers.

• Individual Plan is for individuals who do not have health insurance coverage through an employer. Dean Health Plan offers multiple plans with a variety of deductible and benefit levels to meet an individual’s needs.

• Dean PPO is for employer groups who have employees living outside of the Dean Health Plan service area. The PPO product utilizes extensive provider networks to provide local, regional, and national coverage. To provide our PPO members access to physicians and facilities throughout Wisconsin, Dean Health Plan has partnered with HealthEOS by Multiplan. Access to physicians and facilities outside Wisconsin, Dean Health Plan has partnered with PHCS. PPO members can be identified by their Dean Health Plan-PPO ID card, which will show both the Dean Health Plan and HealthEOS, or PHCS logos.

• Dean Focus EPO is a narrow network product limited to members residing in Dane, Sauk & Rock counties. The Dean Health Plan network for this product will be limited to Dean Medical Group providers and SSM Health St. Mary’s Hospital - Madison, SSM Health St. Mary’s Hospital - Janesville Hospital, and SSM Health St. Clare Hospital – Baraboo along with the necessary specialty providers required to cover the full realm of health care services. This product is an HMO design, so plan providers must be used to obtain coverage. Members under the Focus Plan can be identified by an ID card that mirrors the standard HMO ID card. The ID card will show a network name “Focus” indicator as the member’s network name.

• Administrative Services Only (ASO) is a self-insurance arrangement whereby employer provides benefits to employees with its own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents. In self-funded health care, the employer assumes the direct risk for payment of the claims for benefits. The terms of eligibility and covered benefits are set forth in a plan document which includes provisions similar to those found in a typical group health insurance policy. If you are an ASO provider, please refer to the Dean Administrative Services Only (ASO) Manual for information specific to the ASO product.

• DeanCare Gold is a product offered under Dean Health Plan only and is a “Cost” plan currently offered to Medicare eligible members residing in Columbia, Dane, Dodge, Grant, Iowa, Jefferson, Rock and Sauk County. If you are a DeanCare Gold provider please refer to the Dean Care Gold Provider Manual for information on the ID card and specific prior authorization guidelines.

• Dean Advantage Medicare Advantage is a product is offered under Dean Health Plan only and is a Medicare Advantage with Part D plan offered to Medicare eligible members residing in Columbia, Dane, Dodge, Iowa, Jefferson, Rock and Sauk County. If you are a Dean Advantage provider please refer to the Dean Advantage Provider Manual for information on the ID card and specific prior authorization guidelines.

https://en.wikipedia.org/wiki/Self_insurance

https://en.wikipedia.org/wiki/Employer

https://en.wikipedia.org/wiki/Employee_benefits

https://en.wikipedia.org/wiki/Employees

https://en.wikipedia.org/wiki/Risk

https://en.wikipedia.org/wiki/Cause_of_action

https://en.wikipedia.org/wiki/Health_insurance


• Dean Health Plan Senior Select is a product is offered under Dean Health Plan only, and is a Medicare Supplement

Plan currently offered to Medicare eligible members in and outside of Dane County. Claims must be submitted to the fiscal intermediary as primary. Senior Select member’s package will begin with a “Z” and their group number will be in the 20000 range.

• BadgerCare Plus is a state sponsored program that provides health care coverage to qualified members. BadgerCare Plus combined Family Medicaid, BadgerCare, and Healthy Start into a single program. To qualify for BadgerCare Plus members must meet income requirements and fall into one of the following groups:

o Uninsured Children o Pregnant Women o Parents and Caretaker Relatives o Parents with children in foster care who are working to reunify their families o Young adults exiting out-of-home care, such as foster care, because they have turned 18 years of age. o Certain Farmers and other self-employed parents and caretaker relatives.

Not all BadgerCare Plus members will be enrolled in HMOs. Some members will remain straight Medicaid or Fee-for-Service (FFS), where they have access to any BadgerCare Plus Certified provider. This product is offered under Dean Health Plan only. This is an HMO product that follows most of the HMO guidelines. Please refer to the Dean Health Plan Medicaid Manual for information on the and prior authorization guidelines.

BADGERCARE PLUS IDENTIFICATION (ID) CARD Wisconsin BadgerCare Plus members receive a “ForwardHealth” Medicaid ID card upon initial enrollment into Wisconsin BadgerCare Plus. Each individual in a BadgerCare Plus family is enrolled with their own individual ID number and card. It is important that providers or their designated agents determine the member’s eligibility and HMO enrollment status prior to each visit. Providers should verify eligibility for each date of service and cannot charge a member for doing so. This is important because members can move between eligibility groups thus copays and benefits may change between appointments. The ForwardHealth card is designed to be kept indefinitely by members, who are encouraged to always keep their cards even though they may have periods of ineligibility. It is possible a member will present a card when he or she is not eligible; therefore, it is essential providers confirm eligibility before providing services. If a card is lost, stolen or damaged, Wisconsin BadgerCare Plus will replace the card at no cost to the member. Members should contact ForwardHealth Member Services at (800) 362-3002, on the back of the card, for replacement cards.

Forward Card Features (Resembles an automated teller card)

Dean Health Plan will not issue members a separate ID card; the ForwardHealth card will serve as their insurance card.


DEAN HEALTH PLAN IDENTIFICATION (ID) CARD Your role as a Dean Health Plan provider is to identify which plan a member has to assure that the correct prior authorization, and pre-certification guidelines are followed. To help you and your staff identify the different plans that Dean Health Plan offers, we have included examples of the different ID Cards that our members may present. We recommend checking the member’s ID card at every visit to verify Dean Health Plan coverage. Questions regarding member benefits and member identification may be directed to our Customer Care Center.

EXAMPLE OF IDENTIFICATION CARDS ID cards contain the Dean Health Plan Product and Network Type (such as HMO, POS or FOCUS) along with copay levels.

COMMERCIAL ID CARD

(FRONT) (BACK)

FOCUS ID CARD (Offered only in Dane, Rock and Sauk counties)

(FRONT) (BACK)


MEDICARE ADVANTAGE ID CARD

(FRONT) (BACK)

DEANCARE GOLD ID CARD

(FRONT) (BACK)

AUTOMATIC ASSIGNMENT OF PRIMARY CARE PRACTITIONER (PCP) If a member does not designate a PCP site and/or practitioner, Dean Health Plan will automatically assign one based upon the member’s residence. In these situations Dean Health Plan will send a letter to the member informing them of the PCP site assigned. If the member has additional questions, the member can contact Customer Care Center at (800) 279-1301.


PROVIDER PORTAL OVERVIEW OF PORTAL/FUNCTIONALITY The Dean Health Plan Provider Portal is an online resource that assists providers with managing key patient data, simplifying everyday tasks, promoting efficiency in business and streamlining electronic transactions. It has functionality to check HIPAA-compliant real time transactions along with internet-based self-service functionality. Please note that ASO members are not on the Provider Portal. There are two ways to access the Provider Portal:

1. Go directly to deancare.com/providerportal 2. Go to the Provider’s Home page on deancare.com and select the Provider Portal hyper link located under the

Provider Resources section.

SERVICES THROUGH THE PROVIDER PORTAL

Eligibility & Benefits (270/271 EDI) transactions This feature provides human readable real time EDI (Electronic Data Interchange) 270/271 transactions. Checking eligibility can be done in four simple steps. The information would include details regarding Dean Health Plan eligibility and benefit plan coverage, copayments and deductibles.

Claim Status (EDI 276/277) Transactions This feature provides human readable real time EDI (Electronic Data Interchange) 276/277 transactions, which allows providers to check the status of a claim to see if it is pending, processed, or in a finalized status.

Payment Remit-Detailed Electronic Payment Information This feature allows Dean Health Plan to deliver ERAs (Electronic Remittance Advice) or “remits” to providers online. The ERA will show payment information for a specific claim or by batch.

Claim Appeals This feature allows the submission of online claim appeals directly through the Provider Portal for claims that have a finalized status (paid-denied). Appeals Process Please see page 82 for an overview of the appeals process through our Provider Portal.

http://www.deancare.com/providerportal



Authorization Online Submission This feature allows the submission of new authorizations and ability to view authorizations that may have been started, saved or submitted. This feature is limited to our fully contracted plan providers.

Medical Code Look-Up This feature allows the functionality to search for Procedure, Diagnosis and NDC Codes. For additional Provider Portal resources and training documents, visit deancare.com/providers. If you have questions, please contact your assigned Provider Network Consultant.



CREDENTIALING PROCESS

PRACTITIONER CREDENTIALING AND RECREDENTIALING PROCESS Dean Health Plan has developed and implemented a credentialing/recredentialing process for selecting and evaluating practitioners who practice within the Dean Health Plan delivery system. Practitioner credentialing applications must be reviewed and approved by the Dean Health Plan Credentialing Committee or its delegate prior to being authorized to provide services to Dean Health Plan members. The Dean Health Plan Credentialing Committee is comprised of medical directors and participating practitioners within the Dean Health Plan Network; representing a range of participating practitioner specialties.

Recredentialing applications are required to be completed and approved by the Dean Health Plan Credentialing Committee at least every thirty six (36) months, in order to continue to provide services to Dean Health Plan members. Providers are sent a recredentialing application with pre-populated information from the previous credentialing cycle. The provider is responsible to update the information on the application. Dean Health Plan will review the applications and perform primary source verifications of the required documentation. The credentialing/recredentialing process will be completed within 180 days of the date of the practitioner’s signature on the application. If the time of the process exceeds 180 days, Dean Health Plan will return the application to the practitioner for review and updating of signatures.

Practitioners who fall under the scope of credentialing/recredentialing for Dean Health Plan:

• Medical Practitioners o Medical Doctors (MD) o Dentists (DDS/DMD) o Chiropractors (DC) o Osteopaths (DO) o Podiatrists (DPM) o Optometrists (OD)

• Licensed Independent Mid-Level Practitioners o Certified Nurse Midwives (CNM) o Advance Practice Nurse Practitioners (APNP) o Physician Assistants (PA) o Speech Therapists (SLP) o Occupational Therapists (OT) o Physical Therapists (PT) o Audiologists (AUD)

• Behavioral Health Practitioners o Psychiatrists and other physicians o Addiction medicine specialists o Doctoral or master's-level psychologists who are state certified or licensed o Master's-level clinical social workers who are state certified or licensed o Master's-level clinical nurse specialists or psychiatric nurse practitioners who are nationally or state certified

or licensed o Other behavioral health care specialists who are licensed, certified or registered by the state to practice

independently


o Master’s-level Qualified Treatment Trainees who are licensed and work at behavioral health facilities that are certified as DHS 35 by the State of Wisconsin

o Master’s-level Autism Spectrum Disorder (ASD) Providers- who meet training requirements as set forth in Wisconsin Administrative Code 3.36 (exclusion: Qualified Paraprofessional)

CREDENTIALING AND RECREDENTIALING POLICIES All credentialing/recredentialing will be conducted in a non-discriminatory manner. Dean Health Plan’s policies provide practitioners with an opportunity to review and correct any information used in the credentialing/recredentialing process and ensures that all information obtained in the credentialing/recredentialing process is kept confidential. All practitioners have the right, upon their request, to be informed of the status of their credentialing/recredentialing application. Dean Health Plan will notify any applicant of any information obtained during the credentialing/recredentialing process that varies substantially from the information provided to Dean Health Plan by the applicant. Provider Network Services & Credentialing will allow an applicant to correct erroneous information submitted as a part of their application. Dean Health Plan will allow any applicant to review the information submitted in support of their credentialing/recredentialing application. Applicants have the right, upon request, to be informed of the status of their credentialing/recredentialing application. The applicant can arrange for a review of their individual application at the office of Dean Health Plan. Dean Health Plan may request additional information from the applicant or other parties that relates to the information submitted in support of the application or verification of the applicant’s credentials and qualifications. This includes, but is not limited to: Information that is missing or incomplete on the application. Clarification of information obtained during the process that varies substantially from the information provided

by the applicant. Correcting erroneous information.

All applicants must complete an application that includes personal identifiers, professional information, education and experience, medical licensure information, medical specialty, hospital privileges, disciplinary actions, malpractice carrier, and conditions of the application. Dean Health Plan then verifies completeness of the following statements by the applicant: Ability to perform the essential functions of the position, with or without accommodation, for any condition,

physical or mental. Lack of current illegal use of drugs. History of loss of license. History of felony convictions. History of loss or limitation of privileges or disciplinary activity. Attestation to the correctness and completeness of the application. Dates and amounts of current malpractice insurance coverage.

Applicants must provide the following information with the application: Signed Authorization for Release of Information form. Completed curriculum vitae form or equivalent information provided. A copy of current malpractice declaration with amounts and dates of coverage. A copy of current Drug Enforcement Agency licensure (as applicable).

Dean Health Plan collects and reviews information about the applicant’s credentials and qualifications, including verification of the following items from primary sources, as applicable.


Verification of a valid state license to practice from the appropriate medical licensing authority. The provider cannot provide services outside of the scope of his/her license.

Verification of hospital privileges (if applicable). Credentialing look-back period is five years and recredentialing two years.

Verification of the applicant’s valid Drug Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS) certificate, as applicable for MDs, DOs, DPMs, DDSs, APNPs, PAs and ODs.

Verification from a physician applicant’s residency training program verifying completion, as applicable. Internships, residencies and fellowships are verified during initial credentialing. If a fellowship is completed post credentialing, Dean Health Plan should be notified so that the fellowship can be verified and added to credentialing file.

Verification of Board certification if the applicant states that he/she is board certified. Board certification can be verified using the following websites:

o The Official ABMS Directory of Board Certified Medical Specialists, the AOA Official Osteopathic Physicians Profile Report or AOA Physicians Master File, or verification from either ABMS or AOA specialty board(s).

o American Board of Oral and Maxillofacial Surgery o American Board of Podiatric Surgery o American Board of Professional Psychology o American Board of Professional Neuropsychology o National Boards of Certified Counselors o American Board of Addiction Medicine

Verification through application or curriculum vitae (CV) with a minimum of five years’ work history in the health care field or since completion of medical or professional school to current. For practitioners who have practiced fewer than five years, verification begins with the completion of education to current. Any gap exceeding six months must be clarified either verbally or in writing. The CV or application must include the month and year for each position in the history. If there has been continuous employment for five years or more, no month or year are required. Any gap exceeding one year must be verified in writing. During recredentialing you will be asked to indicate your work history for previous three years.

Verification of the applicant’s malpractice insurance to verify it is current and adequate, according to Dean Health Plan policy.

Review of the applicant’s history of professional liability claims which result in settlements or judgments paid by or on behalf of the applicant. Provider Network Services & Credentialing reviews the information supplied by the applicant and receives information from the National Practitioner Data Bank (NPDB), which includes previous sanction activity by Medicare and Medicaid.

Review of applicant’s history of Dean Health Plan member complaints. NOTE: Education verifications and work history are not required to be collected during the recredentialing process, unless new information is identified. Physician applicants who have not completed at least one residency that made them eligible for ABMS or AOA board certification in that specialty must apply as a general practitioner. Provider Network Services & Credentialing will verify the following during initial credentialing. Practitioner status will remain the same unless Dean Health Plan is notified of any changes. The applicant’s training program after receiving their medical degree must include at least one year of residency. The applicant’s work experience as a practitioner must include: verification of five (5) years of medical practice in

primary care (Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology or General Practice (GP)).. References in writing from three practitioners familiar with the applicant’s practice and experience in the field of

GP. These references should attest to the applicant’s performance as a GP physician and the quality of care and professional conduct of the applicant.

Dean Health Plan forwards applicant credentialing/recredentialing files to members of the Credentialing Committee when the department staff has determined that information received in support of the applicant meets the Dean Health Plan


requirements for credentialing/recredentialing and all information and verification required for credentialing has been completed.

The Credentialing Committee members review applicant credentialing/recredentialing files. The Credentialing Committee reserves the right to request detailed information when reviewing credentialing or recredentialing applications. Failure to provide information as requested may be the basis for denying participation with Dean Health Plan. The Credentialing Committee has sole discretion to approve or deny applications. Criteria that may be used by the committee to review credentials include, but are not limited to: History of illegal or unethical conduct. History of felony convictions. History of acts of dishonesty, fraud, deceit, or misrepresentation. History of involuntary termination of professional employment. History of professional disciplinary action or sanction by a managed care organization, hospital, medical review

board, licensing agency, or other administrative body. History of NPDB adverse action report. History of misrepresentation, misstatement, or omission of relevant facts. History of physical or mental condition, chemical dependency or substance abuse that may interfere with the

ability to practice in their specialty or may jeopardize patient health or safety. History of malpractice lawsuits, judgments, settlements, or other incidents that might indicate problems with

competence or quality of care. Demonstrated unwillingness to practice their specialty in a managed care environment and to cooperate with

Dean Health Plan in administrative procedures and other matters. Debarment or termination from the Medicare and Medicaid programs by the US Office by Personnel

Management.

Credentialing Committee members may recommend approval, denial or postponement of a decision until the applicant’s qualifications are further clarified.

All material obtained in the credentialing process, including complete applications, will be retained by Provider Network Services & Credentialing. Dean Health Plan maintains strict confidentiality of all information obtained during the credentialing process, except as otherwise provided by law. Access to the credentialing information is limited to Dean Health Plan staff involved in the credentialing process, and the Credentialing Committee members. All credentialing applications, files and other materials and information are kept in locked files, except when being reviewed or processed by Provider Network Services & Credentialing staff or members of the Credentialing Committee.

ASSESSMENT OF ORGANIZATIONAL PROVIDERS Dean Health Plan requires the following organizational providers are credentialed per NCQA Standards: Hospitals Home Health Agencies Skilled Nursing Facilities Free-standing Surgical Centers Behavioral Health Care Facilities (Inpatient, Residential, Ambulatory)

Organizational Credentialing Requirements Dean Health Plan requires the following standards be met for accredited and non-accredited organizations to receive approval, and to participate as a Plan Facility. Dean Health Plan Organizational Application: the entity applying must complete an application prior to being

considered to join as a Network location. State Licensure (if applicable): the entity must have a current, active license issued by the state regulatory agency.


Medicare/Medicaid Sanction History: the entity should not have current or recent sanctions by Medicare or Medicaid programs that would prevent the entity from providing services to Dean Health Plan members.

Malpractice Liability Coverage Insurance: the entity must acquire and maintain adequate malpractice liability insurance.

Accreditation Assessment: Dean Health Plan accepts accreditation by an appropriate nationally recognized accreditation agency. Dean Health Plan currently recognizes the following national accreditation agencies:

o Joint Commission on Accreditation of Healthcare Organizations (JCAHO) o Healthcare Facilities Accreditation Program (HFAP) o Accreditation Association for Ambulatory Health Care (AAAHC) o Commission on Accreditation of Rehabilitation Facilities (CARF) o National Integrated Accreditation for Healthcare Organizations (NIAHO) o Community Health Accreditation Program (CHAP) o Accreditation Commission for Health Care, Inc. (ACHC); o American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) o Center for Improvement in Healthcare Quality (CIHQ) o Healthcare: Det Norske Veritas Healthcare (DNV)

Non-Accreditation Assessment: Dean Health Plan accepts entities who are not accredited by a nationally recognized body if they meet the following requirements:

o Completion of the Dean Health Plan Facility Self Evaluation Form; o If applicable: a copy of the CMS/State Survey Report (CASPER). The survey must be conducted within the

last three years of credentialing or recredentialing. Any survey over three years will require an on-site visit.

Internal Customer Review: Dean Health Plan contacted internal departments via email to ascertain if there have been any issues or concerns identified for the facility which is being credentialed or recredentialed.

Organizational Onsite Visits Dean Health Plan performs site visits on facilities unable to demonstrate meeting program requirements, as identified above. The following categories are discussed during the onsite audit: Policies for the credentialing and recredentialing of its practitioners Physical Appearance/Accessibility Waiting/Session/Restrooms Fire and Safety Medical Recordkeeping Practices Control of Medication General operation policies and procedures Infection control

The onsite audit must score 80% or higher. If the scoring is below 80%, a written plan of correction will be required from the facility. Facilities that score below 80% will receive a letter indicating a written corrective action plan is required. The facility will have 15 days to submit a plan of correction. Failure to comply may result in the denial of credentialing/recredentialing of the facility. The Credentialing Committee has sole discretion to approve or deny the credentialing of a facility. Credentialing Committee decisions will be mailed within 60 days of the Credentialing Committee.


INITIAL CREDENTIALING APPLICATION – CLOSING A FILE/DENIAL Dean Health Plan may close the applicant’s file during the initial credentialing process at any time if the Credentialing Supervisor determines that the applicant does not meet the standards of this or any other Dean Health Plan credentialing policy. This can include, but is not limited to: The applicant does not meet all Dean Health Plan requirements to be approved as a plan practitioner. The applicant is unable or unwilling to provide Dean Health Plan with accurate or complete information regarding

questions on their application. The applicant is unable or unwilling to provide Dean Health Plan with verifiable information to support the

credentialing process. The applicant is unable or unwilling to provide Dean Health Plan with requested information relating to their

credentials, qualifications, history as a medical practitioner, criminal, or illegal activities.

The closing of an applicant’s credentialing file terminates the credentialing process for that applicant. In the event of closing an applicant’s credentialing file, Dean Health Plan will notify the applicant, in writing, stating the reason(s) for closing the file, and returning the applicant’s original application materials.

The applicant may withdraw their application at any time during the credentialing process. An applicant may reapply for Dean Health Plan credentialing at any time they are able to demonstrate they can meet all requirements for credentialing under this or any other Dean Health Plan credentialing policy. Providers denied by the Credentialing Committee during initial credentialing may reapply with Dean Health Plan after 12 months.

RECREDENTIALING APPLICATION DENIAL Providers denied during the recredentialing process will be notified in writing of the decision for denial, and of their rights to appeal the decision. All decisions made by the appeal committee are final. For more detail regarding denials, see section Altering Participation Station.

ALTERING PARTICIPATION STATUS Any decision to alter participation will be based on quality of care issues, professional competence or conduct. Dean Health Plan shall follow a standardized policy and procedure for altering a practitioner's participation in the network. This policy shall not apply to actions taken pursuant to a practitioner’s Participating Provider Agreement with Dean Health Plan that do not relate to the above. The action of altering a practitioner's participation with Dean Health Plan will be recommended by the Credentialing Committee. Reasons for altering of participation include, but are not limited to: Professional state licensure revocation, suspension or limitation Drug Enforcement Agency licensure revocation or limitation Debarment or termination from the Medicare or Medicaid programs by the U.S. Office of Personnel Management Loss or suspension of medical staff membership or restrictions on clinical privileges at any Dean Health Plan

participating hospital for reasons related to quality, professional competence or conduct Notification which involve imminent danger and/or concerns of quality to members Notification from Dean Health Plan Medical Peer Review Committee (MPRC) indicating quality concerns that

warrant altering participation Reported suspensions from the National Practitioner Data Bank (NPDB)

Information received regarding a practitioner or organization will be fully investigated by the credentialing staff, Provider Credentialing Supervisor and/or the Credentialing Committee Chairperson. All compiled information received will be reviewed by the Credentialing Committee.


Forms of investigation may include but are not limited to: Correspondence with practitioner; written and/or verbal Documentation from previous employers Documentation from current or past facilities that clinical privileges were held

In the event that the investigation reveals concerns about quality, professional competence or conduct that do not rise to the level of requiring immediate termination, the Credentialing Committee may recommend appropriate actions. Any recommendation of the Dean Health Plan Credentialing Committee involving the reduction of privileges, suspension or termination of a practitioner or organizational provider shall be reviewed within 30 business days by the Dean Health Plan Executive Staff members: President and Chief Executive Officer, Chief Medical Officer and the Vice President – Network Management & Group Product Segment Leader. The Executive Staff will: Approve the Credentialing Committee decision; or Deny the Credentialing Committee recommendation and stipulate alternate action to be taken.

The Executive Staff decision is final, subject to any appeal by the practitioner. In the event the Executive Staff does not agree with the recommendation of the Credentialing Committee, the rationale for taking alternate action will be provided in writing to the Credentialing Committee. The Executive Staff decision will be communicated to the affected provider in accordance with Section 1 of Dean Health Plan Credentialing Policy CR3017: Practitioner Appeal Process for Decisions Resulting in Reduction, Suspension or Termination. To obtain a copy of any of the policies references, please contact your designated Provider Network Consultant. The range of actions that can be taken by the Credentialing Committee or the Executive Staff includes but is not limited to: Continued Medical Education (CMEs) as appropriate; Proctoring; Communication by Dean Health Plan Chief Medical Officer; Ongoing Practice Assessments; or Reduction, suspension or termination of practitioner’s participation.

If the Executive Committee approves of the Credentialing Committee recommendation, notification of the adverse action shall be sent to the affected practitioner in accordance with Dean Health Plan Credentialing Policy CR 3017: Practitioner Appeal Process for Decisions Resulting in Reduction, Suspension or Termination. The affected practitioner shall remain listed as a participating provider until he or she has waived or exhausted his or her right to an appeal of the adverse action as set forth in Dean Health Plan Credentialing Policy CR 3017: Practitioner Appeal Process for Decisions Resulting in Reduction, Suspension or Termination. In the event that immediate action is required to prevent harm to Dean Health Plan members, employees or other participating providers, Dean Health Plan Executive Staff and Credentialing Committee Member may approve an immediate-termination action. These Committee Members will include the President and Chief Operating Officer, Senior Vice President and Chief Medical Officer, Vice President – Network Management & Group Product Segment Leader, and the Credentialing Committee Chairperson. Reasons for immediate termination include but are not limited to:

Professional state license revocation Drug Enforcement Agency licensure revocation Debarment or termination from the Medicare or Medicaid programs by the U.S. Office of Personnel Management Loss or suspension of medical staff membership or restrictions on clinical privileges at a Dean Health Plan

participating hospital for reasons related to quality, professional competence or conduct


In the event that Dean Health Plan takes immediate action, Dean Health Plan will provide the practitioner written notice of the action, including reasons for the action. Upon receiving the notice, the practitioner may request a hearing as described in Dean Health Plan Credentialing Policy CR3017: Practitioner Appeal Process for Decisions Resulting in Reduction, Suspension or Termination. In order to initiate an appeal, the plan practitioner must submit a written request identifying the reason he/she believes the decision was made in error, within 30 days of notification, to the Chief Medical Officer (CMO) or Credentialing Committee Chair. The practitioner may submit any substantiating documentation pertinent to the Appeals Committee’s review. The Appeals Committee will consist of no less than two Dean Health Plan physicians, who are not in direct competition with the plan practitioner and who are not members of the Credentialing Committee, the Chairperson of the Dean Health Plan Credentialing Committee, and a Dean Health Plan non-physician officer. The Appeals Committee cannot be scheduled less than 30 days from the date Dean Health Plan sends the practitioner the notice of hearing date and time. The practitioner has the right to appear and present information to the Appeals Committee. If the practitioner chooses not to be present at the Appeals Committee meeting, the Appeals Committee will make their final decision based on the information available. A majority vote is needed to reject an appeal. This decision will be communicated in writing to the practitioner within 14 days from conclusion of the Appeals Committee’s deliberations. The decision of the Appeals Committee is final. Based on that decision, Dean Health Plan will coordinate proper notification to the NPDB and the Department of Regulation and Licensing, per Dean Health Plan Credentialing Policy CR3018: Reporting Serious Quality Deficiencies.


CLAIMS, TIMELY FILING, AND EOPs

Claims Submission To allow for more efficient processing of your claims, we ask for your cooperation with the following: When a physician or a clinic becomes a “Contracted Provider,” they agree to accept payment made by Dean Health

Plan as payment in full. Discounts and withholds are not to be billed to the member or the secondary insurance company. Members may be billed for copayments, coinsurance, deductible amounts, and non-covered services.

Dean Health Plan requires providers to use the correct and complete member number. Families share the first nine

digits of their subscriber number. The remaining two digits signify the individual member (i.e. spouse, dependents, etc.). Using the correct member numbers on the claims submitted to Dean Health Plan will help us ensure correct claim payment.

Dean Health Plan requires contracted providers to file claims in a timely manner. All claims must be submitted in

accordance with the claim filing limit stipulated in your Provider Agreement/Contract. Refer to the Timely Filing Guidelines in this section for further instructions.

All claims for services regarding work-related injuries or illness should be submitted to the worker’s compensation

carrier. If claims are denied by the worker’s compensation carrier, you may submit the claim along with the denial for consideration by Dean Health Plan. All prior authorization guidelines apply in this situation. You must submit the claim(s) in a timely manner along with the denial as outlined in the timely filing guidelines.

Submit subrogation claims (where the third party may have caused the injury or illness due to an auto accident, a slip or fall, and/or a defective product) to Dean Health Plan for processing. We will pursue recovery of those expenses from the at-fault party and/or their liability insurer. All prior authorization guidelines apply in this situation. You must submit the claim(s) in a timely manner as outlined in the timely filing guidelines.

Dean Health Plan requires that all services billed be appropriately documented in the patient’s medical records in accordance with Dean Health Plan’s Medical Records Policy. If the services billed are not documented in the patient’s medical record, in accordance with the policy, they will not be considered reimbursable by Dean Health Plan. Dean Health Plan’s Medical Records Policy can be found in the Quality Improvement section of this manual.

While Dean Health Plan will accept paper or electronically submitted claims, it’s recommended to submit electronically to expedite processing and reduce claim rejections. All claims submitted, regardless of submission method, must comply with the applicable national billing rules as well as the published Dean Health Plan Companion Guides. Only the latest published versions of the claim forms will be accepted for processing. Please see the EDI Transactions section for more information on submitting electronically.

Coordination of Benefit (COB) claims must be received along with the primary payer’s explanation of payment within the TF limit outlined in your agreement with Dean Health Plan; beginning with the date noted on the primary payer’s explanation of benefits. Please note, COB claims may also be submitted via electronic data interchange (EDI) on the 837 claims transaction. When submitting COB claims electronically, be sure to add the prior payer’s payment information in the relevant segments. Full details can be found in the HIPAA Implementation Guides or the Dean Health Plan Companion Guides.

If your office would like to check the status of a claim, please utilize the Provider Portal’s claim status functionality or utilize a HIPAA standard 276/277 claims status transaction.


Providers can send claims to: Dean Health Plan PO Box 56099 Madison, WI 53705

Failure to submit all required information could result in claim payment denials or reduction in benefits.

Corrected Claims Dean Health Plan recognizes that it is sometimes necessary to change a claim or to challenge a decision. Specifically, a corrected claim is any claim that has a change to the original (e.g., changes or corrections to charges, procedure or diagnostic codes, dates of service, member name, etc.). If a provider agrees with the denial and in order for the claim to be reconsidered for payment a corrected claim would be required.

If a provider disagrees with the denial determination the claim can be appealed. Please see the Provider Appeals section of the manual for further details. All lines billed on the original claim must also be billed on the corrected claim.

All corrections will require an appropriate Claim Frequency Code and Payer Claim Control Number (Original Claim ID).

Corrected claims will be returned if any of the requirements are not met.

The following table explains specifically which information is required.

Scenario #1: Corrected Claims - Not Requiring Supporting Documentation

General Rule 837P & 837I CMS-1500 CMS-1450 Claim Frequency Code

Must include one of the following: • ‘7’ - Replacement • ‘8’ - Void

Note: Corrected claims submitted with a ‘1’ will be denied as duplicates.

Loop 2300: CLM05-3

Box 22 – Resubmission Code and/or Original Reference Number

Box 4 – Type of Bill Note: For Institutional claims, this represents the third digit of the Type of Bill being submitted.

Payer Claim Control Number

Must include the original Dean Health Plan claim number associated with the correction. Note: Corrected claims without a Dean Health Plan formatted original claim ID will be rejected.

Loop 2300: REF*F8


Box 64 – Document Control Number

Scenario #2: Corrected Claims – Requiring Supporting Documentation

Supporting documentation may still be required for certain claim-edit denials related to code bundling, new patient visits, global surgery, diagnosis, unlisted codes, etc.


Submitters must only submit claims requiring supporting documentation via the CMS-1450 or CMS-1500 form, using version 02/12. No electronic processing of these claims is currently supported. While Dean Health Plan is able to accept the PWK segment on an 837 transaction, we cannot guarantee it is being used in claims processing.

In addition, submitters must complete a Code Review Request Form along with any additional, required supporting documentation. In order to abide by HIPAA guidelines, only documentation pertinent to the correction should be submitted.

General Rule CMS-1500 CMS-1450 Claim Frequency Code

Must include one of the following: • ‘7’ - Replacement • ‘8’ – Void Note: Corrected claims submitted with a ‘1’ will be denied as duplicates.


Box 4 – Type of Bill Note: For Institutional claims, this represents the third digit of the Type of Bill being submitted.

Payer Claim Control Number

Must include the original Dean Health Plan claim number associated with the correction. Note: Corrected claims without a Dean Health Plan formatted original claim ID will be rejected.


Box 64 – Document Control Number

Acknowledgment of Submitted Claims Dean Health Plan provides acknowledgment of all new claim submissions via the Confirmation Reports Portal. Confirmation reports show all claims accepted in for processing as well as all claims that were rejected and not accepted in for processing. Confirmation reports will be available within 48 hours of when Dean Health Plan receives a claim. This includes claims submitted electronically or on paper. A link to the Confirmation Reports Portal can be found on the Provider Resources page of deancare.com. Please contact your Provider Network Consultant to sign up for the Confirmation Reports Portal. If you do not have access, you will receive paper notification of rejections only. Providers should review each report received to confirm all claims were received by Dean Health Plan and to work the rejected claims. The rejected claims portion of the report will include error codes to explain the specific reason a claim was not accepted. Based on the error codes provided, please resubmit the claims with the necessary changes. Providers are required to make corrections and resubmit the claim within the allotted timeframe agreed upon in the contract beginning with the date of receipt. If you are submitting claims electronically, a 999 acknowledgement transaction will be used to indicate whether or not your transaction sets (ST/SE) passed SNIP types 1 and 2 compliance. Please work directly with your clearinghouse or EDI team to validate claim transaction acceptance. In cases of rejected 999s, please use the content of the transaction to understand the errors and resubmit the entire transaction. Please refer to the timely filing guidelines when resubmitting. There is no need to resubmit with an Untimely Filing Waiver Request Form unless you are resubmitting outside of your timely filing guidelines.


The following is an example of the Confirmation Reports Portal: Accepted

Rejected

Timely Filing (TF) Guidelines for Initial Submission

The initial submission of a claim is subject to the timely filing guidelines outlined in your agreement with Dean Health Plan. When a provider’s claims (paper and/or electronic) are received in our Claims Department, Dean Health Plan will provide proof of receipt and return confirmation via the Confirmation Reports Portal to the submitting provider. This receipt will include the date that Dean Health Plan received the paper or electronic claim. If a claim is rejected for improper submission, resubmission must be completed by the provider within the filing limit outlined in your agreement with Dean Health Plan. When you receive your confirmation report back from Dean Health Plan, retain them for your records in the event that you need to file an untimely filing waiver request. Please be aware that when a provider fails to submit a claim timely, rights to payment from Dean Health Plan are forfeited and the provider may not seek payment from the member as compensation for these covered services.

Exceptions to Timely Filing Guidelines on Initial Claim Submission Requests for temporary waiver of the TF limit must be made in advance due to computer system conversions or

other short term circumstances. Such requests may be made, in writing, to your assigned Provider Network Consultant.

Coordination of Benefit (COB) claims must be received within the TF limit outlined in your agreement with Dean Health Plan; beginning with the date noted on the primary payer’s explanation of benefits.

Crossover claims are exempt from the filing limit. Crossover claims are those claims that are initially filed with CMS, and forwarded by CMS to Dean Health Plan.

If the provider had difficulty obtaining Dean Health Plan coverage information from the subscriber, claims must be received within the timely filing limit beginning with the date the Dean Health Plan coverage is identified, but not longer than 180 days from the date of service. Provider shall submit supporting documentation to demonstrate measures the provider has taken to obtain this information. Upon receipt of such information, provider must submit claims and supporting documentation within the filing limit outlined in their agreement.

Claims for prenatal visits, which would have been normally billed as part of a global obstetrics (OB) charge, must be billed separately due to a change in physician and need to be submitted within timely filing limit, beginning with the date of delivery. Dean Health Plan will not accept a global obstetrical charge from a provider.

Timely Filing Guidelines for Claim Resubmissions/Corrections All resubmitted/corrected claims need to be received by Dean Health Plan within the filing limit outlined in your agreement. The first day of the filing limit for resubmissions/corrections begins with the date upon which Dean Health Plan notifies the Provider a claim has failed processing. You will find this date on the Explanation of Payment (EOP) or your 835.


Exceptions to Timely Filing Guidelines on Claim Resubmissions

Resubmitted claims as a result of our error can be resubmitted/corrected up to one year after the run date of the Rejected Claims Reports or the EOP date.

If the provider has hospital-based providers (radiology, anesthesiology, etc.) or is submitting claims for a hospital-based provider who must wait for the inpatient discharge of the member, the provider must submit claims within the timely filing limit from the discharge date of the inpatient confinement for Dean Health Plan to consider payment.

The provider discovers new or additional information and requests additional payment on a processed and paid claim. Provider must submit this information within the timely filing limit in order for Dean Health Plan to consider additional payment.

Medical Assistance HealthCheck claims are exempt from the timely filing limit.

Newborn claims must be received no later than 14 months from the date of birth.

Explanation of Payment Dean Health Plan produces Explanation of Payments (EOP) on a weekly basis. If you have questions on an item on the EOP, please review on the Provider Portal Remit Functionality or contact the Customer Care Center. When either Dean Health Plan or a provider determines that payment has been made for services for which payment should not have been made, the provider should promptly return such overpayments to Dean Health Plan. Upon the discovery of any such overpayments, Dean Health Plan may alternatively offset such overpayments against any amounts otherwise due or thereafter becoming due from Dean Health Plan as in the terms of your agreement.

The offset adjustments are made to the provider’s claims in Dean Health Plan’s claims processing system. These adjustments will appear on the provider’s EOP following the processing of a provider’s claims. You will find the adjustments on your EOP in the “negative” (-) adjustment field.

The negative adjustments deduct payments from the provider’s future claims. Overpayments may be taken from the same EOP, as the adjusted claims appears or may be on future EOPs. Dean Health Plan will continue to offset the negative amount on a provider’s future claims until the overpayment is satisfied. In addition or in lieu of the paper EOP, many providers are receiving and posting their payment via our 835 HIPAA transactions. Providers my sign up to receive our 835 transactions via our website at: deancare.com/health-insurance/quality/hipaa-transactions/

Electronic Claims Responses Now Available To speed efficiency, Dean Health Plan now offers electronic acknowledgements for health care claims. They arrive in an EDI format, known as the 277 Claims Acknowledgement transaction, or 277CA. Previously, we only provided such acknowledgements through our Confirmation Reports Portal for acceptance or rejection. If the submitting providers did not sign up for our Confirmation Reports Portal, they received a printed rejection letter in the mail. Please note, the Confirmation Reports Portal will still be available to providers. If a provider’s office enrolls to receive these acknowledgement files, a response file will be generated for each electronic (837) claim file Dean Health Plan receives. To get started, providers need:

http://www.deancare.com/health-insurance/quality/hipaa-transactions/



• A secure FTP connection • Ability to submit the claim files electronically prior to being able to receive acknowledgment files

If providers submit their claims through a clearinghouse, the clearinghouse would need to have a secure FTP connection established with Dean Health Plan. The system will identify each claim individually - within the claim file - whether the claim was accepted or rejected. All accepted and rejected claims go out with corresponding industry codes.

• HIPAA transaction page has been updated to reflect this new offering. • DHP sends these files using PGP encryption. This is to ensure the most secure transmission of protected health

information. For more details on the file exchange process using PGP encryption, please contact DHP’s EDI team.

For electronic claims enrollment and responses, please visit our HIPAA transaction webpage at deancare.com/health-insurance/quality/hipaa-transactions/. You can also reach out directly to the EDI team at 800-356-7344 ext. 4320 or [email protected].




CLAIMS CODING PROCESS

Claims Coding

Dean Health Plan is committed to processing claims in a consistent, timely and accurate manner. To support this ongoing effort, our claims processing logic is maintained to support the application of correct coding principles and Health Insurance Portability and Accountability Act (HIPAA) code-set standards. These payment policies are derived from recommendations from a variety of clinical and coding sources including, but not limited to:

• American Medical Association (AMA) correct coding principals • Centers for Medicare and Medicaid (CMS) medical and coding policies including local and regional Coverage

Determinations • Nationally recognized academy and society guidelines • Manufacturer’s package insert (FDA approved indications) for injectable drug and biologic agents

Code Review Request If, after review, you believe the claim is coded correctly and that the charge was denied in error, you have the option to request a coding review via our Code-Edit Review process.

To submit electronically:

• Complete the Claim Review Request form found under the Claim Appeal feature of our Provider Portal at deancare.com/providerportal.

• Include a brief statement indicating why the decision should be overturned along with relevant supporting documentation (operative reports, medical records, etc.)

To submit via paper:

• Complete the Claim Review Request form found on deancare.com/providers/forms/ • Include a brief statement indicating why the decision should be overturned along with relevant supporting

documentation (operative reports, medical records, etc.)

If you have any questions, please contact the Customer Care Center at (800) 279-1301.


http://www.deancare.com/providers/forms/


EDI TRANSACTION PROCESS Electronic Data Interchange (EDI) An array of electronic transactions are available to facilitate a more efficient experience for providers. Please see the HIPAA Transactions page of deancare.com for the EDI set-up form, companion guides, and FAQs.

Claim Submission (837) Electronic claim submission allows for standardized transmission of claims data, resulting in fewer rejections and more streamlined claims adjudication. To submit claims electronically, please complete an EDI set-up form and, if necessary, work with your clearinghouse or billing service to arrange transmission. In addition, the Confirmation Reports Portal is available to see the status of claim submission through the pre-processing compliance edits. Please work with your Provider Network Consultant to set-up access.

Claim Remittance Advice (835) & Electronic Funds Transfer (EFT) Dean Health Plan works with Emdeon to provide the electronic remittance advice as an alternative to the printed explanation of payment (EOP). Please review the Emdeon 835-EFT-ERA FAQs document on the HIPAA Transaction webpage.

Claim Status Request & Response (276/277) Electronic claim status requests allow real-time inquiry and response to quickly know the status of a claim. This transaction is available to providers via EDI transactions as well as through the Provider Portal. Please note that the provider should wait a minimum of 30 days after claim submission to send a claim status response to allow for the known payment processing time. To engage in EDI transmission, please complete an EDI set-up form and, if necessary, work with your clearinghouse or billing service to arrange transmission. Please work with your Provider Network Consultant to set-up access for the Provider Portal.

Eligibility Request & Response (270/271) The most timely and accurate way to confirm a member's benefits and coverage amounts is to submit an eligibility request transaction. Dean Health Plan offers this transaction in real-time through traditional EDI as well as through the Provider Portal. To engage in EDI transmission, please complete an EDI set-up form and, if necessary, work with your clearinghouse or billing service to arrange transmission. Please work with your Provider Network Consultant to set-up access for the Provider Portal.

EDI Help Desk If you have questions related to EDI set-up, data content, or other EDI issues please contact the EDI help desk directly at [email protected] or (800) 356-7344 ext. 4320.




AUTHORIZATION PROCESS It is important to understand the difference between Dean Health Plan’s products to ensure proper authorization guidelines are followed. Failure to understand or follow these guidelines will result in claim payment denials or reduction of benefits. Some products require authorization for some services, while others may not. Because Dean Health Plan has different types of products and/or benefits within the benefits certificates, it is best to confirm the benefits via the Eligibility functionality available on the Provider Portal (deancare.com/providerportal). The second step is to confirm the authorization requirements as noted in the member’s certificate of benefit or Summary Plan Benefit and/or the Dean Health Plan Medical Policies. As such, the guidelines contained in this manual are general and should be confirmed with the specific member’s benefit certificate or Summary Plan Document. What is a Plan or Adjunctive Provider? A provider that is contracted with Dean Health Plan to provide services and is listed in our provider directory. What is a Non-Plan with Agreement Provider? A provider that is contracted with Dean Health Plan, however is not considered to be a plan provider and requires an authorization from a plan provider for services to be considered for coverage. If you have a question regarding a provider’s participation within the Dean Health Plan contact the Customer Care Center. What is a Non-Plan/Non-contracted Provider? A provider that does not have a signed contract with Dean Health Plan. The Health Plan has no liability or responsibility for the quality of care provided by a non-plan provider. Controlling Cost Dean Health Plan’s goal is to provide high quality, cost-effective care for its members. One method of controlling the increasing cost of medical care is to manage services by monitoring services provided to our members. The following are services Dean Health Plan monitors:

• Behavioral health and Substance abuse • High-end radiology • Physical medicine (physical therapy and occupational therapy) • Speech therapy • Authorizations based on Medical Policies • Inpatient Admissions • Pharmacy Formulary/Medications

What is an Authorization? A Dean Health Plan authorization form requests approval of outpatient treatment for an HMO or POS member by

a non-plan with agreement and/or non-contracted provider of health care. An authorization may also be required for services based on the Dean Health Plan Medical Policies.

Authorizations are required for all inpatient and observation admissions to a plan facility. It is completed in full by an in-plan Dean Health Plan Primary Care Provider (PCP) or an in-plan Dean Health Plan

Specialty Provider. The completed form is submitted to the Dean Health Plan Utilization Management for determination of approval.

The authorization must be obtained and approved prior to the member receiving services. A verbal or written request for services does not constitute an approved prior authorization. An approved inpatient hospital authorization confirms the medical necessity of hospital based services.



Providers with access to the Provider Portal system can submit authorizations via the online Provider Portal Authorization functionality authorization link.

Outpatient Day surgery services (which include up to 23 hours of hospital monitoring post discharge from the PACU) are considered an elective admission and do not require prior authorization unless the procedure is specifically indicated to require prior authorization in a Dean Health Plan Medical Policy.

What is Prior Authorization? Prior Authorization is written approval from the Dean Health Plan Utilization Management department prior to

the member receiving services. A verbal or written request for services does not constitute prior authorization until a determination has been made by Dean Health Plan.

The prior authorization request must be submitted by a Plan Dean Health Plan PCP or Specialty provider. Prior authorization should be obtained no later than seven days prior to the planned procedure.

Prior authorization is required for all elective inpatient admissions to a plan facility. The authorization issued by Utilization Management will state the type and extent of the treatment or benefit authorized.

Failure to complete the required prior authorization may result in a denial of a claim (HMO or plan POS) or reimbursement of a claim at a lesser benefit.

It is the plan provider’s responsibility to confirm member eligibility and benefits either via Provider Portal, direct EDI transaction or by contacting the Customer Care Center (800-279-1301).

If a plan facility provider has Provider Portal access the prior authorization request should be submitted via the Provider Portal. If the plan facility provider does not have Provider Portal access the prior authorization may be obtained by contacting the Dean Health Plan Utilization Management Department by fax (608-252-0830) or phone (800-356-7344 ext. 4455).

What is Concurrent Authorization? Concurrent authorization is required for all urgent/emergent admissions (both Inpatient and Observation status)

to a hospital facility. Notification of the admission of any Dean Health Plan member must be made to Dean Health Plan no later than

one business day following the admission. It is the provider’s responsibility to confirm member eligibility and benefits either via the Provider Portal, direct

EDI transaction or by contacting the Customer Care Center (800-279-1301). Urgent/emergent admission authorization requests should be made via Provider Portal if the provider has access,

or can be obtained by contacting the Utilization Management Department by fax (608-252-0830) or phone (800-356-7344 ext. 4455).

How can I verify that an authorization has been processed by Dean Health Plan? You will receive a copy of the authorization either by mail or by fax if you do not have access to the Provider Portal.

If you have access to the Provider Portal, you will receive authorizations through the Portal. The notification will indicate if the requested services were denied, approved, or if the member has been denied and redirected to another provider.

Hospital authorizations are approved unless you are notified by Dean Health Plan Utilization Management of a denial. Written denial notifications are issued to the hospital provider, attending physician and member if a prior authorization is denied.

Concurrent authorization denials are communicated verbally to the facility Utilization Management department with a letter to the facility, attending physician and member within 72 hours of the verbal notification.

Contact the Customer Care Center (800-279-1301) for the status of authorization requests.

Approved authorizations indicate only that the services are considered medically necessary. If a member’s benefits have been exhausted or the requested service is not a covered benefit of the member’s plan, the member’s claim will deny indicating this. If a member becomes ineligible under their Dean Health Plan policy the claim will deny indicating that the member is not eligible for coverage.


What happens when an authorization is submitted with insufficient information in order for a determination to be made? All providers must submit any documentation relevant to the authorization request when the authorization is submitted. The following steps will occur if the provider who fails to submit relevant documentation or if Dean Health Plan Utilization Management identifies that additional information is required to make a determination:

• Dean Health Plan Utilization Management will review and determine if all the information that might be required for a determination has been provided.

• If insufficient information has been submitted, the Dean Health Plan Utilization Management will make an outreach phone call to the provider to request the information. Dean Health Plan Utilization Management will advise of:

o Member name and DOB o Specific authorization request for the member that is missing information o Specific information which is required o Fax number and name of individual that the information should be made attention to

• The provider office will be advised that if the information is not received within 2 business days, one additional phone call will be made in an attempt to obtain the needed information.

• If the requested information is not provided to Dean Health Plan Utilization Management within the requested 2 business days, Dean Health Plan Utilization Management will contact the provider office again and advise:

o Member name and DOB o Specific authorization request for the member that is missing information o Specific information which is required o Fax number and name of individual that the information should be made attention to

• The provider will be advised that if the information is not received within 2 business days of this 2nd phone request, the authorization will be submitted to the Medical Director for review based on the information which is available after the 2nd business day.

• Authorization and any available information will be directed to the Medical Director for review on the 3rd business day following the 2nd request.

• If the authorization is denied a new authorization request with new objective medical documentation must be submitted for consideration of the services. The required information cannot be provided via the peer to peer process for the authorization denial.

• Resubmission of an authorization request must contain new objective medical documentation for it to be considered. New authorizations should not be submitted simply to re-open the peer to peer process.

• Authorizations without new objective medical documentation will be cancelled back to the provider if entered through the Provider Portal or will not be entered if submitted on paper and the requesting physician office will be contacted to advise why the authorization is not being processed.

HMO/EPO AUTHORIZATION GUIDELINES As an HMO, Dean Health Plan requires that members choose a primary care clinic. The PCP acts as a “gatekeeper” to ensure members receive appropriate, high quality care in a cost effective manner. Primary care practitioners (and sometimes plan specialists) should assist members by completing an authorization to a non-contracted provider when the plan provider feels that the request is medically necessary. If you are a contracted provider with Dean Health Plan it is your responsibility to make sure the prior authorization is in place prior to rendering services. Failure to understand or follow these guidelines will result in claim payment denials or reduction of benefits. Dean Health Plan does not require authorizations to the following locations and physicians: All Plan-to-Plan clinics and physicians Plan Behavioral Health Providers Plan Alcohol and Other Drug Abuse (AODA) clinics and/or facilities


Prior authorization may also be required due to a medical policy for a specific service. A listing of services which require prior authorization or are not a covered benefit of the plan may be found at deancare.com/providers/patient-care/medical-management/ Medical Policies may be accessed online at: deancare.com/providers/medical-management/ All other Dean Health Plan clinical guidelines used by the Quality and Care Management Division, such as Milliman Care Guidelines (MCG) are accessible to the provider upon request. Contact the Quality and Care Management Division at (800) 356-7344 ext. 4012 to request the clinical guidelines. All services provided by a non-contracted or non-plan with agreement provider require a prior authorization. An

approved authorization (one that has been processed by the Utilization Management Department prior to care being provided) constitutes prior authorization. These requests are only considered for services that cannot be provided within the Dean Health Plan network of providers. It is recommended that an appointment to a non-contracted provider is not made until prior authorization has been obtained.

Authorization Request forms may be found at the Provider Portal or deancare.com/providers/forms/ All services provided by a non-contracted or out of network behavioral health providers require an authorization.

Please contact the Customer Care Center at (800) 279-1301 if you have any questions.

If you have questions regarding our prior authorization requirements for our Medicare supplemental plans, please contact the Customer Care Center at (800) 279-1301.

POINT OF SERVICE (POS) AUTHORIZATION GUIDELINES Dean Health Plan Point of Service (POS) members are not required to use plan providers, but may have lower out-

of-pocket costs by using a plan provider. POS members may be subject to a prior authorization penalty if the authorization is not obtained prior to receipt of medically necessary services.

Members of Dean Health Plan who are enrolled in the POS Plan are not required to select a PCP or clinic. They have the option to use plan and non-contracted providers, but may receive a different level of benefits based on that provider’s status with Dean Health Plan.

Because POS members have the choice to utilize plan or non-contracted providers, prior authorization for non-contracted services is not necessary unless required by Dean Health Plan medical policy.

Services that require prior authorization are outlined in the member’s Certificate of Coverage and/or the Dean Health Plan Medical Policies.

Contact the Customer Care Center for assistance with questions regarding the authorization process for a POS member.

If a member seeks services from a non-contracted provider, the member is responsible for prior authorization requirements and may be subject to penalty or denial of services if prior authorization is not obtained before the services are received. When a member is required to obtain prior authorization, they should contact the Customer Care Center to obtain assistance with how to prior authorize their care, unless a separate guideline exists in this section of the Provider Manual.

POS IN-PLAN BENEFIT EXCEPTION POLICY If medically necessary services are not available within Dean Health Plan’s plan provider network, services with non-contracted providers will be considered for coverage at the in-plan benefit level only if:

• A Dean Health Plan provider has submitted an authorization request on the member’s behalf indicating that they are requesting services at the in-plan benefit level because they are not available in plan.

and • The request has been reviewed and approved for in-plan benefits by the Dean Health Plan Utilization Management

Department prior to the delivery of the services.

http://www.deancare.com/providers/patient-care/medical-management/


http://www.deancare.com/providers/medical-management/



Authorization requests will be cancelled if all the following criteria are met: to non-contracted providers for services that do not require an authorization the request does not indicate that the prior authorization request is being made specifically for in-plan benefits.

NOTE: A notification letter will be sent to the provider and these claims will be processed at the non-plan benefit level. Authorization requests will be denied to non-contracted providers requesting in-plan benefits when the services are available with plan providers. The denial will indicate that the in-plan benefit level of payment has been denied and the plan provider who can deliver the requested service. EXCEPTION: Prescription drugs and DME supplies are not covered if prior authorization has not been obtained.

PREFERRED PROVIDER ORGANIZATION (PPO) AUTHORIZATION GUIDELINES Dean Health Plan Preferred Plan Organization (PPO) members are not required to use plan providers, but may

have lower out-of-pocket costs by using a plan provider. PPO members may be subject to a prior authorization penalty if the authorization is not obtained prior to receipt of medically necessary services.

Members of Dean Health Plan who are enrolled in the PPO Plan are not required to select a PCP or primary care clinic. They have the option to use plan and non-contracted providers, but may receive a different level of benefits based on the rendering provider’s status within the indicated national network.

Because PPO members have the choice to utilize plan or non-contracted providers, prior authorizations for non-contracted services are not necessary unless required by the Dean Health Plan medical policy.

Services that require prior authorization are outlined in the member’s Certificate of Coverage and/or in the Dean Health Plan Medical Policies.

Members enrolled in PPO plans have access to nationwide networks of providers. Dean Health Plan Utilization Management does not authorize services for these members for plan or non-contracted benefit levels of payment. Claims for services will be processed based on the rendering provider’s affiliation or lack of affiliation with the PPO network that the member is enrolled in.

MEDICARE SELECT AND DEANCARE GOLD PLAN AUTHORIZATION GUIDELINES For Medicare supplemental plans, prior authorization is not required for outpatient services provided by a plan provider for services covered by Medicare. Because a PCP acts as the “gatekeeper” to ensure members receive appropriate and high quality care, we encourage you to discuss any specialty care that your patients may be receiving, even when a prior authorization is not required. Plan hospitals are not required to notify Dean Health Plan and authorize inpatient admissions when Medicare is the primary insurance. These are the specific situations in which a prior authorization IS required: An authorization is required if a member participates in a Dean Health Plan Medicare supplemental plan and is

seeking care from non-contracted providers. Prior authorization is required for all elective admissions to non-contracted facilities. DeanCare Gold members are required to utilize DeanCare Gold providers and will require a prior authorization

when receiving services from providers outside of the Dean Care Gold network.


Members who have Medicare as primary insurance and a Dean Health Plan commercial or self-funded plan (not a supplement plan or not DeanCare Gold plan) as secondary insurance through an employer (or former employer) are required to follow all of the current authorization guidelines required for HMO/POS members.

In the event a member has a Dean Health Plan policy that is secondary to Medicare (through an employer or former employer), therapies are subject to the retiree plan benefits and HMO guidelines. Please refer to the DeanCare Gold Provider Manual for additional details regarding this process.


PRIOR AUTHORIZATION REQUESTS Authorization Priority The authorization status refers to the urgency with which the authorization requires processing. This is a required field for authorization entry. There are six authorization statuses; two are specific to inpatient authorizations and four are specific to outpatient authorizations.

INPATIENT AUTHORIZATION STATUSES OUTPATIENT AUTHORIZATION STATUSES

Urgent Admission Elective Admission

Pre-service Non-Urgent Post service Pre-service Medically Urgent: Must have a physician signature certifying the

medical urgency of the request (please refer to definition of medically urgent) Pre-service Administratively Urgent

Authorization Priority Definitions AUTHORIZATION

STATUS TIMEFRAME DEFINITION STATUS TYPE Pre-service non urgent

Determination within 15 days of receipt This status is used for outpatient requests. Outpatient

Urgent admission Urgent/Concurrent Review

This status is used for inpatient or observation admission to a facility when the member is admitted from either the emergency room, an observation status or a physician office.

Inpatient

Elective Admission

Provider notification at least seven days prior to scheduled elective admission. Determination within 15 days of receipt

This status is used for elective inpatient admissions to a Hospital or Skilled Nursing Facility

Inpatient

Post-Service

Determination within 30 days of receipt (unless additional information is required for determination)

This status is used for reqeusts that are received after the member’s services have already been received. Most post-service requests will not be accepted. Exceptions will only be considered that initiate over a weekend or holiday.

Outpatient

Pre-Service Medically Urgent

Determination within 72 hours of receipt. Must have physician signature on authorization form to process as medically urgent. **See below for pathway

This status is used for requests when the delay of service could jeopardize the life or health of the member orwould subject the member to severe pain that cannot be adequately managed without this care or treatment.

Outpatient

Pre-Service Administratively Urgent

Respond as promptly as possible to these requests goal seven days)

This status is used for reqeusts which do not meet the definition of Medically Urgent, however, are deemed to be time-sensitive by one or more of the affected parties.

Outpatient

PATHWAY TO AUTHORIZATION FORM: deancare.com/providers/forms (Patient, column 4) or via the Provider Portal at deancare.com/providerportal.

http://www.deancare.com/providers/forms



ELECTRONIC AUTHORIZATION SUBMISSIONS If you are a Dean Health Plan Provider Portal-enabled office, all authorization request submissions are sent to Dean Health Plan electronically via the secured Provider Portal. You will receive the response to your request electronically via the Provider Portal. The member and referred to physician will receive a response to the request via written correspondence. If you are not a Dean Health Plan Provider Portal-enabled office, then you must complete and submit the Authorization Request Form and fax to Utilization Management at (608) 252-0830. Authorizations submitted as “pre-service medically urgent” that do not meet the definition of medically urgent AND/OR do not have a physician signature may be changed to “administratively urgent.” This determination is made only by Dean Health Plan medically licensed personnel and a call to the requesting provider office advising of this change and why will be made.

NON-ELECTRONIC AUTHORIZATION SUBMISSIONS Once you have determined that you will need to complete a Written Authorization Request Form, follow the guidelines below: The Authorization Request Form can be found at deancare.com/providers/forms/

Authorization request forms should be mailed or faxed on the date the request has been completed to ensure timely processing of the authorization request.

Please complete ALL fields on the top part of the form in their entirety, otherwise the Utilization Management Department will return it to the referring physician for completion.

Authorization requests must be signed by the ordering provider if they are indicated as Pre-service Medically Urgent.

When an authorization is requested to a non-contracted provider, please include as much information as possible regarding why the request is being submitted and the plan providers that the member has already seen. The Utilization Management Department will review the authorization request to ensure that medically necessary care has been requested and that the services requested are not available with plan providers.

All copies of these authorizations must be faxed to: (608) 252-0830

or

Mailed to: Dean Health Plan ATTN: Utilization Management

P.O. Box 56099 Madison, WI 53705

Only services that are NOT provided within the Dean Health Plan provider network are considered for approval with a non-contracted provider. Authorizations submitted as “medically urgent” that do not meet the definition of medically urgent above and/or do not have a physician signature may be changed to “administratively urgent.” This determination is made only by medically licensed personnel, and includes a call to the requesting provider office advising of this change and determination.

PRIOR AUTHORIZATION GUIDELINES The following pages contain an overview of some of the most common coverage of services for Dean Health Plan. These descriptions are intended to provide only an overview, and should not be construed as a description of coverage for members. Please contact the Customer Care Center at (800) 279-1301 for member benefits.



AMBULANCE SERVICES The ambulance benefit is a transportation benefit and without a transport there is no payable service, thus the transport of a member must occur for there to be a payable service. When multiple ambulance providers and suppliers respond, payment is made only to the provider or supplier that actually transports the member. Ambulance transportation includes the services of ambulance attendants and the provision of reusable equipment and devices (e.g., stretchers, restraints, backboards, inflatable leg and arm splints).

Coverage of non-emergency ambulance transport will be based on criteria established by the Quality and Care Management Division as medically appropriate under the Dean Health Plan Medical Policy as well as the member’s Certificate of Coverage or summary plan description. Ground Ambulance Transportation Ambulance ground transportation is covered to or from a hospital when the transportation is emergent or urgent in nature and medical attention is required en route. Coverage of non-urgent/non-emergent ground ambulance transportation will be based on the following criteria: The patient's condition contraindicates the use of any other method of transportation. The services are not available in the hospital to which the patient has been admitted (e.g., the patient was

transported to another facility for cardiac catheterization, then returned to the admitting hospital). The facility furnishing the services is the nearest one with the appropriate facilities. Or as requested by our Quality and Care Management Division.

Air Ambulance Transportation An air ambulance transport to transfer a member from one hospital to another hospital must meet the following requirements: Meets the requirements of ambulance ground transportation A ground ambulance transport would endanger the member’s health The transferring hospital does not have the needed hospital or skilled nursing care for the member’s illness or

injury The transfer is to the closest medical facility that can provide the required level of care Or as requested by our Quality and Care Management Division

Non-Covered Ambulance Expenses: Member’s condition does not meet medical criteria for ambulance transportation Ambulance initiated by the member for convenience or non-medical reasons Charges for Basic Life Support or Advanced Life Support when the member is not transported by the ambulance

supplier

An ambulance service that is not an emergency transportation is not considered a covered service, unless it is prior authorized and approved by the Dean Health Plan Utilization Management Department.

BEHAVIORAL HEALTH AND SUBSTANCE ABUSE Dean Health Plan provides coverage of mental health and substance abuse treatment for those members whose benefit package includes mental health/substance abuse services.

Dean Health Plan HMO and POS members seeking in-plan benefits must obtain an authorization for Behavioral Health and Substance abuse services (listed below) from Magellan Behavioral Health, a subsidiary of Magellan Healthcare who is delegated to provide the determination of medical necessity for all behavioral health and substance abuse services. All behavioral health/substance abuse services must be obtained from a network provider for HMO and EPO Plans. You can contact Magellan Behavioral Health customer service representatives at (800) 424-4710 to obtain prior authorization and concurrent review services.


Behavioral Health and Substance Abuse Levels of Care

Behavioral Health Inpatient Care is a medically necessary treatment for behavioral health conditions in an inpatient setting.

o The admitting facility is required to call Magellan Behavioral Health by the next business day for admission notification/approval of admission.

Behavioral Health Residential Care is a benefit for some policies. o This level of care is considered elective and must be prior authorized by Magellan Behavioral Health

prior to admission. Detoxification Inpatient Care is considered a medical benefit.

o The admitting facility is required to call Magellan Behavioral Health by the next business day for admission notification/approval of admission.

Substance Abuse Inpatient/Residential Care is a medically necessary treatment for substance abuse conditions in an inpatient setting.

o This level of care is considered elective and must be prior authorized by Magellan Behavioral Health nurses prior to admission.

Outpatient Care is a medically necessary treatment for behavioral health/substance abuse conditions in an outpatient setting.

o Network providers do not require prior authorization. o Services with a non-contracted provider require an approved prior authorization.

Other Behavioral Health and Substance Abuse Services is a medically necessary treatment for behavioral health/substance abuse conditions in a less restrictive manner than inpatient care, but a more intensive manner than outpatient care:

o Day treatment/Partial Hospitalization Programs is for behavioral health/substance abuse conditions.

o This level of care is considered elective and must be prior authorized by the Magellan Behavioral Health nurses prior to admission.

Court Ordered Care Court-ordered services may not be covered unless the services are a result of an emergency detention or received on an emergency basis and you or your provider notifies Magellan Behavioral Health within72 hours after the initial services.

BEHAVIORAL HEALTH/SUBSTANCE ABUSE EXCLUSIONS The following services are generally excluded from coverage: Hypnotherapy Phototherapy Marriage Counseling Family counseling for non-medical reasons Wilderness and camp programs, boarding school, academy-vocational programs and group homes Residential Care, except for transitional substance abuse care Halfway houses Biofeedback Gambling addiction Long-term or maintenance therapy

CHIROPRACTIC CARE Please refer to the Chiropractic Care Overview section of the manual.


COSMETIC SURGERIES Prior authorization is required for any surgical procedure that may be considered cosmetic. A listing of medical policies or specific procedures which are considered to be cosmetic can be found at deancare.com/providers/medical-management/

DENTAL SERVICES

Dean Health Plan will cover dental services, required to treat sound natural teeth that are injured. The term “injured” does not include conditions resulting from eating, chewing, or biting. Covered treatment must begin within 90 days after the accident and covered services for tooth extractions must begin within 18 months after the accident. Dean Health Plan may allow for the initial examination and/or x-rays to determine a diagnosis. Any services or treatment requested beyond that must be prior authorized by the Quality and Care Management Division.

In most cases, benefits are limited to the extraction and replacement of teeth related to an accident or injury. Restorations, such as crowns, are not covered (coverage varies between policies and some members may have different coverage for these types of services). Coverage will also be provided in connection with dental care that is received by a member in a hospital or ambulatory surgery center if the medical necessity indicated in the applicable Dean Health Plan medical policy is met. These services must be prior authorized by Dean Health Plan. To access the most up-to-date Dental and Oral Surgery policies regarding prior authorization requirements go to: deancare.com/providers/medical-management/ Please contact the Customer Care Center if you have questions regarding a member’s schedule of benefits or benefit plan coverage.

DIAGNOSTIC TESTS Dean Health Plan HMO plans do not require a prior authorization for diagnostic services that are ordered by a plan provider and are rendered by a plan provider, unless indicated as required for some radiology services (CT/CTAs, MRI/MRAs, PET scans and nuclear image stress tests (ETT) or by Dean Health Plan Medical Policies. Dean Health Plan POS/PPO plans do not require authorization for most routine outpatient diagnostic tests. Diagnostic services that fall under the CPT classification of surgery (such as colonoscopy, endoscopy, or arthroscopy) and are being done for the purpose of diagnosing an illness or injury do not require prior authorization. When unsure if a procedure will require prior authorization, please call the Customer Care Center or to find a list of prior authorization requirements please go to: deancare.com/providers/medical-management/

DURABLE MEDICAL EQUIPMENT (DME) AND SUPPLIES All DME and supply items must be obtained through a plan Dean Health Plan DME provider for HMO/Focus members. Dean Health Plan will not be responsible for any items obtained through a non-contracted provider. It is the responsibility of the DME supplier to prior authorize services for HMO and POS members. Dean Health Plan will provide coverage for most supplies when: Prescribed by a plan provider for treatment of illness, a condition, or injury.

Medically necessary and not solely for comfort or convenience of the member. If the DME item is received within a physician’s office, prior authorization is needed only if the item is over the

amount indicated by the member’s benefit contract with Dean Health Plan. This includes all Coordination of





Benefits (COB) claims when the billed amount is more than the amount indicated by the member’s benefit contract with Dean Health Plan.

Please contact the Customer Care Center at (800) 279-1301 with questions. Glucose meters may be provided by any Dean Health Plan pharmacy when prescribed by a diabetic specialist or physician. The pharmacy will then submit a prior authorization request with Navitus (the Dean Health Plan Pharmacy Benefits Manager). If a member is being discharged from an inpatient stay and will need DME equipment at home, the facility will be required to contact a DME provider to obtain prior authorization. If non-contracted providers are used for POS and/or PPO, the member is responsible for obtaining prior authorization, as specified by their benefits contract from Dean Health Plan.

• PPO and POS members may be subject to a prior authorization penalty if the authorization is not obtained prior to receipt of medically necessary services.

Plan DME providers will deliver to rural communities. If our DME providers are unable to meet the member’s needs, they will work with other DME providers on an as needed basis.

The prescribing physician or health professional may contact the DME vendor directly to arrange for the necessary equipment. Any questions about coverage of DME and supplies or a member’s benefits can be directed to the Customer Care Center at (800) 279-1301. To access the most up-to-date DME polices regarding prior authorization requirements, please visit: deancare.com/providers/medical-management/

EMERGENT AND URGENT CARE SERVICES Emergent/Emergency Care An emergency medical condition is one brought on by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child, or

• Serious impairment to bodily function, or • Serious dysfunction of any bodily organ or part.

Emergency services are covered services given by any qualified provider, and are services needed to evaluate or stabilize an emergency medical condition. Emergency Care from Dean Health Plan Providers Most of the time, your patient will get emergency care from a Dean Health Plan policy provider. If a patient is unable to reach a plan provider, they should go to the nearest medical facility to receive care. Emergency Care from Non-contracted Providers If your patient must go to a non-contracted provider for care, they should call the Customer Care Center as soon as possible and tell us where they received emergency care. Follow-up must be received from a plan provider unless it is prior authorized by the Dean Health Plan Utilization Management Department. Applicable emergency room copayments apply whenever emergency services are received at an emergency room.



Urgent Care Urgent care is care that is needed sooner than a regular physician’s office visit (ex. broken bones, sprains, minor cuts and burns, drug reactions, and non-severe bleeding). Urgently needed care in the plan’s service area If the member is in the plan’s service area and has a sudden illness or injury that is not a medical emergency, the member should call his/her PCP. Dean Health Plan expects members receive care from plan providers. In most cases, Dean Health Plan will not pay for urgently needed care that a member receives from a non-contracted provider while the member is in the plan’s service area. Urgently needed care outside the plan’s service area Authorization is not required for urgent care services. If the member is outside of the service area, the member should call their PCP or the 24-hour nurse access line to see if their condition needs immediate attention. Urgent care should be received at the nearest appropriate medical facility unless the member can safely return to the service area to be seen by their PCP. There are no available benefits for follow-up care with a non-contracted provider unless such care is necessary to prevent further health risks. Such care must be prior authorized through the Dean Health Plan Utilization Management Department. The above guidelines do not apply to Dean Health Plan PPO/POS members; they are not required to use Dean Health Plan policy providers for coverage of services.

GENETIC TESTING A number of genetic tests require prior authorization and (depending on the test) are available only through a limited number of laboratories.

Genetic testing - prior authorization

• If you are a Dean Health Plan Provider Portal user, submit prior authorization requests via the Provider Portal • If you do not have access to submit prior authorization via the Provider Portal, fax the Genetic Testing prior

authorization form to the number indicated on the form

Genetic counseling requirement

Certain tests require pre-test and post- test genetic counseling. Prior authorization is not required for referrals to a genetic counselor. **As a reminder, ASO members are excluded from this requirement Genetic counseling resources Dean Health Plan network providers who employ genetic counselors may continue to use a current process that may be in place to comply with Dean Health Plan’s updated genetics testing medical policies where genetic counseling is required. Dean Health Plan recognizes the limited accessibility of genetic counselors. We have partnered with InformedDNA (IDNA) to provide telephonic genetic counseling services for Dean Health Plan members. Our goal is to improve member satisfaction and ease the burden for our providers. If no genetic counselors are available within your organization or there is an access issue, Dean Health Plan’s member may be referred to InformedDNA (IDNA). Use the IDNA Cancer Genetic Counseling Referral Form or the Cardiac Genetic Counseling Referral Form to refer to IDNA. For additional information on genetic testing, please visit deancare.com/providers/genetic-testing/ When unsure if a procedure will require prior authorization, please call the Customer Care Center or to find a list of prior authorization requirements please visit deancare.com/providers/medical-management/

https://office.emdeon.com/vendorfiles/Dean.htm

http://www.deancare.com/app/files/public/9719/genetic-testing-pa-form.pdf

http://www.deancare.com/app/files/public/9719/genetic-testing-pa-form.pdf

http://www.deancare.com/app/files/public/9723/idna-cancer-gc-referral.pdf

http://www.deancare.com/app/files/public/9723/idna-cancer-gc-referral.pdf

http://www.deancare.com/app/files/public/9722/idna-cardiac-gc-referral-form.pdf

http://www.deancare.com/providers/genetic-testing/



HIGH END RADIOLOGY PRIOR AUTHORIZATION Dean Health Plan HMO and POS members seeking in-plan benefits from a non-contracted provider must first be authorized to use the non-contracted provider via Dean Health Plan’s prior authorization process. If Dean Health Plan authorizes the use of the non-plan provider, the service itself must then be determined medically necessary by National Imaging Associates (NIA), a subsidiary of Magellan Healthcare, who is delegated to provide outpatient elective determinations.

Dean Medical Group ordering physicians utilize an internal authorization system for the medical necessity determination of high end radiology services. All other contracted Dean Health Plan network ordering physicians utilize National Imaging Associates/NIA, a subsidiary of Magellan Healthcare to determine medical necessity.

Prior authorization is required for the following outpatient radiology procedures through National Imaging Associates (NIA):

CT Scan Nuclear Exercise Tolerance Test (ETT) MRI/MRA PET Scan

You can contact NIA's customer service representatives Monday through Friday from 7:00 AM – 7:00 PM (CST) at (866) 307-9729 or via NIA's website RadMD.com. It is the responsibility of the ordering physician or clinic to obtain authorization. Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim. Imaging Procedures ordered by Emergency room and urgent care providers or for members in an observation and/or inpatient level of care do not require authorization from NIA for their service. Other information regarding prior authorization of the above radiological services can be found under the following link: deancare.com/providers/medical-management/

HOME HEALTH CARE Dean Health Plan provides coverage for home health care. These services must be prior authorized through the Utilization Management Department. Home health care will not be covered unless hospital confinement or confinement in a skilled nursing facility would be needed if home health care was not provided. The member’s immediate family or others living with the Dean Health Plan member cannot provide the needed care and treatment without undue hardship.

A state licensed or Medicare certified home health agency or certified rehabilitation agency will provide or coordinate the home care.

The member is confined to the residence; o Unable to leave residence without demanding effort, o Illness or injury restricts ability to leave residence with assistance or special transportation, or o Unable to leave residence without jeopardizing health or condition.

Home Health Care includes one or more of the following: Home nursing care is given part-time or intermittently. It must be given or supervised by a registered nurse.

http://radmd.com/



Home health aid services that are given part-time or intermittently. They must be medically necessary as part of the home care plan. They must consist solely of caring for the patient in a skilled care capacity. A registered nurse or medical social worker must supervise them. The service is required to be prior authorized by Dean Health Plan Utilization Management for medical necessity. Non-coverage of services is related to assistance with activities of daily living (ADL’s) and custodial services.

Physical, respiratory, occupational, and speech therapy.

Administration of drugs and medicines prescribed by a physician and are covered under the pharmacy benefit which cannot be self-administered by the member or the member’s caregivers. These services are covered to the same extent as if the Dean Health Plan member was hospital confined. HMO members must utilize Home Health United if the member is within the Dean Health Plan service area.

POS and PPO members are not required to utilize Home Health United, however prior authorization must be obtained for the services.

Home infusion services are considered to be home health services but do not count against any benefit maximums indicated under the member’s benefit plan

The assessment of the need for a Home Health Care plan and its development. A registered nurse, physician extender, or medical social worker must complete an assessment. The attending physician must request or approve this service.

If a member was confined in a hospital immediately prior to the care beginning, the home care plan must be approved by the primary provider of care during the hospital confinement.

Home Health Care benefits are limited to the maximum number of visits in the member’s certificate or Summary Plan Document (SPD). Each period up to four hours within a 24-hour period of home health care services counts as one home health visit.

HOSPICE All hospice services are prior authorized on a case-by-case basis subject to the policy limitations outlined in the member’s Certificate.

To access the Dean Health Plan Hospice Medical Policy requirements go to: deancare.com/providers/forms-and-documents-search-results/

INPATIENT HOSPITAL STAY Plan hospitals are required to contact Dean Health Plan upon the urgent/emergent admission of Dean Health Plan

members and obtain authorization for the medical necessity of the member’s continuing stay. Prior authorization is required for elective inpatient admissions a minimum of seven days prior to the scheduled

admission date. Hospitals and Physicians supervising the care of hospitalized patients should assume that continuing inpatient

care is approved unless the Dean Health Plan Utilization Management Department contacts you indicating otherwise. o Should this occur, Dean Health Plan will request additional clinical information to support the medical necessity

of the member’s continued hospital stay and facilitate discussion of the stay by the attending physician with a Dean Health Plan Medical Director when warranted.

o Dean Health Plan Utilization Management will assist you regarding alternative care avenues that are available to the member and assist you in expediting a timely discharge.

If you have any questions regarding this information or any Utilization Management processes, please contact the Customer Care Center at (800) 279-1301.

http://deancare.com/providers/forms-and-documents-search-results/



NEW TECHNOLOGIES

Procedures not commonly accepted as a standard of care within the health profession are not a covered benefit of the member’s plan. Prior authorization should be obtained before scheduling the procedure to determine if the requested service is a covered procedure under the member’s plan. New technology services are reviewed by the Dean Health Plan Quality and Care Management Division for medical appropriateness and efficacy by the Dean Health Plan Medical Directors. If you would like to request a new technology be reviewed and considered for coverage by Dean Health Plan, please send an email to [email protected]. Through that email, you will be asked to provide further information and fill out a form with the information the Medical Directors use to review new technologies. A listing of procedures considered investigational/experimental by Dean Health Plan may be found at: deancare.com/providers/medical-management/

OFFICE INJECTABLES Some office injectables require prior authorization for medical necessity. Prior authorization for these services is handled by Navitus, the pharmacy benefits manager (PBM) for Dean Health Plan. Please contact the Dean Health Plan Customer Care Center if you have questions regarding the prior authorization process for office injectables. A complete list of office injectables requiring prior authorization, as well as the forms required, are available on-line at: deancare.com/providers/medical-management/

ORAL SURGERY Dean Health Plan provides coverage for oral surgery for Dean Health Plan HMO/EPO members when services are obtained from a plan provider. To access the Dean Health Plan Medical Policy requirements go to deancare.com/providers/forms-and-documents-search-results/ Oral surgical procedures that are generally eligible for coverage are as follows: Surgical removal of impacted teeth; Non-surgical removal of impacted teeth (pulling). Contact the Customer Care Center for additional clarification

regarding coverage on surgical removal of impacted and/or infected teeth for State of Wisconsin and local government employees;

Surgical removal of tumors and cysts; Surgical treatment for accidental injuries of the jaw, cheeks, lips, tongue, roof and floor of mouth; Apicoectomy; Surgical removal of exostosis of the jaw and hard palate; Treatment of fractured facial bones; External and internal incision and drainage of cellulitis; Cutting of accessory sinuses, salivary glands or ducts; Reducing dislocations; Alveolectomy;

Frenectomy; Vestibuloplasty; Residual root removal (State of Wisconsin and local government employees do not receive coverage for this

service); Temporomandibular Disorders (TMD) - requires prior authorization and provided by a plan provider designated

by Dean Health Plan to treat TMD; Gingivectomy or osseous surgery is covered if performed in place of a gingivectomy for excision or loss gum tissue

to eliminate infection (for State of Wisconsin and local government employees only). Please contact the Customer Care Center if you have questions regarding a member’s schedule of benefits or benefit plan coverage.







ORTHOTICS Foot orthotics are considered medically appropriate for the treatment of significant pain or when deformity is present. Foot orthotics must be supplied by an orthopedist, podiatrist, sports medicine specialist, or DME vendor. Please reference Dean Health Plan’s Medical Policy for conditions that are covered and for prior authorization requirements at deancare.com/providers/forms-and-documents-search-results/ The following items are not considered medically necessary and therefore are not covered:

Off-the-shelf foot orthotics Foot orthotics for:

o Back pain o Calluses o Corns o Knee conditions other than patellofemoral syndrome

Specific member certificate exclusions for foot orthotics include:

Athletic related conditions Work related conditions

Requests to replace medically appropriate foot orthotics (only one orthotic per foot is covered) are considered at three year intervals. All requests for orthotic replacement within less than three years, due to growth or significant modification because of surgery, require prior authorization through the Utilization Management Department. For members enrolled in the Dean Health Plan Medicare Select or DeanCare Gold Plans, Dean Health Plan pays when Medicare also covers a benefit. For Dean Health Plan Gold members, a provider should follow the benefit coverage found in the DME Regional Carrier Supplier Manual.

PHYSICAL MEDICINE (PHYSICAL AND OCCUPATIONAL THERAPY) Dean Health Plan has contracted with NIA/Magellan to provide medical necessity determinations for PT/OT services except for members with the following conditions: Diagnosis of autism as indicated in the Wisconsin State Autism Mandate BadgerCare members who are participating in a Birth to Three Program

Providers are responsible for submitting prior authorizations for the situations listed above immediately following an initial evaluation/assessment and are not subject to the process documented below. Dean Health Plan policies may cover habilitative services. Habilitative services are defined as services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. All physical medicine services are limited to the benefit maximums indicated in the Certificate of Coverage or Summary Plan Document. When a member requires physical medicine services, the therapy provider should follow the prior authorization process outlined below. If requests are made to a non-contracted therapy provider, prior authorization to utilize the non-contracted therapy provider must be approved prior to any services being rendered. If, at any time, the therapist begins to treat the member for a new condition, a new authorization request must be submitted for approval.

http://www.deancare.com/providers/forms-and-documents-search-results/


The Therapy Provider’s responsibilities are: All physical and occupational therapy visits following completion of an initial evaluation require prior authorization

by the therapist. Visits are limited to medically necessary treatment. The initial evaluation for physical and/or occupational therapy does not require a prior authorization.

Therapy providers must prior authorize care for physical and occupational therapy. The initial eight visits require authorization registration through the Care Registration process. Services that extend beyond eight visits will require a medical necessity authorization from NIA/Magellan.

Prior authorization for services beyond eight visits will be submitted via NIA/Magellan’s online portal at RadMD.com. NIA/Magellan will approve/deny the requests for covered services. A copy of the approved/denied request will be sent to the therapist, ordering physician, and Dean Health Plan member.

Contact NIA/Magellan Customer Service at (866) 307-9729 or the Dean Health Plan Customer Care Center at (800) 279-1301 with any additional questions.

Care should end when services are no longer medically necessary and transitioned to a home exercise program. Please note: updating the treating physician of the member’s progress is strongly recommended to ensure the best coordination of care for the member. Other information regarding prior authorization of the above therapy services can be found at the following link: deancare.com/providers/medical-management/ Physical Medicine Exclusions and Limitations The following services are generally excluded from coverage: Vocational rehabilitation, including work hardening programs. Therapy services such as recreational or educational therapy, physical fitness or exercise programs. Services to enhance athletic training or performance. Services or treatment received at intermediate care facilities.

PODIATRY Dean Health Plan provides coverage for specific Podiatry services. An authorization is not required unless a service is indicated as needing a prior authorization in a Dean Health Plan Medical Policy. To access the Dean Health Plan Medical Policy requirements, go to deancare.com/providers/forms-and-documents-search-results/

Podiatry services that are generally excluded from coverage are: Routine examinations, treatments, or removal (paring) of all or part of corns, calluses, hyperplasia of the skin or

subcutaneous tissue of the feet. Routine foot care including, but not limited to clipping, trimming, and debriding of toenails.

Hypertrophy of the nails

Treatment of flexible flat feet

Excision of hyperkeratosis

Removing other excrescences

Hygienic and preventive maintenance: o Cleaning feet o Soaking feet o Use of skin creams

Services rendered in connection with the above listed exclusions.

For consideration of the above-referenced services, an authorization is required and may be considered medically appropriate for members with a systemic condition or who are at high risk of developing serious infections. Treatment of plantar warts is considered medically appropriate and is a covered benefit.

http://www.radmd.com/




SHOES Custom Molded/Corrective/Therapeutic Custom molded shoes are considered medically appropriate for certain conditions. Please reference Dean Health Plan’s Medical Policy for conditions that are covered and for prior authorization requirements: deancare.com/providers/forms-and-documents-search-results/ Special shoes and shoe modifications are limited to one pair per calendar year. All custom shoes and shoe modifications require prior authorization through the Dean Health Plan Utilization Management Department. Bebax corrective shoes are not considered medically appropriate and therefore are not a covered benefit.

For members enrolled in the Dean Health Plan Medicare Select or DeanCare Gold Plans, Dean Health Plan pays when Medicare also covers a benefit. For Dean Health Plan Gold members, a provider should follow the benefit coverage found in the DME Regional Carrier Supplier Manual.

SKILLED NURSING FACILITY CARE/SWING-BED Please see the “Skilled Nursing Facility” section of this manual for information on SNF and swing-bed authorizations.

SPEECH THERAPY SERVICES All Speech authorizations need to be obtained by Dean Health Plan. Dean Health Plan Policies may cover habilitative services. Habilitative services are defined as services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. All speech therapy services are limited to the benefit maximums indicated in the Certificate of Coverage or Summary Plan Document. Other information regarding prior authorization of the above therapy services can be found at the following link: deancare.com/providers/medical-management/ The Speech Therapy Provider’s responsibilities are: The patient’s physician will assess the need for speech therapy and write a prescription for an evaluation and

treatment to a plan Dean Health Plan therapy provider.

All speech therapy visits following the initial evaluation require prior authorization by the plan therapist. Visits are limited to medically necessary treatment.

The initial evaluation for speech therapy services does not require a prior authorization.

Following the completion of the evaluation, the request for therapy should be immediately submitted to Dean Health Plan for processing. Requests received later than seven days of being written will be considered late and may be denied.

Dean Health Plan will approve and/or deny the prior authorization for covered services and note any limitations regarding non-covered services or limited benefits (e.g.; developmental delay). A copy of the approved and/or denied prior authorization will be sent to the therapist, ordering physician, and Dean Health Plan member.

Requests for additional medically necessary therapy visits require submission of a written treatment plan with a new prior authorization

Contact the Customer Care Center at (800) 279-1301, with any additional questions.

Care should be ended when services are no longer medically necessary and transitioned to a home program. Please note that updating the treating physician of the member’s progress is strongly recommended to ensure the best coordination of care for the member.





Speech Therapy Exclusions and Limitations The following services are generally excluded from coverage: Vocational rehabilitation, including work hardening programs. Therapy services such as recreational or educational therapy, physical fitness or exercise programs. Services or treatment received at intermediate care facilities.

To access the most up-to-date medical policies regarding the prior authorization requirements for speech therapy go to deancare.com/providers/forms-and-documents-search-results/

SURGERY Dean Health Plan only requires a prior authorization on outpatient day surgery if required per the Dean Health Plan Dean Health Plan medical policy. If a member has a PPO/POS plan and is utilizing a non-contracted provider for the service, the member is responsible to obtain the prior authorization. Failure to prior authorize services may result in a penalty or full denial of payment for the services rendered. All elective inpatient admissions require a prior authorization. A listing of procedures that require prior authorization may be found at deancare.com/providers/medical-management/

TRANSFERRING PATIENTS If it is medically necessary that a patient receiving inpatient hospital services be transferred to another inpatient hospital facility, a plan facility should be used whenever possible. Please note that Dean Health Plan POS or PPO members are not required to use a Dean Health Plan participating

provider. POS members may elect to use non-contracted providers with re-imbursement at the non-contracted benefit

level. SSM Health St. Mary’s Hospital - Madison is equipped to handle most critical medical, surgical, and adult psychiatric conditions for our members. It also offers perinatology services for high risk pregnancy, and a neonatal intensive care unit for premature infants. St. Mary’s accepts patients if air ambulance is required. Please contact SSM Health St. Mary’s Hospital - Madison prior to transferring to a non-contracted facility if you are unsure if a service is or is not available. If services are available with plan hospital facilities, and the member is deemed medically stable by the attending physician, Dean Health Plan HMO members are required to be transferred to a plan facility. Dean Health Plan POS members are required to be transferred to a plan facility once deemed medically stable by the attending and accepting providers to continue receiving in-plan benefit levels.

When transfer to a non-contracted facility is determined to be appropriate for emergency and/or specialty care that is unavailable in plan, the admission is authorized. However, Dean Health Plan must be notified within 24 hours or the next business day of the transfer as well as the medically necessary reason. For all non-emergent transfers to non-contracted facilities, prior authorization is required by our Quality and Care Management Division before transfer to the non-contracted facility occurs. If a Dean Health Plan HMO member is emergently admitted to a non-contracted facility, the member will be required to transfer to a plan inpatient facility once they are medically stable. If you have any questions about transferring one of your patients, please contact our Customer Care Center at (800) 279-1301.

TRANSPLANTS




All services related to transplant-including pre-transplant evaluation and post-transplant follow-up services - require prior authorization.

VISION Dean Health Plan provides coverage for one routine eye exam per year for those members whose benefit package includes The components of a routine eye examination are the medical exam and the refraction. Senior Select Policies (20000 groups) have routine vision coverage. Dean Health Plan does not provide coverage for: Eyeglasses Lenses Frames Contact lens fitting Contact lenses Replacement lenses

Exceptions: Patients who have had cataract surgery may receive one lens per operative eye. Pediatric Vision Hardware is available in some plans - this benefit is specifically for obtaining eyeglass frames and

lenses, and is available only to members under 19 years of age. To confirm a Dean Health Plan member’s coverage eligibility, please use the Provider Portal, direct EDI transaction or contact the Customer Care Center (800-279-1301).


SKILLED NURSING FACILITY (SNF) AUTHORIZATION GUIDELINES

HMO & POS (including Medicare Supplemental), DeanCare Gold and Medicare Select Policies Dean Health Plan requires skilled nursing facilities (SNF) to prior authorize all admissions for Dean Health Plan members. The SNF should first utilized the Provider Portal or contact our Customer Care Center to verify a member’s benefits. Once the member’s benefits have been verified, the SNF will need to complete the on-line prior authorization form or fax in the Skilled Nursing authorization form. This form is available at: deancare.com/app/files/public/3872/pdf-providers-SNF_Swingbed_Auth_Form.pdf A SNF is required to notify Dean Health Plan Dean Health Plan within 24 hours of the admission. If the admission takes place on a holiday or weekend, notification of the admission must take place by the next business day. When notifying or requesting prior authorization for an admission to a skilled nursing facility, the following information needs to be provided: Name and subscriber number of member Proposed date of admission Admitting Physician’s name Diagnosis Name of hospital or facility member is currently confined in, if appropriate Name of contact person to assist in Utilization Management (UM) process

Please also indicate: The number of SNF days member has already used (this information is obtained when the SNF contacts the

Customer Care Center to verify benefits) Primary payer Clinical notes/medical record

Once Dean Health Plan has received a notice of admission, the Dean Health Plan Utilization Management Nurse Reviewer will review the available medical records to determine the medical necessity of the SNF services being requested. Admission to a skilled nursing facility is a covered benefit when a member requires skilled therapy services provided by qualified personnel to recover from a serious illness or injury that cannot be provided in an outpatient setting (i.e. home) or lower level of care due to the complexity or frequency of the skilled services required. Skilled services are those ordered by a physician, which require development and execution of a plan of care by licensed providers designed to improve the physical health of a person in a reasonable period of time. Skilled licensed personnel include registered nurses, licensed practical nurses, physical, respiratory, occupational and speech therapists. Admission to a skilled nursing facility may be considered when: The member requires skilled services as defined above Skilled services are required on a daily basis and for a minimum of two hours per day Skilled services can be provided only in an inpatient setting Skilled services are medically necessary There is a reasonable expectation that the prescribed services will result in enough improvement in function for

the member to be able to return to a lower level of care in a predictable amount of time.

http://www.deancare.com/app/files/public/3872/pdf-providers-SNF_Swingbed_Auth_Form.pdf


Custodial or Domiciliary Care Custodial care is the type of care given when the basic goal is to help a person in the activities of daily life, including, but not limited to, help in: Bathing Dressing Eating Taking medicines properly Getting in and out of bed Using the toilet Preparing special diets Walking 24-hour supervision for potentially unsafe behavior Range of motion exercises Strengthening exercises Wound care Ostomy care Tube and gastrostomy feedings Administration of medications Maintenance of urinary catheters

These are also referred to as Activities of Daily Living (ADL). Daily care such as assistance with getting out of bed, bathing, dressing, eating, maintenance of bowel and bladder function, preparing special diets, and assisting patients with taking their medicines, or 24-hour supervision for potentially unsafe behavior, do not require “skilled care” and are considered to be custodial. If the Dean Health Plan Utilization Management Nurse Reviewer determines that the member’s condition does not meet the skilled nursing criteria indicated in the Dean Health Plan Medical Policy, the case is referred to a Dean Health Plan Medical Director for review. This policy is available at: deancare.com/app/files/public/4696/pdf-medicalpolicies-9310Skilled-Care.pdf If the services are denied, the member and the SNF will receive a written denial notice from Dean Health Plan.

This also applies to members who have Benefit Contracts that extend beyond the maximum-allowed Medicare days or Medicare qualifying events if Medicare is the primary payer for the stay.

If the services are approved because they are medically necessary, the facility will be notified with a copy of the submitted Skilled Nursing and Swing Bed prior authorization form indicating the approved authorization number.

Concurrent review of the SNF stay will be required between the facility and the Dean Health Plan Utilization Management Nurse Reviewer. Continued coverage and level of care will be based on the ongoing medical necessity as determined by the information provided by the facility for concurrent review. If sufficient information is not provided or is illegible, the UM Nurse Reviewer will outreach to the SNF contact indicated on the Skilled Nursing and Swing Bed prior authorization form to advise of the concern and request additional information regarding the continued stay request. If the ongoing stay is denied, the facility will be verbally notified of the denial and a denial letter will be mailed to

the member, facility and attending physicians notifying of the denial determination. If ongoing stay is approved, then the approval will be communicated back verbally to the provider with notification

of the approved through date of service and the need for medical update if the member stay will continue.

http://www.deancare.com/app/files/public/4696/pdf-medicalpolicies-9310Skilled-Care.pdf



Continuation of a stay in an inpatient skilled care facility requires: • An ongoing need for and daily participation in skilled care to achieve goals set in the initial treatment plan • Documented progress documented in a legible way toward achieving those goals • Documentation that the skilled care services that are being received cannot be done in a home or outpatient

setting • Ongoing care is not considered custodial

It is expected that discharge planning begins upon the member’s admission to the SNF facility. Approved dates of service include possibility that the member will no longer meet medical necessity and continued services may be denied. The expectation is that all efforts are being made to facilitate the member’s discharge to home or a lower level of care. The member does not need to be completely independent in their activities, so discharge planning for caregiver and home safety assessments should be facilitated as quickly as possible once the member has begun to improve. If the SNF does not obtain authorization for the admission, neither the member nor Dean Health Plan shall be responsible for the services rendered to the member. The SNF should contact Dean Health Plan immediately once it is discovered that the initial notice of admission was not obtained. If the member meets medical necessity criteria, an authorization approval may be issued from the day of notification if the care is deemed skilled and all other guidelines have been met. If Dean Health Plan is covering the SNF stay, skilled therapies (physical, occupational, and speech) are included in the reimbursement. Reimbursement for covered SNF stays is outlined in your Dean Health Plan SNF Agreement.

DeanCare Gold and Medicare Select Policies For a member with Medicare Supplemental or DeanCare Gold, if the care is indicated as meeting Medicare skilled criteria, Dean Health Plan will monitor the continued stay while Medicare is the primary payor. As the member approaches the 100th day of their Medicare Benefit within the defined benefit period, we will reach out to the SNF to confirm that our records mirror the determination of available Medicare SNF benefit days. If a member exhausts their Medicare SNF Benefit, or do not qualify for coverage of the stay under their Medicare SNF Benefit, they may qualify for coverage of up to a maximum of 30 days of additional stay under their DeanCare Gold or Medicare Select policy if the services meet the Dean Health Plan Medical Policy criteria. These services are reimbursed at the facility’s Medicaid Room Rate, (also known as the DHFS Rate or RUGS rate) and are inclusive of all charges including therapy. Because this rate will vary, the facility must provide the rate to Dean Health Plan to facilitate accurate claims payment. The Skilled Nursing Facility medical policy is available at: deancare.com/app/files/public/4696/pdf-medicalpolicies-9310Skilled-Care.pdf The SNF needs to notify Dean Health Plan when the member is no longer meeting Medicare coverage criteria. If the care is not skilled, the SNF will need to inform Dean Health Plan as to the reason why the member is being admitted for care. All skilled nursing facilities are required to notify Dean Health Plan when a member is discharged or transferred from the SNF to a hospital, lower level of care, another SNF, or home. If the member is going to receive outpatient services, as directed by the SNF, the SNF must assist in the prior authorization of the member to a DeanCare Gold provider if the member desires continued payment for services from Dean Health Plan in order for Dean Health Plan to continue paying for services. DeanCare Gold Reconsideration Process All reconsideration requests for DeanCare Gold must be submitted in writing from the treating physician. Written reconsideration requests can be submitted via fax to (608) 252-0830 or by mail to:

Dean Health Plan 1277 Deming Way

Madison, WI 53717




If the reconsideration request results in a denial uphold, Dean Health Plan will forward your reconsideration request, on your behalf, to the designated IRE, MAXIMUS for an independent review. If the IRE overturns the denial, Dean Health Plan will enter an authorization and notify the facility of the

overturned denial. Approval letters will be sent to the treating physician, the facility, and the member. If the IRE agrees with the Dean Health Plan denial, the IRE will notify the treating physician of the denial uphold.

Patient notification of a continued denial is solely the treating physician’s responsibility.


CHIROPRACTIC CARE OVERVIEW CHIROPRACTIC CARE Dean Health Plan provides coverage for chiropractic care at a plan provider with the exception of long-term and maintenance therapy. (Dean Health Plan Point of Service members are not required to use plan providers.) For emergent/urgent chiropractic care by a non-plan provider, refer to emergent and urgent care services in this section. A prior authorization request from a member’s primary care provider is not required in order to see a plan chiropractor. AT modifier is required for Active Therapy and must be in the first modifier position.

Long-Term Therapy: Therapy extending beyond two months that is determined, by our Medical Affairs Division, to be primarily maintenance therapy.

Maintenance Therapy: means ongoing therapy delivered after the acute phase of an accident or illness has passed. It begins when a patient’s recovery has reached a plateau or improvement in his/her condition has slowed or ceased entirely and only minimal rehabilitative gains can be demonstrated. The determination of what constitutes “maintenance therapy” is made by our Medical Affairs Division after reviewing an individual’s case history or treatment plan submitted by a health care provider.

The determination of what constitutes “maintenance/long-term therapy” is made by the chiropractor. Dean Health Plan Managed Care Division would review the case history or treatment plan of the patient if a questionable situation would arise.

When a patient reaches long-term/maintenance therapy you should give them a copy of our “Chiropractic Handout” on the following page. This will give the patient a brief description of benefits that are not available for long-term/maintenance therapy.

See example of the Chiropractic Handout on the following page.


CHIROPRACTIC HANDOUT Dean Health Plan covers chiropractic services provided by a plan provider. Refer to a member’s Group Member Certificate to determine if the patient is required to pay an office copayment for each visit. Items supplied by your chiropractor may or may not be covered benefit. Examples of covered supplies include:

Slings Rib Belts Lumbar-sacral orthosis Wrist Cock-up Splint

Cervical Collars Sacroiliac Support Elbow Orthoses Air Cast

Examples of non-covered supplies include: orthopedic pillows, cushions, and other convenience items. Services not covered for chiropractic care: Long-term and/or maintenance therapy Chiropractic care provided by a non-contracted chiropractor (unless the member has a POS or PPO policy)

The following definitions have been taken from the Dean Health Plan Group Member Certificate. Dean Health Plan provides coverage for chiropractic care at a plan provider with the exception of long-term and maintenance therapy. Dean Health Plan Point of Service members are not required to use plan providers.

• Long-Term Therapy – means therapy extending beyond two months which is determined, by the Dean Health Plan Quality and Care Management Division, to be maintenance therapy.

• Maintenance Therapy – means ongoing therapy delivered after the acute phase of an illness or injury has passed. It begins when a patient’s recovery has reached a plateau or improvement in his/her condition has slowed or ceased entirely and only minimal rehabilitative gains can be demonstrated.

The determination of what constitutes “maintenance therapy” is made by the chiropractor and/or Dean Health Plan Quality and Care Management Division after reviewing an individual’s case history or treatment plan submitted by a provider of health care. When a patient reaches long-term/maintenance therapy you should give them a copy of our “Chiropractic Handout.” This will give the patient a brief description of benefits that are not available for long-term/maintenance therapy. Services are not covered if the member seeks chiropractic care at a non-contracted provider, unless it is urgent or emergent. If you need further assistance in understanding chiropractic benefits, contact the Dean Health Plan Customer Care Center at (800) 279-1301.


SUPPLIES Dean Health Plan will provide coverage for most supplies when: Prescribed by a plan provider for diagnosis of illness or injury (Point of Service members are not required to use

plan providers). Medically necessary and not solely for comfort or convenience of the member.

Dean Health Plan will provide coverage for the following chiropractic supplies listed below:

Code Description A4565 Slings L0120 Cervical Collars L0220 Rib Belts L0628 Lumbar-sacral L0629 Sacroiliac Support L3710 Elbow Orthoses L3908 Wrist Cock-up Splint L4350 Air Cast

Other supplies should be obtained through Dean Health Plan’s durable medical equipment suppliers. A list of these specific supplies with their appropriate HCPCs codes are also referenced in your Chiropractor Agreement with Dean Health Plan.

CAPITATION Beginning in February each year, the Chiropractic Capitation Pool (CCP) is funded during the first week of each month based on the total member months for the year (for the period ending with the previous month) multiplied by a per member, per month (PMPM) rate. From this gross amount, all year-to-date reimbursement to non-Dean Health Plan chiropractors for urgent/emergent care services provided to members within the service area are deducted. Ten percent of the remaining amount will be withheld. Dean Health Plan funds the CCP at a per member, per month rate that is established by the Dean Health Plan Chiropractic Agreement. The member months is calculated based upon Dean Health Plan members only. Funding of and distributions from the CCP will be based on calendar year-to-date information. Distributions to chiropractors from the CCP are based on the chiropractor’s year-to-date estimated unique patient counts, rather than actual unique patient counts. While not specifically addressed in the contract, we believe the use of estimates is necessary in order to avoid subjecting chiropractors to large variations in their monthly payments. Distribution from the CCP is based on the chiropractor’s percentage share of unique patients to the total unique patient count. Because there are time lags between the date of service, the submission of a claim, and the processing of a claim, credit for an actual unique patient may or may not occur during the month in which the patient was seen. This is particularly true if claims are submitted on paper, rather that electronically. As a result, if Dean Health Plan used actual patient visits for a particular month, some chiropractors would receive no payment, while others (especially those who submit electronically) would receive a very large payment. It is the goal of the Provider Network Services Department to have all plan chiropractors submit their claims electronically to avoid some of lag problems. The estimates are based on claims lag data from the previous year and applying it to the current year patient counts. Dean Health Plan anticipates having to use estimates each year when addressing the lag issue. When feasible, Dean Health Plan will revert to the use of actual patient counts. Even though the lag issue will always be a factor, the variability in patient counts should smooth out over the course of a year, allowing Dean Health Plan to calculate the monthly capitation payment based on actual unique patient numbers.


From the year-to-date distribution amount, all previous month’s distributions to the chiropractor (excluding supplies) will be subtracted; the remaining amount will be distributed to the chiropractor by the fifteenth (15th) of the month. Distribution amounts may vary from year-to-year based on changes to the PMPM rate.

A final, year-end payment will be made to the chiropractor, including distribution of its share of the ten percent withhold, and will be based upon the Chiropractor’s pro rata share of actual unique patients seen during the year. Distribution of the final year-end settlement will occur following completion of an annual reconciliation and will be paid no later than six (6) months after the end of the calendar year.

Reimbursement for Medicare Select The chiropractor should submit claims for services provided to Medicare Select Members directly to the Medicare Part B fiscal intermediary. Reimbursement for Medicare Select claims is as follows:

Copayments, deductibles, & coinsurance: Provider will receive payment directly from the Medicare B fiscal intermediary for Medicare-covered services. Dean Health Plan will reimburse the provider for all applicable copayments, deductibles, and coinsurance as

specified on the Explanation of Benefits form the Medicare Part B fiscal intermediary.

Non-Medicare Covered Services (i.e. supplemental benefits) Dean Health Plan shall reimburse provider for covered services which are not Medicare-covered services (i.e.

services that are supplemental benefits under the Medicare Select Product) at the Medicare par prevailing rate. Covered Services for which there is no Medicare par prevailing rate shall be paid at Dean Health Plan’s maximum allowable rate.

Medicare Select services are not paid under the Chiropractic Capitation Pool. Example of How Distribution of Monthly Capitation is Calculated Refer to Explanation of Chiropractic Capitation Allocation example. Total Allocation of Capitation Revenue for the entire chiropractic network:

Member months (Commercial Member Months Year to Date (YTD))

x Commercial Member Months at the Per Member Per Month (PMPM) rate = Gross Chiropractic Capitation Pool (CCP) - Non-contracted urgent/emergent care (within service area) = Net Capitated Revenue before Withhold - 10% Withhold = Net Capitation Revenue YTD

+ Supplies YTD = YTD Allocation for entire chiropractic network Allocation for Dean Health Plan Sample Chiropractic Office:

Actual + Accrued chiropractic unique patients YTD ÷ Actual + Accrued total unique Dean Health Plan Chiropractic patients YTD = % of Unique Patients x Net Capitation Revenue YTD = Net Capitation Revenue for individual chiropractor YTD - Prior Capitation Payments YTD - Supplies = Monthly YTD Capitation Payment for Sample Chiropractic Office Payments will be distributed before or on the 15th of the following month.


Explanation of Chiropractic Capitation

CONFIDENTIAL BUSINESS INFORMATIONDean Health Plan, Inc.Allocation of Capitation RevenuePeriod Ending January 01, 2006 - September 30, 2006Gross Capitation Revenue{Commercial Member Months @ $1.87} YTD (1) $3,257,164.13Commercial Member Months YTD = 1,741,799 (2)Less: Urgent/Emergent-Care services rendered to Managed Care Population by Non-Plan (3) Non-Defunct Chiropractors within DHP Service Area: YTD $10,165.74Equals: Net Capitated Revenue before Withhold YTD (4) $3,246,998.39Less: Withhold @ (10%) YTD (5) $324,699.84Equals: Net Capitation Revenue YTD (6) $2,922,298.55Plus: Supplies YTD (7) $7,364.89Total YTD Allocation (8) $2,929,663.44

Allocation of Capitation Revenue for the Month of SeptemberGross Capitation Revenue{Commercial Member Months @ $1.87} (9) $368,683.59Commercial Member Months = 197,157 (10)Less: Urgent/Emergent-Care services rendered to Managed Care Population by Non-Plan (11) Non-Defunct Chiropractors within DHP Service Area: $2,096.17Equals: Net Capitated Revenue before Withhold (12) $366,587.42Less: Withhold @ (10%) (13) $36,658.74Equals: Net Capitation Revenue (14) $329,928.68Plus: Supplies (15) $812.43Total September 2006 Allocation (16) $330,741.11

Allocation for: Dean Health Plan Sample Chiropractic Office (17)YTD

Your Actual + Accrued unique patients YTD 437 (18)Actual + Accrued total unique DHP Chiro. pat. YTD 17,164 (19)% of unique patients 2.5460078% (20)Net Cap. Revenue YTD $74,401.95 (21)Plus: Supplies YTD $66.45 (22)Plus: Medicare Select YTD $0.00 (23)Total 2006 Revenue YTD $74,468.40 (24)Less Prior Capitation Payments $67,445.65 (25)Less Prior Supply Payments $107.83 (26)Less Prior Medicare Select Payments $0.00 (27)Total Paid $'s in September 2006 $6,914.92

(29) (30) (31) (32) (33) (34) (35) (36) (37)

Accrued Accrued % Prior Pymts Prior Pymts Prior Pymts Current YTD Current YTD Current YTD Monthly (28) Pat. YTD Pat YTD Sup $'s Cap $'s Med Select Sup $'s Cap $'s Med Select PaymentJanuary YTD 38 2.18% $0.00 $0.00 $0.00 $0.00 $7,148.61 $0.00 $7,148.61February YTD 76 2.18% $0.00 $7,148.61 $0.00 $0.00 $14,150.05 $0.00 $7,001.44March YTD 113 2.18% $0.00 $14,150.05 $0.00 $52.58 $21,163.42 $0.00 $7,065.95April YTD 272 2.63% $52.58 $21,163.42 $0.00 $107.83 $33,900.11 $0.00 $12,791.94May YTD 343 2.88% $107.83 $33,900.11 $0.00 $107.83 $46,395.97 $0.00 $12,495.86June YTD 381 2.87% $107.83 $46,395.97 $0.00 $107.83 $55,650.11 $0.00 $9,254.14July YTD 405 2.74% $107.83 $55,650.11 $0.00 $107.83 $62,030.88 $0.00 $6,380.77August YTD 415 2.60% $107.83 $62,030.88 $0.00 $107.83 $67,445.65 $0.00 $5,414.77September YTD 437 2.55.% $107.83 $67,445.65 $0.00 $66.45 $74,401.95 $0.00 $6,914.92October YTDNovember YTDDecember YTD

Explanation of Chiropractic Capitation Allocation


Allocation Key 1. Year-to-date gross capitation dollars 2. Total year-to-date months for Dean members. A member is allocated one month, per each month they are on the

plan 3. Urgent/Emergent services rendered by non-contracted chiropractor in Dean Health Plan service area 4. Net capitated revenue (gross revenue minus urgent/emergent payments) 5. Contracted withhold held by Dean Health Plan 6. Net capitated revenue minus the withhold. 7. Payment for covered supplies year-to-date 8. Total dollars paid year-to-date 9. Refer to #1 10. Total members counted for the current period/month 11. Refer to #3 12. Refer to #4 13. Refer to #5 14. Refer to #6 15. Refer to #7 16. Refer to #8 17. Chiropractor’s name 18. Total unique patient counts -- year-to-date for each individual chiropractor 19. Total unique patient counts -- year-to-date for entire Dean Health Plan network 20. Individual chiropractor percentage of unique patients 21. Individual chiropractor net capitation revenue year-to-date 22. Total supplies paid year-to-date 23. Total Medicare Select dollars (not included and paid on separate remittance) 24. Individual chiropractor total revenue year-to-date 25. Individual chiropractor’s prior capitation payments 26. Individual chiropractor’s prior supply payments 27. Individual chiropractor’s Medicare Select payments 28. Month -- year-to-date 29. Accrued patients -- year-to-date (including patient estimates) 30. Accrued percentage of unique patients -- year-to-date 31. Prior payments for supply dollars 32. Prior payments for capitation dollars 33. Prior payment for Medicare Select payment 34. Current year-to-date supply dollars 35. Current year-to-date capitation dollars 36. Current year-to-date Medicare Select payment 37. Monthly payment to Chiropractor


Explanation of Chiropractic Payment Key 38. Current periods capitation payment 39. Current periods supplies payment 40. Current periods Medicare Select payment (not included on separate remittance) 41. Prior year supplies payment for current period 42. Total payment for period/month

Chiropractic Supplies Paid Key

43. Billing Chiropractor 44. Service Date 45. Patient Name 46. Member Number 47. Service Code 48. Supply Description 49. Number of Units 50. Dollar Amount Claimed 51. Copay Amount 52. Total Amount Paid for Supplies


ADMISSIONS AND CONCURRENT REVIEW PROCESS

BEHAVIORAL HEALTH AND AODA SERVICES All Behavioral Health and AODA hospital admissions and concurrent review services were delegated to Magellan Behavioral Health. Notification of urgent/emergent, elective inpatient and concurrent review must be directed to Magellan Behavioral Health and are subject to all of the requirements indicated below. Magellan Health may be reached by phone at (800) 424-4710.

URGENT/EMERGENT ADMISSION NOTIFICATION Plan Hospitals are responsible for notifying the Dean Health Plan Utilization Management Department within 24 hours of an urgent/emergent admission or by the next business day if the admission occurs on a weekend or holiday. A member may require emergent/urgent inpatient admission to an acute hospital from any of the following settings: Home Doctor’s office Emergency room Observation bed Surgical day care (SDC) unit Transfer from another facility (including neonatal intensive care unit admission from another facility)

The following information is required for notification of an urgent/emergent admission: Patient name (middle initial if available) Subscriber number and date of birth Admission date (must be the actual date the member was admitted to inpatient status) Admitting physician Admission diagnosis Type of admission: ER, direct admit, day of surgery

Plan Hospitals with Provider Portal access must notify of emergent/urgent admissions by submitting the authorization request through the Provider Portal. All hospitals without Provider Portal access have two options to notify Dean Health Plan of the admission: Fax the required admitting information to: (608) 252-0830 Phone the required admitting information to: (800) 356-7344, extension 4455.

Urgent/Emergent inpatient admissions that meet medical necessity requirements will be approved for the date of admission only, pending concurrent review and ongoing medical necessity determinations for facilities that do not have a DRG/Perdiem contract with Dean Health Plan. Hospital facilities that do not have a DRG/Perdiem contract with Dean Health Plan are required to provide ongoing, concurrent review information for determination of the continued medical necessity of the member’s stay. Concurrent review information is required to be provided to the Dean Health Plan Utilization Management department from the facility’s Utilization Management Department.

Facilities that have a DRG/Perdiem contract with Dean Health Plan are not required to provide concurrent review to the Dean Health Plan Utilization Management Department, however they are required to provide the date of the member’s discharge from the facility. Authorization dates of service will be based on the admission and discharge dates provided by the DRG/Perdiem hospital facility.


ELECTIVE ADMISSION AUTHORIZATION NOTE: This section is specific to non-urgent/emergent conditions ONLY. The Hospital or Servicing provider is responsible for notifying Dean Health Plan at least five to seven days prior to the planned inpatient admission.

Elective Admissions are defined as non-urgent/emergent inpatient services that are planned and are able to safely be scheduled at a future date and are not being admitted from one of the settings indicated in the “Urgent/Emergent Admission Notification” section above. Notification of elective inpatient admission by the servicing hospital or specialist provider is required a minimum of five to seven days prior to the scheduled admission date. Elective inpatient services that were scheduled but were not prior authorized in the indicated minimum time frame are not considered an urgent/emergent service. Plan providers who fail to follow the indicated prior authorization requirements for Elective Admissions may be responsible for services denied as not medically necessary.

Provider Portal Authorization Submissions Only one authorization will be processed for the requested inpatient elective admission. The determination will be viewable only to the submitting hospital or specialty provider. It is the responsibility of the submitting hospital or specialty provider to communicate the determination to the non-submitting provider. To access the Provider Portal go to deancare.com/providerportal. For additional Provider Portal resources and training documents, visit deancare.com/providers.

Elective Inpatient Prior Authorization Requirements The following information is required for prior authorization of an elective admission: Patient name (middle initial if available) Subscriber number and date of birth Admitting physician/specialist’s name Hospital’s name Diagnosis and clinical information Service requested (i.e. admission, procedure, etc.) CPT code(s) appropriate to the type of admission (medical or surgical) must be provided Admission/Procedure date

Providers with Provider Portal access to authorizations must submit the required information through the Provider Portal. All providers without Provider Portal authorization access have two options to provide the required information indicated above: Fax the required information to (608) 252-0830 Phone the required information to (800) 356-7344, ext. 4455

Elective inpatient admissions that meet medical necessity requirements will be approved for the date of admission only. Hospital facilities that do not have a DRG/Perdiem contract with Dean Health Plan are required to provide ongoing, concurrent review information for determination of the continued medical necessity of the member’s stay. Concurrent review information is required to be provided to the Dean Health Plan Utilization Management department from the facility’s Utilization Management Department. Facilities that have a DRG/Perdiem contract with Dean Health Plan are not required to provide concurrent review to the Dean Health Plan Utilization Management Department, however they are required to provide the date of the member’s discharge from the facility. Authorization dates of service will be based on the admission and discharge dates provided by the DRG/Perdiem hospital facility.

If the elective date of admission is rescheduled or cancelled, please notify the Dean Health Plan UM department at (800) 356-7344, ext. 4455.




OBSERVATION STAYS Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge.

An Observation stay is an alternative to an inpatient admission that allows reasonable and necessary time to evaluate and render medically necessary services to a member to determine if they may require an inpatient stay or follow-up care in another setting. An observation stay will generally not exceed 48 hours.

Hospitals are responsible for notifying the Dean Health Plan Utilization Management Department within 48 hours after admission to observation status or if on a weekend or holiday or the next business day, whichever is later. Examples considered appropriate for Observation Stay include, but not limited to: Abdominal pain Asthma Back pain Bronchitis Chest pain Croup

Providers with access to submit authorizations via the Provider Portal must notify of observation admission by submitting the authorization request.

All providers without Provider Portal authorization access have two options to notify Dean Health Plan of the admission: Fax the required information to (608) 252-0830 Phone the required information to (800) 356-7344, ext. 4455

OUTPATIENT SURGERY Some outpatient procedures require authorization prior to the surgery according to Dean Health Plan Medical Policy. If the surgery requires an authorization, providers are responsible for obtaining an approved authorization prior to the services being received.

Providers with Provider Portal access to authorizations must submit the required information through the Provider Portal. All providers without Provider Portal authorization access have two options to provide the required admitting information: Fax the required information to (608) 252-0830 Phone the required information to (800) 356-7344, ext. 4455

The applicable Dean Health Medical Policy for the service being requested should be reviewed prior to submission of an authorization. The Medical Policies can be found at: deancare.com/providers/forms-and-documents-search-results/?termId=fbe80271-bd07-e011-88a4-e0cb4ef9b7ad

Definitions of Outpatient Surgery/Ambulatory Surgery Center (ASC)

Surgical Day Care Services (SDC)/Surgical Day Care with Overnight (SDCON) are services generally more invasive than ambulatory/minor surgery and usually requires incision or excision procedures. General anesthesia and recovery room services are frequently required. SDC services are usually performed either in a hospital setting or ambulatory surgical center (ASC) and can frequently require an overnight stay (not expected to exceed 23 hours post procedure) as part of the routine recovery period.

Concussion Dehydration Drug overdose False labor Gastroenteritis Migraine headache

Pneumonia Renal colic/calculus Seizure Sepsis Syncope Upper limb closed fracture or

dislocation

http://www.deancare.com/providers/forms-and-documents-search-results/?termId=fbe80271-bd07-e011-88a4-e0cb4ef9b7ad

http://www.deancare.com/providers/forms-and-documents-search-results/?termId=fbe80271-bd07-e011-88a4-e0cb4ef9b7ad


Please note: members who may need more than 23 hours of monitoring but do not have an acute medical need which meets inpatient criteria guidelines and are discharged home that same day cannot be admitted to observation status for continued stay.

Ambulatory/Minor Surgery Service (ASC) is classified as surgery that usually does not require general anesthesia or extended recovery room time and the member is expected to be discharged home that same day.


CARE MANAGEMENT

CARE MANAGEMENT PROGRAM SUMMARY Dean Health Plan’s Care Management Programs review and evaluate the health care members receive to make sure that the member care is coordinated, and that appropriate levels of service are available to members. This includes preauthorization of select services, inpatient care services, complex case management, and disease management. The Dean Health Plan Care Management Department includes the following:

• UM • Case and Disease Management • Medical Review

The Care Management Department is staffed by non-licensed personnel, licensed registered and practical nurse reviewers, social workers and physician reviewers who are available to our network physicians.

UTILIZATION MANAGEMENT PROGRAM Utilization Management Hours of Operation Dean Health Plan staff is available to members and providers seeking information about UM processes and authorization of care. UM staff is available for inbound and outbound communication from 8:00 A.M. to 4:30 P.M. (CST) Monday through Friday except for recognized national holidays (e.g. Labor Day, Memorial Day, Christmas Day, etc.) UM staff is available via voice message outside the indicated business hours, and will contact the requester within one business day of receipt of the request of the voice message, provided the voice message contains the requester’s return contact information. Members may access Dean Health Plan via a toll-free number to the Member Services Department or via a toll-free number to the UM Department. The Customer Care Center (CCC) handles general inquiries, but callers with questions that cannot be addressed by the CCC regarding specific UM decisions are directed to UM staff by the CCC. UM staff identifies themselves by name, title and the organization when receiving or initiating calls to providers regarding UM issues. Access to TTY/TDD services are available to the members via the Telecommunications Relay Service (TRS) number of 711 and this is communicated to members in the Dean Health Plan member newsletter Notables, as well as on any correspondence provided to the member from the UM department. Translation services are also available to members and providers through a collaborative process between the Customer Care Center and the UM department. The Customer Care Center toll-free number is provided to members who require this service via member/provider letters generated by the UM department as well as being communicated to members in the Dean Health Plan member newsletter Notables and to providers in the provider newsletter. The Customer Care Center then facilitates obtaining an interpreter of the required language via telephone with the appropriate UM department personnel. Purpose of the Utilization Management Program Dean Health Plan’s goal is to have members receive high quality care that is the most appropriate care, in the most appropriate setting, by the most appropriate provider, in the most cost effective manner. Therefore, Dean Health Plan encourages all, providers, and Dean Health Plan employees making utilization decisions to base their decisions on the appropriateness of care and service, and the existence of coverage. Dean Health Plan does not specifically reward providers or other individuals making UM decisions for issuing denials of coverage or care nor does it provide financial incentives for UM decision makers which encourage decisions that result in underutilization. All Dean Health Plan, providers, and employees making UM decisions have been made aware of and adhere to this policy.


The purpose of the UM Program is to ensure that health care resources are used efficiently and effectively to provide the best value to individuals and organizations purchasing health care and services. UM involves the evaluation of requests for coverage by determining the medical necessity, appropriateness, and efficiency of the health care services under the applicable health benefit plan. The UM Program directs UM activities for all business products of the Health Plan, including membership in the Commercial population, ASO/self-funded, BadgerCare Plus, and Medicare Cost contracts. UM Program Objectives Comply with State and Federal regulations, as well as National Committee for Quality Assurance (NCQA) standards Monitor potentially avoidable admissions and develop appropriate mechanism to address identified areas of

concern Focus inpatient review activities on problem areas determined by appropriate data sources Trend and monitor data to identify areas of possible over and under-utilization. Areas may include but are not

limited to procedure utilization, pharmacy utilization (certain medications and classes of medications), ER utilization, inpatient utilization, laboratory utilization, and physician practice utilization

Assess provider satisfaction with UM activities and address areas of provider dissatisfaction when appropriate Assess member satisfaction with UM activities and address areas of member dissatisfaction when appropriate Integrate UM with Disease and Case Management as appropriate when identified during UM activities Monitor and analyze variations in the delivery of care in the network for which evidence based standards of

appropriate care exist, and consider opportunities for the UM programs that will improve quality of care and reduce medical costs

Implement or maintain policies and procedures in accordance with applicable regulatory and accreditation requirements and standards

Develop or adopt UM criteria and guidelines that are consistent with generally accepted standards and are based on sound clinical evidence

Implement and maintain a process to review emerging medical technology and new uses for existing medical technology to determine both safety and effectiveness;

Maintain a process to ensure that relevant information is collected to review medical necessity requests for coverage

Utilize qualified health professionals to assess the clinical information used to support UM decisions; Maintain a process in which UM decisions are made in a timely manner and to ensure that members and providers

are notified of determinations of coverage in accordance with federal and state requirements, and accreditation standards

Provide access to staff for members and providers seeking information about the UM process and the authorization of care and prompt turnaround of decisions by qualified health reviewers

Implement and maintain mechanisms for objective and systematic monitoring, evaluation, and improvement of UM processes and services

Implement and maintain mechanisms and policies and procedures that assist in monitoring the quality of UM decisions. These mechanisms include but are not limited to: inter-rater reliability and manageability, case audits and the identification of potential adverse events

Scope of the UM Program The UM Program incorporates the review and evaluation of patient care for medical, dental, and managed behavioral health (delegated to Magellan Behavioral Health) services. The UM Department maintains processes to ensure: (a) equitable access to care across the network and (b) the most appropriate use of medical services in accordance with benefit coverage. UM is performed for the following Dean Health Plan products: Commercial Health Maintenance Organization (HMO) plans Point of Service (POS) plans Medical Assistance (Badgercare Plus)


Senior plans including Medicare supplemental Administrative Services Only (ASO)/Self-Funded ASO Contracts

Major Categories of UM The scope of UM activities include the following major categories: Concurrent Review and Evaluation/ Discharge Planning

o Hospital inpatient admissions o Skilled Nursing Facility (SNF) care and rehabilitation o Home health care o Hospice o Behavioral health outpatient care/AODA services (delegated to Magellan Behavioral Health)

Retrospective Review o Hospital inpatient admissions o Skilled Nursing Facility care o Home health care o Hospice o Behavioral health/AODA services (delegated to Magellan Behavioral Health) o Ambulatory care

Authorization Management/Prior Authorization o Plan ambulatory care o Out-of-plan care o Behavioral health/AODA services (delegated to Magellan Behavioral Health) o Home health care o Hospice o Durable medical equipment (DME) o Targeted Utilization Reporting o Prior Authorization

Quality of Care Monitoring: The UM program coordinates quality of care monitoring with the Quality Improvement (QI) Program and reviews service using the following indicators. • Clinical Indicators

o Sentinel events o Under-utilization and over-utilization

Member complaint and appeal data analysis Review of practitioner utilization profiles Adverse event and sentinel diagnoses data analysis Member satisfaction surveys High volume/high cost drug use

o Continuity and coordination of care monitoring Application of case management selection criteria Member complaint and appeal data analysis Adverse event and sentinel diagnoses data analysis Member satisfaction surveys Member claims for out-of-network services Retrospective reviews

o Monitoring ancillary services (Pharmacy, Lab, Imaging, DME, Physical, Occupational, and Speech Therapy)

• Service o Member satisfaction surveys o Practitioner satisfaction surveys.


Quality Assurance: Dean Health Plan is committed to quality improvement and assumes responsibility for assisting providers to improve the health status of its members. Dean Health Plan recognizes there is an important place for traditional quality assurance activities. Recognition of single or sentinel events through generic screening can indicate trends as well as highlight areas requiring QI study and possible intervention.

Quality and Care Management Division, which consists of: Associate/Assistant Medical Directors Medical Management (UM, Case Management, Prevention and Health Promotion and Medical Review) Quality Improvement and Grievance & Appeals Medical Affairs Informatics Team Pharmacy Department

Customer Operations Division, which consists of: Customer Care Center (Enrollment) Claims Department Subrogation & Third Party Liability Department

Executive Division, which consists of: Provider Relations/Credentialing Department Corporate Compliance Department Contracting Department

Quality Assurance review monitors care delivered in the following areas: Hospital admissions and subsequent care Care in outpatient and inpatient settings Monitoring of underutilization and over utilization Laboratory services Medical imaging Prescription drugs Durable medical equipment Behavioral health care including AODA Care by non-physicians

Utilization review, tracking and follow-up of sentinel events and quality of care issues, is accomplished through the review process and regular meetings of the Medical Peer Review (MPR) Committee. Summaries of events and trends are analyzed and practitioner committee members conduct a retrospective review to identify practice patterns that can be improved.

PROGRAM AUTHORITY AND RESPONSIBILITY Program Authority The UM Committee provides program oversight, review, and direction to the UM Department and Pharmacy Department. The purpose of the UM Committee is to review over and underutilization of plan services with the goal of ensuring that members get high quality appropriate and cost effective care. The goals of this committee are to identify opportunities and recommendations to promote adherence to evidence based protocols and develop processes to encourage appropriate utilization of services by Dean Health Plan providers as applied to Dean Health Plan Members. The UM Committee’s activities and recommendations are reported to the Quality Improvement Committee (QIC). Based upon the information provided, the QIC recommends changes or revisions to the UM program, and as necessary, forwards their recommendations to the Board of Directors for their review and approval.

Care provided by tertiary care centers Ambulatory surgery Home healthcare Rehabilitation Urgent care Emergency care Physical therapy Occupational therapy


Program Responsibility

The UM Department is responsible for carrying out and/or overseeing all UM activities. Activities pertaining to peer review for medical providers and feedback to provider organizations in the area of quality and utilization are reported to the Medical Peer Review (MPR) Committee. All other UM activities are reported as required to the UM Committee. The UM review process is conducted by licensed Registered Nurses (RNs), Registered Health Information Technicians (RHITs), and physician staff. Physician staff are supervised and directed by the Senior Vice President of Medical Affairs and/or the CMO of Medical Affairs, both full-time board certified physicians. Assistant Medical Directors, who review issues brought to them by UM staff, are licensed, board certified physicians who actively practice in their specialties. Other board certified specialists are consulted as necessary when specific expertise is required to provide specialty peer review. UM staff are supervised by the Manager of UM and the Director of Care Management (who reports directly to the Senior Medical Director). UM Committees Medical Policy Committee: The purpose of this Committee is to work to promote the appropriateness of medical

care and service delivered to members through ongoing monitoring, evaluation, and provider education. It is a mechanism by which physicians (Dean Health Plan Medical Directors) can interact on a regular basis and discuss issues relevant to medical management, UM , case management, quality improvement, and pharmacy issues. This Committee offers medical input into the development of clinical programs, adoption of clinical guidelines, and UM criteria. The Committee is chaired by the Senior Medical Director for Medical Management and consists of a panel of multi-disciplinary Board Certified Participating Physicians, along with Dean Health Plan Medical Management staff, as appropriate.

It is a mechanism by which network physicians can interact on a regular basis and discuss issues relevant to

medical management, UM, case management, quality improvement, and pharmacy issues. This Committee offers medical input into the development of clinical programs, adoption of clinical guidelines, and utilization criteria. The Committee is chaired by the Senior Medical Director for Medical Management and consists of a panel of multi-disciplinary Board Certified Participating Physicians, as appropriate.

Medical Peer Review Committee: The MPR Committee is responsible for providing peer review for medical

providers and providers in the areas of quality and utilization. The MPR Committee identifies acceptable levels of utilization and quality performance for Dean Health Plan providers and facilities, and sets performance thresholds for referral of cases to the MPR Committee for review. Once a case is referred, the MPR Committee takes action as necessary, including requesting an action plan or imposing a sanction upon a practitioner or provider. The MPR Committee activities are reported to the QIC quarterly and the Committee notifies other Dean Health Plan committees of their actions as appropriate.

UM Committee: The purpose of the UM Committee is to review over and underutilization of plan services with

the goal of ensuring that members get high quality appropriate and cost effective care. The goals of this committee are to identify opportunities and recommendations to promote adherence to evidence based protocols and develop processes to encourage appropriate utilization of services by Dean Health Plan providers as applied to Dean Health Plan Members This Committee reports its activities to the QIC quarterly.

Pharmacy and Therapeutics Committee: Dean Health Plan uses an established P & T Committee (composed of

physicians and pharmacists) to evaluate new and existing products, determine formulary, and coverage status. Determinations are based on the uniqueness, medical necessity, efficacy, safety, and cost of each drug product reviewed. Relevant information is obtained from primary literature, expert physician input, accepted medical standards of practice, and other sources as needed.


The P&T Committee is also responsible for developing guidelines for the use of various drug products and coordination with the Value of Care Initiative. Guidelines are developed using an “evidence based” approach. Where evidence is lacking, expert opinion is used.

The Pharmacy & Therapeutics Committee reports to the UMC and is evaluated annually. Recommendations for improvement are reviewed and approved by the UM Committee and considered in future work plan development. Pharmacy management is delegated to Navitus and the UM Committee is responsible for the oversight of all activities delegated.

UM CRITERIA Dean Health Plan utilizes written criteria based on medical evidence in making its determination of medical necessity. The medical necessity criteria used in authorization decisions is available upon request. If you have a question about the criteria used in a specific determination, you may contact the UM Department by calling (800) 356-7344 ext. 4455 or (608) 827-4455. We will be happy to provide you with information about our criteria or the specific criteria which was utilized in making a medical necessity determination.

Furthermore, Medical Directors are available to review new technologies for determinations of coverage and to discuss medical policies or decisions made on specific requests. Please contact our Customer Care Center at (608) 828-1301 or (800) 279-1301 for assistance with this process or mail information/requests to Dean Health Plan, Attn: Division Quality and Care Management Division.

REVIEW CRITERIA AND GUIDELINES Criteria used in determining medical necessity are reviewed at least annually by the UM Committee. Criteria currently used are: MCG® Guidelines (Milliman Care Guidelines): The MCG® Guidelines allow for the individual needs of each patient.

The MCG® Guidelines consider demographics as they pertain to the given condition, co-morbidities, complications and progress of treatment, as well as the home environment.

The MCG® Guidelines Criteria are developed by MCG®’s clinical research staff, which includes physicians, registered nurses, and other health care professionals. The criteria’s clinical content is evidenced-based, achievable in real-life situations, and annually reviewed and updated.

All coverage determinations are the responsibility of Dean Health Plan or their delegated entities. All clinical care decisions are strictly and solely the obligation and responsibility of the health care provider. The MCG® Guidelines criteria are used for the following types of services which include but are not limited to:

o Acute inpatient services o Skilled nursing facilities services o Rehabilitation services o Homecare services o Select inpatient surgeries o Select outpatient surgical services o Mental health and substance abuse services for acute inpatient services, partial hospitalization services,

acute residential treatment, and intensive outpatient treatment

Medicare Coverage Guidelines: Dean Health Plan Gold (Medicare Cost Plan) and Dean Health Plan Medicare Select Plans must at a minimum provide coverage for all services and items covered by Medicare. Dean Health Plan Gold utilizes National Coverage Decisions (NCD), Medicare Interpretive Manuals (such as the Medicare Benefit Policy Manual), and Local Coverage Determinations (LCDs) to make coverage determinations for Dean Health Plan Gold members. NCDs, Medicare Interpretive manuals, and LCDs are available on the Center for Medicare Services website.


BadgerCare Plus Coverage Guidelines: Dean Badgercare Plus policies utilize the Forward Health Portal for guidelines specific to coverage of services requested by Dean BadgerCare Plus providers and members. If the Forward Health Portal does not address or provide medical necessity or coverage criteria for services requiring prior authorization, the UM staff will then utilize the Dean Health Plan Medical Policies and/or have the request reviewed by a Dean Health Plan Medical Director. This site is used for determinations specific to the Dean Health Plan BadgerCare products only.

Dean Health Plan Medical Policies: the UM, Medical Director and P&T Committees develop medical policies based on existing technology assessment resources and on input from network providers. These medical policies are reviewed at least annually. Practitioner and member feedback is periodically reviewed to determine if any revisions to the procedures or criteria are necessary. Dean Health Plan will make these criteria available to providers upon their request. Dean Health Plan medical policies are also available via the web at: deancare.com/providers/medical-management/

New policies and procedures pertaining to UM and benefit issues are distributed to providers as necessary, through the quarterly Provider Newsletters and yearly departmental or specially arranged meetings.

EVALUATION OF MEDICAL TECHNOLOGIES Dean Health Plan routinely evaluates and monitors new medical technologies and new applications of existing technologies to determine coverage decisions and benefits. All non-urgent policy requests for the use of medical technologies are reviewed and approved or denied by the Medical Policy Committee and the UM Committee. Technology assessments include the review of medical technologies for medical devices, procedures (including behavioral health through Magellan Behavioral Health), and pharmaceuticals. New pharmaceuticals are primarily reviewed by the P&T Committee. Revisions are made periodically based on new input from the sources noted below.

Several review organizations’ published technology assessments are regularly reviewed by the medical directors. When responding to a request for evaluation, at least two medical directors review the information pertinent to the technology and consult with appropriate specialists as needed.

Dean Health Plan has established processes for proactive technology assessments (new technology reviews identified by published sources) and reactive technology assessments (practitioner or member request for a planned service or procedure), which includes the process for urgent or emergency technology reviews. Each identified technology assessment undergoes an investigation and consideration process, and an approval process.

UM FOR PHARMACY For information regarding Dean Health Plan Pharmacy Management please refer to the Pharmacy Management section of the Provider Manual.

SPECIFIC UM METHODS The UM staff reviews all hospital inpatient admissions for quality and utilization issues. They perform discharge case management as needed, handling cases where the member is in need of additional or alternative inpatient services, home health care, skilled nursing care or DME. They coordinate cases between the members, providers, and organizational providers to ensure quality services are provided in a timely manner. The UM staff screens all prior authorization requests, based on approved criteria established by the Medical Policy and UM Committees as well as the benefits covered under the member’s health plan certificate or summary plan description. All cases requiring review of medical necessity are referred to a Dean Health Plan Medical Director. Members, providers, and organizational providers are informed of the final decision on all denied authorization requests. Specific methods for



each of the major categories of UM activities are outlined below, followed by an overview of the denial and appeal processes: • Concurrent Review: Dean Health Plan members are not at financial risk for non-acute days determined through the review process. These issues are addressed concurrently with the physician or provider when care is delivered by a plan provider, and retrospectively, if necessary, through the MPR Committee.

o Utilization Issues: the following are reviewed by the UM Department staff: Hospital inpatient admissions Skilled Nursing Facility (SNF) care and rehabilitation Home health Hospice As part of concurrent review and prior authorization request reviews, UM staff review inpatient and ongoing outpatient care for potential UM issues. All UM issues are investigated and monitored for potential quality concerns. When a provider, facility, or department reaches an established threshold, all of their UM issues are forwarded to the Quality and Care Management Division for review. The Quality and Care Management Division reviews the information and determines the appropriate action. The categories of disposition are:

Issue resolved - no further action needed on the case issue Issue monitored - the established criteria was not met and the issue will continue to be monitored for

trends and thresholds Refer to MPR Committee for further review and/or action

The QI Department will monitor any corrective action(s), document any progress, or lack of reports. The information is then presented to the UM and Credentialing Committee. All plan hospitals are contractually required to notify the UM Department of a Dean Health Plan member’s admission within 24 hours or by the next business day. The member is not financially responsible for non-covered days if this notification does not take place. However, for emergency or approved admissions to non-contracted facilities, the member is responsible for assuring that notification takes place within the next business day or in the time frame indicated in their certificate or summary plan description or as soon as practical (in case of an emergency admission). Skilled Nursing Facility services require prior authorization. Dean Health Plan applies appropriate and applicable criteria to all inpatient hospital and skilled nursing facility admissions.

o Quality of Care Issues: Quality of care issues may be concurrently identified by UM staff according to sentinel

events determined by Dean Health Plan Care Management staff and/or Medical Director review.

Issues pertaining to potential quality of care are forwarded to the QI Department with copies of pertinent medical records. Quality issues are addressed concurrently when possible, but retrospective reviews may be necessary. The process for review of these issues is documented in the QI Program Description. In each case requiring retrospective review, pertinent information or research is collected and the issue is summarized. A Medical Director then makes a determination regarding disposition and action to be taken, which can be one of the following:

Resolution and tracking Development and implementation of an action plan for improvement by the practitioner or facility Referral to the Medical Peer Review Committee for discussion and/or action

The QI Department monitors the actions listed above to ensure that quality of care issues are appropriately resolved.


• Discharge Planning: UM staff work closely with the attending physicians, social service departments, and facility discharge planners to ensure a smooth transition to alternative care or outpatient treatment methods. Discharge planning assistance is provided for all hospital inpatient admissions, SNF care, home health care, rehabilitation, and behavioral health inpatient/substance abuse services (delegated to Magellan Behavioral Health). • Retrospective Review: Retrospective medical record review is conducted on cases where Dean Health Plan was not notified either prior to, or at the time services were provided. Hospital admissions and non-acute days that do not meet the applicable medical necessity criteria are referred to a Medical Director for review for appropriateness of admission and continued stay. Care that does not meet established criteria may be denied or benefits may be reduced according to certificate provisions if non-contracted providers were used when plan providers were available, and it was determined that the member could have reasonably been expected to comply with the notification requirements. Dean Health Plan UM will not approve “back-dated” authorization requests for elective services that required an authorization determination prior to receipt of the services. The member cannot be held financially responsible for services delivered by a plan practitioner or provider which required prior authorization or notification if the practitioner or provider failed to comply with the terms of their Dean Health Plan contract. Retrospective review may be performed for the following:

Hospital inpatient admissions Skilled Nursing Facility (SNF) care Home health care Hospice Behavioral health/AODA services (delegated to Magellan Behavioral Health) Ambulatory care

• Authorization Management: Dean Health Plan requires members to choose a primary location/clinic if the member has an HMO plan. Prior authorization is required for targeted services and medical necessity is reviewed. If the member has a point of service (POS) or preferred provider organization (PPO) plan they are not required to choose a primary location/clinic, however use of non-contracted providers may result in larger out-of-pocket expense for the member. Prior authorization requirements for POS and PPO members are the responsibility of the member. Prior authorization approval is required for the use of non-contracted providers by HMO and POS members if services cannot be provided within the Dean Health Plan provider network. Non-emergent follow-up with a non-contracted provider following emergency or urgent care services requires an approved prior authorization for HMO members.

All authorizations are screened to determine if they meet Dean Health Plan criteria for medical necessity. If a case does not meet the criteria, it is presented to a Medical Director, who reviews the case and issues a final decision. Enrollees and providers are informed of the final decision on all denied authorization requests. For more specific details regarding Authorization Management and Prior Authorization, refer to the Authorization section of the Provider Manual.

• Denial Process: Denials occur under the following circumstances: o When services are not a covered benefit o When medical necessity has not been demonstrated as determined by a Dean Health Plan Medical Director

review determination o When services do not meet Dean Health Plan Medical Policy or the applicable, evidence based medical

necessity criteria guideline as determined by a Dean Health Plan Medical Director review determination


HMO and POS members receiving services with plan providers are not held financially responsible for charges related to a denied service unless it is a benefit exclusion of the member’s plan contract with Dean Health Plan. The reason for the denial or redirection, along with appeal information, is provided in writing to the member. The referring and the servicing providers are notified of the denial or redirection via the Provider Portal, or in writing if access to the Provider Portal is not available to the provider. In many instances, care is not approved based on benefit limitations and exclusions in the Plan Certificate. These determinations are considered administrative denials and may be made by non-physician staff the reason for the denial or redirection, along with appeal information, are provided in writing to the member. The referring and the servicing providers are notified of the denial via the Provider Portal or in writing if access to the Provider Portal is not available to the provider.

• Peer to Peer Review Process: The peer-to-peer review process offers the requesting provider an opportunity to discuss the determination to deny an authorization request. It is NOT considered a provider appeal. The peer-to-peer review process is intended to give the requesting physician an opportunity to discuss the determination to deny when he or she feels that the submitted documentation supported an approval determination. The peer to peer process should not be used as a means for the provision of additional information that should have been provided with the initial request. All applicable medical documentation should be provided or available to Dean Health Plan UM when an authorization is initially submitted for review and/or a determination is in process. If additional objective medical information is obtained following the denial determination a new authorization request must be submitted with that additional information. New authorization requests submitted without additional objective medical information will not be accepted. The opportunity for a peer to peer review is available for up to ten calendar days after the denial determination has been made. Alternatives to consider if the ten calendar day window has elapsed include filing a formal provider appeal or directing the member to the appeals and grievance process outlined in his or her letter; member certificate or by contacting the Dean Health Plan Customer Care Center. • Appeal Process:

Members: Dean Health Plan members may file an appeal or grievance relating to any aspect of the Health Plan by following the formal grievance procedure outlined in their member certificate. The Member Services Department is responsible for the research and resolution of the grievance.

Providers: Whenever a practitioner proposes modifications or exceptions to Dean Health Plan policies or procedures, the proposal is considered by an appropriate health plan representative.

Please refer to the Member Grievance and Appeals Process section in this manual for the Provider Appeal Process for more detailed information.

PROGRAM EVALUATION

The UM Department annually evaluates the UM Program and submits their UM Program Evaluation to the UM Committee for review and approval. The evaluation includes a review of the UM Program using member complaint, grievance and appeal data; the results of member satisfaction surveys; practitioner complaint, grievance, and appeal data; and the results of practitioner satisfaction surveys, as appropriate. The evaluation includes both program accomplishments and limitations/barriers. Recommendations from the annual Program Evaluation are incorporated into the next year’s UM Program Description and QI Work Plan as appropriate.


CASE AND DISEASE MANAGEMENT

DEPARTMENT HOURS OF OPERATION

The Case and Disease Management Department is available to members and practitioners seeking information about the Case and Disease Management Programs. Case Management staff is available for inbound and outbound communication from 8:00 a.m. to 4:30 p.m. (CST). Providers may refer a member to Case or Disease Management by calling the Case and Disease Management Department at (800) 279-1301, ext. 4132 or (608) 827-4132. Members may access Dean Health Plan by calling (800) 279-1301 or (608) 828-1301 to the Customer Care Center. The Customer Care Center handles general inquiries, but members with questions regarding specific case or disease management programs are directed to the Case Management Staff. Members may also self-refer to case management at deancare.com/health-insurance/health-and-wellness/case-management/. The Case Management staff identifies themselves by name, title, and the organization when receiving or initiating calls to members and practitioners regarding Case and Disease Management Programs.

CASE MANAGEMENT PROGRAM DESCRIPTION

Dean Health Plan’s Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The Case Management staff is comprised of specially qualified nurses and social workers, who assess the member’s risk factors, develop an individualized case management plan, establish member centric goals, monitor outcomes, and evaluate the outcome for possible revisions of the case management plan of care utilizing sound principles of practice and evidence-based guidelines. The Case Management program serves in a support capacity to the Primacy Care Physician (PCP) and assists in coordinating care actively linking members to providers, medical services, residential, social & other support services as needed. The Case Management staff adheres to the Case Management of America (CMSA) standards of practice and NCQA standards for complex case management. Dean Health Plan uses a combination of telephonic case management and embedded case management to meet its members’ and physicians’ needs. Telephonic case management is available to Dean Health Plan’s entire membership. In some clinics, Dean Health Plan case management staff is embedded in the primary care departments to provide case management at the point of member care. Dean Health Plan has incorporated case management programs that manage members with specific health care needs such as catastrophic disease (adult and pediatric) high risk conditions and transplants. Member participation in case management is voluntary and members may opt out at any time. Referral into the Case or Disease Management Program may be requested by the provider. Go to deancare.com/providers/care-management/ for more information on how to refer a member for a Case or Disease Management Program.

http://www.deancare.com/health-insurance/health-and-wellness/case-management/

http://www.deancare.com/providers/care-management/


CASE MANAGEMENT PROGRAMS Complex Case Management (CCM) Dean Health Plan’s Complex Case Management Program is a multi-disciplinary approach to the coordination of care and services provided to members who have experienced a critical event or diagnosis that requires the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. The CCM Program is a process directed at the coordination and integration of resources to create cost-effective options for catastrophically ill or injured members on a case-by-case basis. The focus is to use available resources in the most effective manner to facilitate quality goals and outcomes.

The Complex Case Management Program supports the practitioner-patient relationship and plan of care. The CCM Program continuously evaluates the clinical, humanistic, psychosocial and economic outcomes with the goal of helping members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The essential elements of complex case management include: Comprehensive assessment of the member’s condition; Determination of available benefits and resources; And development and implementation of a case management plan with performance goals, monitoring and

follow-up.

Conditions, diseases or high-risk groups most frequently managed by the CCM Program include, but are not limited to the following: Multiple/frequent ER visits (two or more ED/UC Facility visits in one month) Multiple/frequent acute inpatient admissions Multiple prior authorizations and/or providers Multiple providers, in and out of network Multiple/severe disabilities Chronic Diseases w/ co-morbidities Transplants (evaluation, pre-transplant, transplant, and post-transplant phase) Leukemia Out of Network (OON) Services related to a Cancer Diagnosis Traumatic Brain Injuries Second and Third Degree Burns Multiple Congenital Defects High risk OB NICU admissions

Identification of members for possible CCM services includes: Direct referral by the primary care physician or specialist Discharge Planners Pharmacy data Claims Hospital discharge data Internal referrals from other departments Family/Member self-referral Dean Health Plan’s UM


DISEASE MANAGEMENT PROGRAMS Living Healthy Dean Health Plan’s Disease Management Programs are multi-disciplinary and continuum-based systems developed to proactively identify populations with, or at risk for, chronic medical conditions. Dean Health Plan case managers provide disease management services to the Dean Gold, Medicare Advantage, and self-funded populations as well as all members under the age of 18 years. Populations currently being managed include members with asthma, chronic obstructive pulmonary disease (COPD), diabetes, and heart failure. In partnership with WebMD, Dean Health Plan offers commercial and Medicaid members, over the age of 18 years, disease management services for COPD, diabetes, heart failure and coronary artery disease (CAD) through its Living Healthy Program. The WebMD program is NCQA accredited. Disease management programs support the practitioner-patient relationship and plan of care; emphasize the prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies such as self-management. The Dean Health Plan programs continuously evaluate clinical, humanistic, and economic outcomes with the goal of improving overall health status. The essential elements of disease management include: Understanding the course, clinical implications, and trajectory of specific diseases; Identifying and targeting members likely to benefit from intervention; Focusing on prevention; And working toward resolution of resource-intense problems.

Each disease management program includes condition monitoring that is ongoing and proactive. This allows the member, the practitioner, and the case manager to assess how well the condition is being managed. Monitoring is done through the use of regular clinical assessments with surveillance of pharmacological management and utilization management (pre-authorizations of services; concurrent review of inpatient services and hospital admission/discharges) data, lifestyle management, and assessment of the member’s knowledge of the condition itself as well as the related comorbid conditions likely to affect overall health status. Member adherence to the program’s treatment plan is an integral part of disease management. Members are followed to determine their success with self-management, self-monitoring activities, and medication compliance. High-risk members are called at periodic intervals. Detailed questions are asked about the member’s condition and information is gathered regarding health status, treatment plan adherence, functional status, and quality of life. A specific plan of care is developed based on the findings from a clinical assessment and functional inventory. Ongoing monitoring by the case manager ensures timely intervention when a change in risk status is identified. The frequency of outbound calls to participants by the case manager is determined by the severity of symptoms. If home care or other services are needed in high risk-cases, the case manager works with the practitioner and appropriate agencies to coordinate the necessary care and services. In all instances, disease management programs must give consideration to other health conditions that directly affect the member’s overall health status. A multidisciplinary approach to disease management enables the case manager to develop a treatment plan that includes condition monitoring of comorbid conditions frequently associated with chronic medical conditions. Because lifestyle issues are strongly linked with chronic disease and high risk pregnancy, strategies to address current lifestyle and the need to modify behavior are addressed in every program. Whether members need interventions addressing issues such as smoking cessation or weight loss management, the case manager is able to address readiness to change and to provide additional resources to affect needed change.


Dean Health Plan’s Disease Management Program elements include: Identification of evidence-based standards of care, best practices, evidence-based intervention strategies, and

targeted outcomes such as HEDIS measures. Identification of the member and assessment of health status. Proactive intervention to include the application of appropriate therapies and systematic surveillance of

appropriateness of medication, education and counseling about daily self-management, and symptom management.

Tracking of the member’s clinical and functional status over time. Assessment of effectiveness of treatment and sharing of knowledge gained to achieve optimal member

outcomes. Coordination of behavioral health care services. Routine reporting, including feedback to members and health care providers.

Attention to all program elements and improvements in all of these areas will likely lead to improved outcomes for the many who are at risk or who suffer chronic diseases. Go to deancare.com/providers/care-management/ for more information on how to refer a member for a Case or Disease Management Program, or contact the Case and Disease Management Department at (800) 279-1301, ext. 4132 or (608) 827-4132. A copy of the specific targeted condition’s program content, method of identification, and program goals is provided upon request.

STATEMENT OF CONFIDENTIALITY Dean Health Plan has a Corporate Confidentiality policy that states that employees have a responsibility to ensure that all personal, member, and employee information remains confidential. Earning the trust and confidence of our members and fellow employees is a responsibility each employee shares. Every employee has an obligation to comply with Dean Health Plan policies on confidentiality and with laws and regulations that apply to us and our industry. Disclosure of confidential information at work or elsewhere about members or employees violates a valued trust and that individual’s legal right to confidentiality. If an employee is found to have violated any confidentiality policy, disciplinary action, up to and including immediate termination of employment, may result.

STATEMENT OF CONFLICT OF INTEREST Employees and consultant practitioners are prohibited from reviewing cases and request that pertain to themselves, family members, or acquaintances in which the case/request that is being reviewed and the decision reached would be influenced by personal knowledge. Employees are also prohibited from reviewing cases in which they have provided care. The case/request must be deferred to another reviewer. Compensation plans for individuals who provide utilization review services do not contain incentives, direct or indirect, for these individuals to make inappropriate review decisions. Employees are prohibited from working for other companies, while employed with Dean Health Plan, where that employment may be construed as a conflict of interest.

PROGRAM EVALUATION The Care Management Departments of UM and Case & Disease Management annually evaluate their respective programs. The UM and Pharmacy Departments submit their UM Program Evaluation to the UM Committee for review and approval; Case & Disease Management Program Evaluations are reported to the QI Committee. Recommendations from the annual Program Evaluations are incorporated into the next year’s Program Description and QI Work Plan as appropriate.

http://www.deancare.com/providers/care-management/


MEMBER GRIEVANCE AND APPEALS PROCESS MEMBER COMPLAINT, APPEAL, & GRIEVANCE PROCEDURE The Complaint, Appeal, and Grievance Procedure is used to resolve member issues. We ask that our providers familiarize themselves with this process, and refer all complaints to Dean Health Plan, with consent from their patients; this process may also be used by providers to file appeals or grievances on behalf of their patients. When a complaint, appeal, or grievance has been submitted, Dean Health Plan may contact a provider for more information related to the issue. We require that our practitioners respond promptly to any requests for information from Dean Health Plan. This will assist us in providing a timely response and resolution to complaints, appeals or grievances filed with our office. To ensure a fair decision, Dean Health Plan gives our practitioners the opportunity to discuss decisions that are based on medical necessity with a Dean Health Plan Medical Director. The treating physician will be informed at the time of the denial by the Medical Affairs Division how to initiate this process should he/she want to discuss the decision. The procedure for filing a complaint, appeal, or grievance is defined below. This information is also located in the Member Certificates. Your understanding of this process will assist us in resolving member issues in a timely manner.

Complaint Dean Health Plan takes all member complaints seriously and is committed to responding to them in an appropriate and timely manner. If a member has a complaint regarding any aspect of care or decision made by you or the Health Plan, please contact the Customer Care Center at (608) 828-1301 or (800) 279-1301. We will document and investigate the member complaint and notify the member of the outcome of the complaint. If the complaint is not resolved to their satisfaction they can file a grievance. Because most concerns can be addressed informally, we encourage either you or the member to contact the Customer Care Center first for discussion before taking any formal action. Any written expression of dissatisfaction will automatically be addressed as a grievance (see Grievance subsection).

Grievance To file a grievance, a member can submit it to us in writing or contact the Customer Care Center at:

Dean Health Plan P.O. Box 56099

Madison, WI 53705 (608) 828-1301 | (800) 279-1301

Upon receipt of the grievance, Dean Health Plan’s Grievance and Appeal Department will acknowledge it within five business days. Our acknowledgment letter will advise the member of their right to: Submit written comments, documents or other information regarding their grievance, Be assisted or represented by another person of their choice, Appear before the Grievance and Appeal Committee if they wish to do so, And the date and time of the next scheduled meeting, which will not be less than seven calendar days from the

date of their acknowledgment and within 30 calendar daytime frame of receiving the grievance.

If the member chooses to appear before the committee, they must notify us. If they are unable to appear before the committee, they do have the option of scheduling a conference call. The member or the member’s authorized representative have the right to request a copy of documents, free of charge, relevant to the outcome of the grievance by sending a written request to the address listed above. Their grievance will be documented and investigated. All grievances will be resolved within 30 calendar days of receipt.


Independent External Review A member may be entitled to an independent external review (IER) of a final adverse determination involving care which has been determined not to meet the Plans’ requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness of care, or where the requested services have been found to be experimental treatment. Determinations involving pre-existing conditions and Policy Rescissions are also eligible for IER. A member must exhaust all appeal/grievance options before requesting an independent external review. However, if we agree with the member that the matter should proceed directly to independent review, or if they need immediate medical treatment and believe that the time period for resolving an internal grievance will cause a delay that could jeopardize their life or health, they may ask to bypass our internal grievance process. In these situations, the request will be processed on an expedited basis. If the member or the member’s authorized representative wish to file a request for an independent review, the request must be submitted in writing to the address listed above in the “Grievance” subsection and received within four months of the decision date of the grievance. Upon receipt of the request, a URAC accredited IER will be assigned to the case through an unbiased random selection process. The assigned IER will send the member or the member’s authorized representative a notice of acceptance within one business day of receipt, advising of the right to submit additional information. The assigned IER will also deliver a notice of the final external review decision in writing to the member or the member’s authorized representative and Dean Health Plan within 45 calendar days of their receipt of the request. A decision made by an IER is binding for both Dean Health Plan and the member with the exception of pre-existing condition exclusions and the rescission of a policy or certificate. The member is not responsible for the costs associated to the IER. The decision is binding on both the insurer (the Plan) and the insured. Requests for benefits beyond those defined in the benefit package are not eligible for independent external review. Please contact our Customer Care Center for information regarding availability, and the process for initiating the review.

Urgent Grievance If the initial grievance involves the need for urgent care, we will resolve those within 72 hours of receiving the grievance according to Dean Health Plan’s criteria which is based upon the urgent care grievance provisions of state law. If the grievance meets criteria for an expedited grievance, meaning the situation is deemed urgent in nature or the member is receiving ongoing treatment, they are also eligible for an expedited external review concurrent with the internal expedited review of their grievance. The request may be oral or written.

Office of the Commissioner of Insurance Problems may be resolved by taking the steps outlined on the previous pages. The member may also contact the Office of the Commissioner of Insurance, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. They can contact the Office of the Commissioner of Insurance by writing to:

Office of the Commissioner of Insurance P.O. Box 7873

Madison, WI 53707-7873 Or, they can call (608) 266-0103 Madison, or (800) 236-8517 outside Madison, and request a complaint form.


PROVIDER APPEALS

PROVIDER APPEALS PROCESS Dean Health Plan has the authority to establish, modify, and implement various policies and procedures with regard to such matters as clinical practice guidelines, quality assurance, utilization management, quality improvement, credentialing, and coding. Dean Health Plan will accept proposals to modify or make an exception to an established policy or procedure. If Dean Health Plan denies a claim or benefit that results in a partial payment, denial to a practitioner, or makes a determination that is unsatisfactory to the practitioner, the practitioner of care is entitled to appeal the denial. If a claim is specifically denied for timely filing, please reference the process below. Appeal requests will be considered, if submitted in writing, by an appropriate representative of Dean Health Plan. We require that practitioners respond promptly to any requests for information regarding their appeal. This will assist Dean Health Plan in providing a timely response to the appeal filed with our office. If the practitioner is dissatisfied with the decision made by the Dean Health Plan representative, the provider will be advised of their subsequent appeal rights, as outlined in their agreement, to request that the decision be reviewed by the president of Dean Health Plan, or his or her designee, who shall have the right to uphold or overturn the decision. The results of the final review shall be considered final and binding upon Dean Health Plan and provider.

TIMELY FILING APPEALS Dean Health Plan considers timely filing appeals separately from Provider and Coding Appeals. If the timely filing guidelines and/or exception guidelines were not met and the claim(s) remain denied, the provider may appeal the timely filing denial. The provider must submit additional documentation to support filing their claim timely, in writing, in order for it to be review by Provider Network Services. The Provider Network Services will communicate the decision in writing to the requesting provider, specifying the reason(s) for the decision, advising the provider of their right to discuss the decision. The Provider Network Services shall have the right to uphold or overturn a timely filing denial, based on the documentation provided and final review. The results of the final review by Provider Network Services shall be considered final and binding upon Dean Health Plan and Provider.

PROVIDER PORTAL APPEALS Claims that have been processed with a finalized status (denied-paid) can be appealed online through the Dean Health Plan Provider Portal or via paper submission. Contracted providers are encouraged to submit claim appeals online via the Claim Appeal feature of the Provider Portal, deancare.com/providers/

Claim Appeal Types

• COB This claim appeal type would be used to request reconsideration of a coordination of benefits (COB) denial. The primary payer’s EOP is required if not submitted with the original claim.

• Additional Payment This claim appeal type would be used to request reconsideration of a Dean Health Plan payment. Include both the amount originally paid as well as the expected payment amount. A brief statement explaining why the original payment is incorrect is also required.

http://www.deancare.com/providers/


• Recoup This claim appeal type would be used to request a recoupment or refund. Include both the amount originally billed as well as the recoupment/refund amount. The reason for the recoupment/refund is also required.

• Timely Filing

This claim appeal type would be used to request reconsideration of a timely-filing denial. Providers are required to file claims in a timely manner. All claims must be submitted in accordance with the claim filing limit stipulated in your Provider Agreement/Contract. Documentation to support the timely-filing waiver is required.

• Code Review Request

This claim appeal type would be used to request reconsideration of a claims-edit denial. Denials may include frequency/maximum units, code bundling, inappropriate modifier, global surgery and diagnosis. A brief statement explaining why the claim edit should be overturned and corresponding supporting documentation is required.

• Authorization Claim

This claim appeal type would be used to request reconsideration of a failure-to-prior-authorize denial. A brief statement explaining why the denial should be overturned and corresponding supporting documentation is required.

• Medical Necessity This claim appeal type would be used to request reconsideration of a medical-necessity denial. A brief statement explaining why the denial should be overturned and corresponding supporting documentation is required.

• Unlisted Codes

This claim appeal type would be used to request reconsideration of an unlisted code denial. A description of the unlisted procedure, a brief statement explaining why the unlisted code denial should be overturned, and supporting documentation is required.

You can find helpful tips and resources regarding submission of claim appeals by going to deancare.com/providers/. The information includes but not limited to what type of documentation to submit, key considerations when submitting medical records and relevant documentation for unlisted codes.

http://www.deancare.com/providers/


PHARMACY

DEAN HEALTH PLAN PHARMACY MANAGEMENT Dean Health Plan provides a comprehensive drug benefit for those members in a plan with prescription drug coverage. The member’s identification card will assist you in identifying those members with a drug benefit. Dean Health Plan provides all pharmacy information to practitioners, clinics and facilities via our external website: deancare.com/providers/pharmacy/. This website provides updates to formulary coverage, a listing of prior authorized drugs, and information on all pharmacy programs available to members. The formularies can be accessed here: deancare.com/health-insurance/members/drugformulary/ Dean Health Plan notifies clinics of new pharmacy information, Dean Health Plan Pharmacy & Therapeutics (P&T) Committee activities, or reports through notification on deancare.com and the Provider Newsletter.

Pharmacy Management includes but is not limited to: Formulary Tiering Prior Authorization and Step Edits Quantity Level Limits Specialist Restrictions Mandatory Specialty Pharmacy Mandatory Generic Substitution

PHARMACY AND THERAPEUTICS COMMITTEE Dean Health Plan uses an established Pharmacy and Therapy Committee (composed of physicians and pharmacists) to evaluate new and existing products, determine formulary, and coverage status. Determinations are based on the safety, efficacy, expected clinical outcome and cost of each drug product reviewed. Relevant information is obtained from peer-reviewed literature, expert physician input, accepted medical standards of practice, and other sources as needed. The P&T Committee is also responsible for developing guidelines for the use of various drug products and coordination with the Value of Care Initiative. Guidelines are developed using an “evidence based” approach. Where evidence is lacking, expert opinion is used. The P&T Committee reports to the Medical Policy Committee and is evaluated annually. Recommendations for improvement are reviewed and approved by the UM Committee and considered in future work plan development.

DRUG PRIOR AUTHORIZATION PROCESS Providers can start the Prior Authorization process by accessing: navitus.com. Once in Navitus, go to Prescriber Section for Formularies, Prior authorization and information on Specialty Pharmacies. The drug prior authorizations should be faxed to (920) 735-5350. For questions contact the Dean Customer Care Center (800) 279-1301. Should a member or practitioner disagree with a prior authorization decision, or if more information becomes available, the prior authorization request will be reconsidered. Ultimately, the member has the opportunity to pursue the grievance process for any drug prior authorization request that is redirected to other covered drugs or denied.

http://www.deancare.com/providers/pharmacy

http://www.deancare.com/health-insurance/members/drugformulary/

http://deancare.com/

http://www.navitus.com/


THREE (3) TIERED DRUG FORMULARY Dean Health Plan offers members both a three-tier drug formulary and the traditional two tier formulary pharmacy benefit. A three tier formulary offers a much greater choice for both clinicians and patients. Drugs placed on the third tier require a very significant copay or coinsurance. For example, the three tier formulary benefit will have the following copay structure: Tier 1: copay dependent on policy Tier 2: copay dependent on policy Tier 3: 50 percent coinsurance with a minimum payment per prescription of $50 and a maximum payment of $150.

Dean Health Plan patients will be on either a two or three tier formulary benefit. The following rules are the same for both 2 and 3 tier formularies: Tier 1 contains all lower cost generics and some preferred branded drugs. Tier 2 contains higher cost generics and preferred brand drugs. Tier 3 contains expanded formulary brand and select generics. The listing of drugs that require prior authorization will be the same for both the 2 and 3 tier formularies.

However, all drugs on the third tier will not be covered for those with a 2 tier formulary benefit. There is no copay exception policy for drugs on the 3rd tier.

QUICK REFERENCE GUIDE The Quick Reference Guide is an abbreviated listing of commonly used formulary drugs, and is updated monthly. The Quick Reference Guide is available online at: deancare.com/pdf/pharmacy/plan/QuickReferenceDrugList.pdf

EXCLUDED OR NONFORMULARY DRUG POLICY Dean Health Plan has an established policy for handling requests for drugs excluded from the formulary. Physicians may request consideration for excluded drugs on an exception basis. Exception requests should be submitted using the Exception To Coverage form, which can be found on the deancare.com. Exception requests will be considered for approval only after all formulary alternatives have been tried and failed. A contraindication to a specific formulary alternative drug constitutes a failure of the formulary alternative drug without a trial of that drug. All drugs are excluded from the formulary until they have been reviewed and approved by Dean Health Plan Pharmacy & Therapeutics Committee.

NAVITUS HEALTH SOLUTIONS State of Wisconsin Employees who have medical coverage through Dean Health Plan do not have pharmacy coverage through Dean Health Plan. Navitus Health Solutions is the pharmacy benefit manager (PBM) for State of Wisconsin Employees. State of Wisconsin Employees have their own unique formulary and prior authorization process. The Navitus Web site, navitus.com, and Navitus Customer Service (toll free 866-333-2757) should be consulted regarding formulary and benefit information for this population.

http://www.deancare.com/pdf/pharmacy/plan/QuickReferenceDrugList.pdf


http://navitus.com/


The following table highlights the differences between your Dean patients and your Dean patients that are State of Wisconsin Employees.

DEAN PATIENTS DEAN STATE OF WI EMPLOYEES

CUSTOMER SERVICE Call Dean Health Plan’s Customer Care Center (608) 828-1301 or (800) 279-1301

Call Navitus Customer Service (920) 225-7010 or (866) 333-2757

ID CARDS One ID Card for both Medical and Pharmacy

Two ID Cards Dean: Medical ID Card Navitus: Pharmacy ID Card

MAIL ORDER Mail order is available for selected groups through WellDyneRx.com Mail order is available through WellDyneRx.com

PRIOR AUTHORIZATIONS

Prior authorization forms on: navitus.com

Prior authorization forms on: navitus.com Dean Health Plan’s Prior Auth Forms cannot be used for this population; Unique prior authorization list. Associated criteria

ONLINE FORMULARY Dean Formulary: deancare.com Navitus Formulary: navitus.com

EPOCRATES WITH FORMULARY

Dean Formulary: Register at epocrates.com More information is available in provider newsletters.

Navitus Formulary: Register at epocrates.com Also available on the Navitus Website.

OTHER HELPFUL PHARMACY INFORMATION Copayments can be identified on the member’s identification card. For example, a “$10/30%” indicates that the

member has a $10 copayment for Tier 1 drugs and a 30 percent copayment for Tier 2 drugs. When a member requests a brand name prescription when a generic is available, the member will be responsible

for the brand name copayment along with the difference in cost between the generic and brand drug. Generic substitutions will be made by the pharmacy when Food and Drug Administration (FDA) approved generics

are available. Insulin and diabetic supplies are a covered benefit for all members, including groups that do not have a drug benefit. The amount of coverage varies depending on the member’s benefit.

Infertility medications may be subject to 50 percent coinsurance when considered a covered benefit under the plan.

Take-Home Drugs: only retail pharmacies with an active Dean Health Plan Pharmacy Agreement may provide outpatient drugs to Dean Health Plan members. Discharge medications or emergency room/urgent care take home drugs are considered outpatient prescriptions. These medications are not a covered benefit unless dispensed by the institution’s retail pharmacy who is a contracted pharmacy provider.

When a member has more than one insurance, coordination of benefits for pharmacy claims shall occur. If Dean Health Plan is the member’s primary carrier, all pharmacy charges should be submitted according to the Dean Health Plan filing guidelines.

In situations where Dean Health Plan members treated for urgent/emergent care require medications and they do not have access to a plan pharmacy, the following guidelines apply: The member should be given a quantity of medication to last until they are able to access a plan pharmacy (usually

a one day supply). The member should be given a written prescription for the remaining medication needed. They should be instructed to have the prescription filled at a plan pharmacy.

https://dean.welldynerx.com/Default.aspx?tabid=368

https://dean.welldynerx.com/Default.aspx?tabid=368




http://www.epocrates.com/

http://www.epocrates.com/


STATEMENT OF CONFLICT OF INTEREST Employees and consultant practitioners are prohibited from reviewing cases and request that pertain to themselves, family members, or acquaintances in which the case/request that is being reviewed and the decision reached would be influenced by personal knowledge. Employees are also prohibited from reviewing cases in which they have provided care. The case/request must be deferred to another reviewer. Compensation plans for individuals who provide utilization review services do not contain incentives, direct or indirect, for these individuals to make inappropriate review decisions. Employees are prohibited from working for other companies, while employed with Dean Health Plan, where that employment may be construed as a conflict of interest.

PROGRAM EVALUATION The Pharmacy Department annually evaluates their program. The Pharmacy Department submits their Program Evaluation to the UM Committee for review and approval. Recommendations from the annual Program Evaluations are incorporated into the next year’s Program Description and QI Work Plan as appropriate.


QUALITY IMPROVEMENT It is the mission of Dean Health Plan to promote members’ health by ensuring the right care, at the right place, at the right time, and with the right person. The Quality Improvement Program provides the overview of how the Health Plan assesses and improves the quality of clinical care and quality of service delivered to its members. The Quality Improvement Committee is involved in reviewing relevant reports on subjects, including those that follow.

QUALITY OF SERVICE ISSUES Dean Health Plan identifies and investigates all instances of concern for the quality of service provided to Dean Health Plan members. Dean Health Plan typically identifies quality of service issues through member complaints. Dean Health Plan categorizes quality of service issues as follows: Access To Care Communication/Incorrect Information Provider/Staff Behavior Privacy Breach Facility Physical Accessibility Facility Physical Appearance Adequacy of Space in Facility Adequacy of Treatment Record Keeping

All issues relating to quality of service provided to Dean Health Plan members are referred to the Quality Improvement Department for investigation. Quality Improvement logs all incoming issues concerning quality of service, noting the date of receipt and the source. Quality Improvement will determine if the individual(s) involved was a Dean Health Plan member at the time of service. If not, the quality of service concern is referred to the practitioner clinic and/or medical facility for investigation and resolution. This referral is documented in Quality Improvement. Quality Improvement will investigate the issue and verify the concern for quality of service provided to members. Quality of service issues are investigated by contacting the appropriate Dean Health Plan staff, as well as medical and administrative staff at practitioner clinics and medical facilities. Quality Improvement will review the following as they pertain to the service issue:

Dean Health Plan complaint and/or grievance documentation Prior authorization information Utilization review information Medical records Any documentation of the issue at appropriate practitioner clinics and medical facilities Any other available information relevant to the issue

Quality Improvement will document a summary of the investigation which is reviewed by Quality Improvement Management to determine the appropriate disposition of the issue. They will conduct and complete the investigation within 30 working days of receipt. Quality Improvement will update the log of quality of service issues, noting the actions taken by the Quality Improvement Management. They will monitor and, as appropriate, implement corrective action plans. Quality Improvement will document all activities and progress of corrective action plans.


QUALITY OF CARE ISSUES Dean Health Plan identifies and investigates all instances of concern for the quality of care provided to Dean Health Plan members. Dean Health Plan identifies quality of care issues through member complaints, inpatient and outpatient utilization review, case management referrals, studies, reports, and referrals from providers and practitioners. Quality Improvement logs all incoming issues concerning quality of care, noting the date of receipt and the source (member complaints, inpatient and outpatient review, studies, reports, and referrals from providers and practitioners). Quality Improvement will also send any required acknowledgement letter within 5 working days of receipt. Quality Improvement then forwards all quality of care issues involving a Dean Health Plan member at the time of service, to the Utilization Management Department (UM) for investigation. If the individual involved in a quality of care complaint was not a Dean Health Plan member at the time of service, Quality Improvement will refer the quality of care concern to the practitioner clinic and/or medical facility for investigation and resolution. This referral is documented in Quality Improvement.

In investigating the quality of care complaint, UM will follow the Dean Health Plan MPRC (Medical Peer Review Committee) Workflow process. An MPRC Case Summary will be prepared for each case investigated. The investigation may include the following information:

Dean Health Plan complaint and/or grievance documentation. Prior authorization information. Utilization review information. Medical records. Any documentation of the issue at appropriate practitioner clinics and medical facilities. Any other available information relevant to the issue. Results of an External Independent Review if there is a referral for a second level review recommended by a

Dean Health Plan Medical Director.

The Chair of the MPRC, the Dean Health Plan Medical Director or the MPRC Committee may contact the physician under review in writing, via telephone, or electronically to request additional information or clarification. The physician is expected to respond appropriately to the request(s) for additional information.

The Chair of the MPRC or Dean Health Plan Medical Director will conduct and complete his or her investigation of the quality of care complaint within 90 working days of receipt. This 90 day period applies only to the investigation of the Chair of the MPRC or Dean Health Plan Medical Director. If the file is referred to the MPRC Committee for further investigation, that investigation may go beyond the 90 day time period. A summary of the investigation and any actions taken will be documented within MPRC. The Chair of the MPRC, a Dean Health Plan Medical Director and/or Medical Peer Review Committee will determine the appropriate level of severity and disposition of the issue. Levels of Severity include: Level 1 – Predictable event within standard of care. Level 2 – Unpredictable event within standard of care. Level 3 – Marginal deviation from standard of care – MPRC Committee review required. Level 4 – Significant deviation from standard of care – MPRC Committee review required. Level 5 – Significant deviation from standard of care with fatality – MPRC Committee review required.

Where the MPCR Chair or a Dean Health Plan Medical Director believes a case has the potential to be leveled at a three or above, the case will be referred to the MPRC Committee for review, discussion and final determinations.

The purpose of the MPRC and its Committee is to function as an advisory board and to provide a review of medical practitioners by peers in the areas of quality of care and effective utilization of services. The outcome of the review process is to educate practitioners on issues identified as requiring improvement and to initiate any applicable remedial or disciplinary actions. Members of the MPRC Committee are medical practitioners from various specialties. The responsibilities of MPRC include: Review quality of care issues identified through sentinel events monitoring, referred by peers and the QA and

complaint processes of HMOs, hospitals, and other medical facilities.


Determine appropriate remedial steps or discipline needed. Establish a plan for practitioner education and follow up to assure future improvements and compliance as

needed. Monitoring data on identified quality issues. Provide recommendations to medical management, as needed, about individual practitioner and/or group trends

or patterns relating to quality issues.

The MPRC will review the quality of care issues referred by the Chair of the MPRC or a Dean Health Plan Medical Director and determine the appropriate corrective actions. Quality Improvement staff will attend the Medical Peer Review Committee meeting to support the presentation of the quality of care issues.

The MPRC will specify the activities, responsible parties, time frame, and reporting requirements for implementing corrective actions which may include a recommendation for an ad hoc recredentialing if deemed appropriate by the MPRC Committee members. MPRC will update the log of quality of care issues, noting the actions taken by the MPRC Committee. Any actions to reduce, suspend, or terminate a Dean Health Plan practitioner will follow the process outlined in Dean Health Plan’s Credentialing Committee’s policies and procedures.

The MPRC Committee will, as appropriate, implement and monitor corrective action plans. The MPRC Committee will document all activities and progress of corrective action plans.

ACCESSIBILITY OF SERVICES Dean Health Plan has set standards for member access to services provided by Primary Care Practitioner (PCP) office sites and Behavioral Health practitioner sites. Dean Health Plan performs a semiannual Appointment Accessibility Assessments of all Primary Care practitioner and Behavioral Health practitioner sites within the Dean Health Plan network.

A self-assessment reporting tool is provided by Dean Health Plan’s Quality Improvement Department to these practitioner office sites for completion. This self-assessment is reviewed by the Quality Improvement Department which tracks and trends annual compliance with the performance expectations Dean Health Plan has set regarding member access by individual office sites and overall network access averages.

Primary Care Appointment Accessibility Dean Health Plan has defined the following practitioners as PCPs: Internal Medicine, Family Practice, General Practice, Pediatrics and OB/GYN. The access standards for PCP office sites are as follows:

Preventative Care: (physical exams and preventive health visits) 30 Days Routine: (follow up visits, blood pressure checks, suture removal, etc.) 14 Days Symptomatic, non-urgent: (colds, headaches, join/muscle pain, etc.) 4 Days Urgent: (persistent fever, sore throat, diarrhea, vomiting) 24 Hours

Access to after-hours care: Primary care sites must have information available and accessible to members regarding after-hours care and 24-hour emergency room access.

Behavioral Health Appointment Accessibility Dean Health Plan assesses Behavioral Health care accessibility with any of the following providers: physicians, PhD’s, PsyD’s, Mid-Level Mental Health Providers (LPC, LCSW, LMFT, MS) and AODA Counselors. The access standards for Behavioral Health sites are as follows:

Routine office visit: (any request for an established or new patient intake) 10 Days Urgent care visit: (Medication assessment following side effects or patients with increased systems of distress due to a recent event)

48 Hours

Non-Life Threatening services: (not suicidal, but potential for high-risk situation or self-harm 6 Hours


Each element of the appointment accessibility self-assessment will be evaluated to determine compliance with Dean Health Plan standards. All facilities with a total compliance score of 90 percent or greater will be encouraged to improve in any areas of non-compliance. Facilities with a total compliance score of less than 90 percent may be required to submit an action plan to Dean Health Plan within 30 days addressing their plans for improving in areas of noncompliance with Dean Health Plan accessibility standards. Dean Health Plan evaluates the effectiveness of action plans for improvement at least every six months until the site has demonstrated compliance in areas of deficiency sufficient to raise the total score to 90 percent or greater. Identified sites that do not make requested improvements to raise the total score to 90 percent or greater after 12 months will be referred to the Quality Improvement Committee (QIC) for review and follow-up actions.

A report compiling total site and overall network average scores of compliance with accessibility of services standards summarizing the results of all action plans requested, received, and not received during the previous period will be computed and presented annually to the QIC.

CLINICAL GUIDELINES Dean Health Plan, in cooperation with our providers, is dedicated to continually improving the quality of care for our members. Dean Health Plan has adopted the following guidelines to help you make health care decisions for your patients. They are not intended to replace clinical judgment. Please visit deancare.com/providers/clinical-guidelines

HEDIS REPORTING REQUIREMENTS HEDIS (Healthcare Effectiveness Data and Information Set) is a standardized set of performance measures that assess plans’ performance on a number of elements, including such things as financial stability, access, and quality of care. Dean Health Plan annually collects data and reports on performance measures from HEDIS relevant to the commercial, Medicaid, and Medicare populations. Dean Health Plan uses HEDIS information to assess the quality of care delivered by plan practitioners and providers and identify improvement projects and studies. All plan practitioners and providers are expected to cooperate with Dean Health Plan in the accurate and timely reporting, collection of data, and review of medical records. Dean Health Plan will collect data according to HEDIS specifications and notify practitioners and providers of any additional information requirements, and will also identify and communicate the names of patients for medical record review. All practitioners and providers are expected to provide Dean Health Plan with timely access to medical records, as requested, and allow Dean Health Plan to print and/or make photocopies, as necessary. RISK ADJUSTMENT The Risk Adjustment Program was established by the Department of Health and Human Services (HHS) as a requirement of the Affordable Care Act (ACA). The program requires health plans to submit claims and detailed documentation pertaining to each Commercial ACA member in a specific format for each benefit year. The specific diagnoses of each plan member must be documented in accordance with ICD-10 standards and supported by valid documentation within the patient’s medical record. Dean Health Plan is partnering with Inovalon, Inc. to identify members for patient medical record review twice a year. Inovalon’s medical record review is to ensure that our records properly reflect the clinical condition(s) of our Commercial ACA members. Annually, Dean Health Plan must comply with the HHS Risk Adjustment Data Validation (RADV) audit of our Commercial ACA members by using an independent auditor. The independent auditor must retrieve and review the medical records for the members identified by HHS for the audit. All plan practitioners and providers are expected to cooperate with Dean Health Plan in the accurate and timely collection of data and review of medical records. All practitioners and providers are expected to provide Dean Health Plan, and those working on behalf of Dean Health Plan with a Business Associate Agreement (BAA), with timely access to medical records, as requested, and allow these entities to print and/or make photocopies, as necessary.

http://www.deancare.com/providers/clinical-guidelines


PUBLICATIONS

MEMBER RIGHTS & RESPONSIBILITIES Dean Health Plan, Inc. members deserve the best service and health care possible. Dean Health Plan is committed to maintaining a mutually respectful relationship with its members. Rights and responsibilities help foster cooperation among members, practitioners and Dean Health Plan. These Member Rights and Responsibilities, outlined below, also appear annually in the Dean Health Plan provider and member newsletters. Dean Health Plan members have the right to: Be treated with respect and recognition of their dignity. Receive a listing of Dean Health Plan’s participating practitioners in order to choose a primary care provider. Present a question, complaint, or grievance to Dean Health Plan about the organization or the care it provides

without fear of discrimination or repercussion. Receive information on procedures and policies regarding their health care benefits. Timely responses to requests regarding their health care plan. Request information regarding Advance Directives. Participate with practitioners in making decisions about their health care. A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of

cost or benefit coverage. Receive information about the organization, its services, its practitioners and providers, and members’ rights and

responsibilities. Make recommendations regarding the organization’s members’ rights and responsibilities policies. Receive a copy of the Dean Health Plan Notice of Privacy Practices, which describes how medical information

about you may be used or disclosed and how you can get access to this information.

Dean Health Plan members have the responsibility to: Read and understand the materials provided by Dean Health Plan concerning their health care benefits. We

encourage members to contact Dean Health Plan if they have any questions. Present their ID card in order to identify themselves as Dean Health Plan members before receiving health care

services. Notify Dean Health Plan of any enrollment status changes such as family size or address. Supply information (to the extent possible) that the organization and its practitioners and providers need in order

to provide care. Follow plans and instructions for care that they have agreed on with their practitioners. Understand their health problems and participate in developing mutually agreed upon treatment goals to the

degree possible. Fulfill financial obligations as it relates to any copays, deductibles and/or premiums as outlined in your policy. Provide information about any other health insurance coverage you have so that Dean Health Plan can coordinate

benefits with the other insurance plan(s). These rights and responsibilities are available for you to access on our website at deancare.com/health-insurance/about-dean-health-plan/rights-and-responsibilities/.

DEAN HEALTH PLAN’S MEMBER PRIVACY POLICY Protecting the Privacy of Your Personal Health Information Dean Health Plan is required by law to maintain the privacy of your personal health and financial information (collectively referred to as “nonpublic personal information”) and provide you with written notification of our legal duties and privacy

http://www.deancare.com/health-insurance/about-dean-health-plan/rights-and-responsibilities/

http://www.deancare.com/health-insurance/about-dean-health-plan/rights-and-responsibilities/


practices concerning that information. This Notice describes how we protect the confidentiality of our members’ (and former members’) nonpublic personal information. It includes brief explanations on how we obtain, use, and protect your nonpublic personal information. Types of Nonpublic Personal Information Dean Collects About You We collect a variety of nonpublic personal information needed to administer health insurance coverage and benefits. We collect nonpublic personal information about you from some of the following sources: Information we receive directly or indirectly from you or your employer or benefits plan sponsor through

applications, surveys or other forms. The information may be received in writing, in person, by telephone or electronically. Examples include name, address, Social Security number, date of birth, marital status and medical history.

Information about your transactions with us, our affiliates, our providers, our agents and others. This includes information from health care claims, medical history, eligibility information, payment information, service request, and appeal and grievance information.

Information you authorize us to collect from others.

Choices about Your Health Information We will not use or disclose your health information without your written authorization, except as described in this Notice. You generally have the right and choice to tell us to: Share information with your family, close friends or others involved in payment for your care. Share information in a disaster relief situation.

In the following cases we never share your information unless you give us written permission: Most uses and disclosures of psychotherapy notes. Marketing purposes. Sale of your information.

If you do give us written authorization to use or disclose your health information for a particular purpose, you may change your mind at any time. You must let us know in writing if you change your mind.

How Dean May Use or Disclose Your Health Information We will not disclose your nonpublic personal information unless we are allowed or required by law to do so. The following categories describe the ways that Dean may use and disclose your nonpublic personal information. For each category of uses and disclosures, we will explain what we mean and present some examples. Not every use or disclosure we might make will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories. Note: Some of the uses and disclosures described in this notice may be limited in certain cases by applicable State laws that are more stringent than Federal laws, including disclosures related to mental health and substance abuse, developmental disability, alcohol and other drug abuse (AODA), and HIV testing. We are allowed to use and disclose information that falls within one of the following categories: Payment: we may use and disclose your health information to make and collect payment for treatment and

services you receive, such as: determining your eligibility for plan benefits, obtaining premiums, determining your health plan’s responsibility for benefits, and collecting payment for your health services.

Health Care Operations: we may use and disclose your health information to support our business activities and improve our coverage and services. However, we are not allowed to use genetic information to decide whether we will give you coverage or the price of that coverage. Health care operations include such activities as:

o Underwriting o Premium rating


o Claims o Other functions related to plan coverage o Quality assessment and improvement activities. o Activities designed to improve health and reduce health care cost. o Case management and care coordination.

Notice: We are part of an Organized Health Care Arrangement (OHCA) with SSM Health and Dean Health System. As part of the OHCA, we may from time to time share your information with other members of the OHCA in order to perform joint health care operations. These uses and disclosures allow the OHCA to run efficiently. For example, we may share your information in order to: improve population health management; conduct quality assessment and improvement activities; conduct or arrange for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general OHCA administrative activities.

Treatment: we may disclose your health information to a physician or other health care provider that is treating you. We may contact you with information on treatment alternatives and other related functions that may be of interest to you.

Distributing Health-related Benefits and Services: we may use and disclose your health information to provide information on health-related benefits and services that may be of interest to you.

Disclosure to Plan Sponsors: if applicable, we may disclose your health information to the sponsor of your group health plan for purposes of administering benefits under the plan. If you have a group health plan, your employer is the plan sponsor.

Public Safety: we can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; and preventing or reducing a serious and imminent threat to the health or safety of a particular person or the public.

Research: under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.

Required by Law: we will share information about you if laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Workers’ Compensation, Law Enforcement, and Other Government Requests: we can use and share health information about you: for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services.

Legal Actions: we may disclose your health information in the course of any administrative or judicial proceeding.

How Dean Protects This Information We limit the collection of nonpublic personal information to that which is necessary to administer our business, provide quality service, and meet regulatory requirements. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to safeguard your nonpublic personal information. We limit the internal use of oral, written, and electronic nonpublic personal information about you and ensure that only authorized staff and business associates with the need to know have access to it. We maintain safeguards for your nonpublic personal information and review them regularly to protect your privacy. Your Health Information Rights Right to Request Restrictions: you have the right to request restrictions on certain uses and disclosures of your

health information. Right to Request Confidential Communications: you have the right to receive your health information through a

reasonable alternative means or at an alternative location. Right to See and Copy: you have the right to see and copy certain health information about you. Right to Correct Records: you have a right to request that Dean correct certain health information held by Dean

if you think it is incorrect or incomplete.


Right to Accounting of Disclosures: you have the right to receive a list or “accounting of disclosures” of your health Information made by us in the past six years: the list will not include disclosures made for purposes of treatment,

payment, health care operations, or certain other disclosures (such as those you asked us to make). Right to Copy of Notice: you have a right to receive a paper copy of this Notice at any time. Right to be notified of a Breach: you will be notified in the event of a breach of your unsecured protected health

information. Changes to this Notice of Privacy Practices Dean may change this Notice from time to time and make the new provisions effective for all nonpublic personal information we maintain, including information we created or received before the change. Dean will always comply with the current version of this Notice. Complaints Please submit complaints about this Notice or how we handle your health information, in writing, to our Privacy Officer. Dean will not hold any complaint you submit against you in any way. In addition, if you believe your privacy rights have been violated, you may file a complaint with the Secretary of the U.S. Department of Health and Human Services. If you have questions, complaints or want to exercise any of your health information rights, call the Customer Care Center at (800) 279-1301 [or, if you purchased coverage on the Health Insurance Marketplace, at (800) 279-1302 or contact us at the following address]:

Privacy Officer PO Box 56099

Madison, WI 53705

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