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Arcadian Health Plan, Inc.

Provider Manual

May 2011

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Table of Contents Introduction to Arcadian Health Plan .................................................................................................... 4

Contacting Arcadian Health Plan ....................................................................................................... 5

Understanding the Provider Manual .................................................................................................. 5

Product Overview ................................................................................................................................. 6

Our Products ......................................................................................................................................... 6

Membership Identification Cards ....................................................................................................... 8

General Administrative Requirements................................................................................................... 9

Reporting Compliance Concerns......................................................................................................... 9

Contracted Provider Responsibilities ............................................................................................... 10

Claims Processing ................................................................................................................................... 12

Timely Filing........................................................................................................................................ 12

Clean Claim ......................................................................................................................................... 12

Submission of Claim ........................................................................................................................... 12

Claim Inquiry ...................................................................................................................................... 12

Claim Denial and Appeal ................................................................................................................... 13

Recoupment of Overpayment ............................................................................................................ 13

Underpayment by Arcadian Health.................................................................................................. 13

Medicaid and Coordination of Benefits ............................................................................................ 13

Electronic Payment and Reporting ................................................................................................... 14

Utilization Management / Medical Management................................................................................. 15

Clinical Review Criteria ..................................................................................................................... 15

Authorization Process......................................................................................................................... 15

Prospective Review ............................................................................................................................. 16

Provisional Authorization and Admission Review .......................................................................... 16

Discharge Planning ............................................................................................................................. 16

Retrospective Review.......................................................................................................................... 17

Home Health and Hospice Care ........................................................................................................ 17

DME ..................................................................................................................................................... 17

Skilled Nursing Facility (SNF) Review ............................................................................................. 18

Provider Authorization Process............................................................................................................. 18

Direct Access Services......................................................................................................................... 18

Authorization Requests ...................................................................................................................... 19

Out of Network Services..................................................................................................................... 19

Out of Network Providers .................................................................................................................. 20

Emergency Services ............................................................................................................................ 20

Authorizations/Adverse Determination ............................................................................................ 20

Appeals................................................................................................................................................. 21

Provider Termination and Continuity of Care ................................................................................ 21

New Technologies................................................................................................................................ 21

Availability of Arcadian Staff ............................................................................................................ 21

Hospital Services ..................................................................................................................................... 22

Prior Authorization ............................................................................................................................ 22

Acute and Skilled Admissions and Outpatient Hospital Services .................................................. 22

Notification Requirements for Hospital Admissions ....................................................................... 22

Initial Notification Process ................................................................................................................. 22

Case Management Program................................................................................................................... 23

Case Identification .............................................................................................................................. 23

Special Needs Plan (SNP) ....................................................................................................................... 25

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Arcadian Online System (AOS)............................................................................................................. 27

Verifying Eligibility ............................................................................................................................ 27

Authorizations for Medical Services and Procedures ..................................................................... 28

Addendum I – Authorization Guide ..................................................................................................... 29

Addendum II - State Addendums.......................................................................................................... 34

Appendix 1 – Medicare Advantage Regulatory Requirements ......................................................... 36

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Introduction to Arcadian Health Plan Arcadian Health Plan, (“Arcadian”), a Medicare Advantage plan, was founded by John H. Austin, MD and is dedicated to the trust and security of a community based, local network of care. Arcadian has a history of working with and for physicians and hospitals via our management services organization which began in 1996. We are purely focused on being the value leader in Medicare Advantage products in underserved, small to medium sized markets. As of May 2011, Arcadian is offered in 15 states: Arkansas, Arizona, California, Georgia, Louisiana, Maine, Missouri, North Carolina, New Hampshire, New York, Oklahoma, South Carolina, Texas, Virginia, Washington. Depending on the location, Arcadian Health Plan is also known in your service area as the following:

Arcadian Health Plan, Inc.

Arcadian Community Care plan service area in California

Columbia Community Care serving the Tri-Cities area in Washington

Desert Canyon Community Care plan service area in Arizona

Northeast Community Care plan service area in Maine & New Hampshire

Ozark Health Plan plan service area in Missouri

Spokane Community Care serving Spokane County in Washington

Southeast Community Care plan service area in South Carolina & Virginia

Texas Community Care plan service area in Texas

Arcadian Health Plan plan service area in Oklahoma

Arcadian Health Plan of Georgia, Inc.

Southeast Community Care plan service area in Georgia

Arcadian Health Plan of Louisiana, Inc.

Arcadian Community Care plan service area in Louisiana

Arcadian Health Plan of North Carolina, Inc.

Southeast Community Care plan service area in North Carolina

Arcadian Health Plan of New York, Inc.

Northeast Community Care plan service area in New York

Arkansas Community Care, Inc.

Arkansas Community Care plan service area in Arkansas

Texarkana Community Care plan service area in the Texarkana region of Texas and Arkansas

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Contacting Arcadian Health Plan

Support Center Phone Number Provider Access Line 800-998-3057, Option 3

Arcadian Community Care – California 800-699-5125

Arcadian Community Care – Louisiana 888-261-1061

Arkansas Community Care 800-705-0766

Columbia Community Care 800-573-8609

Desert Canyon Community Care 800-887-6177

Northeast Community Care – Maine 800-998-3056

Northeast Community Care – New Hampshire 800-998-3056

Northeast Community Care – New York 866-395-4754

Ozark Health Plan 800-658-3518

Southeast Community Care – Georgia 888-701-2678

Southeast Community Care – North Carolina 877-268-3866

Southeast Community Care – South Carolina 888-998-3055

Southeast Community Care – Virginia 800-653-2924

Spokane Community Care 800-573-8609

Texarkana Community Care 800-705-0766

Texas Community Care – East Texas 800-658-3704

Texas Community Care – El Paso 800-658-5161

Arcadian Online System (AOS) www.arcadianhealth.com (click on Health Plans in top right corner then

complete Provider Access Request Form)

Understanding the Provider Manual This Provider Manual (“Manual”) is effective May 1, 2011 for physicians and other healthcare providers currently participating with Arcadian. The Medicare Advantage Regulatory Requirements attached to your agreement with Arcadian will supersede this Manual if a conflict or inconsistency exists regarding benefit plans within the scope the Regulatory Requirements. The provisions in the agreement between you and Arcadian will control should any conflicts or inconsistencies occur between the agreement and the Manual. The entire Manual is subject to change at any time. The policies and procedures set forth in this Manual fall under the terms of your agreement. The Manual applies to all covered services rendered to Members covered under a benefit plan through Arcadian unless otherwise noted in the Manual. The use of terms such as “Member”, “Health Plan Affiliates”, and “Provider Manual” are defined within your agreement with Arcadian. Please refer to your agreement for any additional terms and definitions as appropriate. Service areas are defined by counties or parishes, in the case of Louisiana, in which Arcadian is authorized to sell our products. For purposes of this manual counties and parishes will be referred to as counties.

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Product Overview Arcadian’s Members can choose from a various plans depending on their needs. Our Members generally have switched from traditional Medicare because they are seeking more benefits and lower out-of-pocket costs. They tend to be on a fixed income and are unable to afford the cost of Medicare Supplements, PPO, or PFFS plans. In order to save money, our Members are willing to enroll in a Coordinated Care Plan (“HMO”). What is a Coordinated Care Plan (HMO)? Arcadian contracts with a network of doctors, hospitals, skilled nursing facilities, home health agencies, and other healthcare professionals. Arcadian HMO Members select a primary care physician (“PCP”) from those that are part of the plan’s network. The PCP is responsible for managing the Member’s medical care, including referrals to specialists and admissions to the hospital when the PCP is the admitting physician. Arcadian plans, as with all Medicare Advantage HMOs, have “lock-in” requirements. In order to access benefits, a Member is locked into receiving all covered care from participating Providers in the Arcadian network. In most cases, if a Member goes outside the plan for services, neither the plan nor original Medicare will pay. The Member will be responsible for the entire bill. The only exceptions recognized by all Medicare-contracting plans are for emergency services, which a Member may receive anywhere in the world, urgently needed care, which Member may receive while temporarily away from the plan’s service area, out-of-area renal dialysis services, and if the service is prior authorized by the plan. Urgent care is also covered inside the service area if the plan’s delivery system is temporarily unavailable or inaccessible.

Our Products Arcadian’s most popular product is our Plus Plan, a true Medicare Advantage HMO. This is followed by the Dual Plus Plan, a Special Needs Plan (“SNP”), which we offer in most of our markets. Dual Plus is targeted for those individuals who qualify for both Medicare and Medicaid. The following is a comparison of benefits between traditional Medicare and Arcadian’s two most popular plans.

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EXAMPLE (Plans may differ in your area)

Original Medicare 2010 Plus Plan* 2010 Dual Plus Plan*

Part B Annual Deductible $135 N/A N/A

Monthly Member Premium Part B = $96.40 Part B + $0 Part B + $0

Inpatient Hospital (Days 1-75)

$1,100 $100-$175 $0

PCP 20% $0-$10 $0

Specialist 20% $0-$35 $0

SNF $0 (days 1-20); $137.50 (21-100); 100%

$0 (days 1-10); $25-$90 (11-100)

$0

ER/Urgent Care 20% $50/$30 $0

Outpatient Surgery Hospital/ASC

20% 20%

$250 / $100 $0 / $0

Vision (Exam/Eyewear) No benefit $25/$70 $5/$100

Preventive Care None $0 $0

* The benefits quoted are not representative for all markets within Arcadian. Please access the

Summary of Benefits under Support on the Arcadian Online System (“AOS”) or call the Provider

Assistance Line or your local Arcadian office for benefits in your service area. Products in some or all of the Arcadian service areas are as follows.

• Plus Plan

• Plus Point Plan (HMO POS)

• Enhanced Plan

• Basic Plan (no Part D coverage)

• Premier Plan

• Dual Plus Plan (Special Needs Plan – SNP)

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PCP Visit: $

Specialist: $ ER:$ Part B RxGRP: XXXXX

PLUS (HMO)

RxBIN: XXXXXX RxPCN: XXX RxGRP: XXXXX

Issuer: XXXXX

Name: <First MI Last>

ID#: <XXXXXXXXX>

PCP: <First Last>

PCP Phone: <XXX-XXX-XXXX>

www.arcadianhealthplan.com

Contract #: <HXXXX> Plan #: <XXX>

Medicaid: Yes Part B RxGRP: XXXXX

DUAL PLUS (HMO)

RxBIN: XXXXXX RxPCN: XXX RxGRP: XXXXX

Issuer: XXXXX

Name: <First MI Last>

ID#: <XXXXXXXXX>

PCP: <First Last>

PCP Phone: <XXX-XXX-XXXX>

www.arcadianhealthplan.com

Contract #: <HXXXX> Plan #: <XXX>

Membership Identification Cards Arcadian will issue membership identification cards within two weeks of the Member’s effective date. The card contains information regarding copays, claims address, and important telephone numbers. Arcadian highly suggests the card be checked each time a Member presents for services and a copy of both sides of the card be kept for your records.

EMERGENCY SERVICES: Call 911 or go to the nearest emergency room. <Plan Name> requests that you contact your Primary Care Physician (PCP) within 24 hours

Send Medical Claims to: Regional Claims Processing <P.O. Box 4946 Covina, CA 91723> <Payer ID: <xxxxx>> [Authorization Rules May Apply]

Member Service/Eligibility 1-800-573-8597

Hearing Impaired (TTY: 1-866-573-8591) [For routine vision services, call <XXX-XXX-XXXX>]

EMERGENCY SERVICES: Call 911 or go to the nearest emergency room. <Plan Name> requests that you contact your Primary Care Physician (PCP) within 24 hours

Send Medical Claims to: Regional Claims Processing <P.O. Box 4946 Covina, CA 91723> <Payer ID: <xxxxx>> [Authorization Rules May Apply]

Member Service/Eligibility 1-800-573-8597

Hearing Impaired (TTY: 1-866-573-8591) [For routine vision services, call <XXX-XXX-XXXX>] [For routine dental services, call <XXX-XXX-XXXX>]

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General Administrative Requirements Compliance Program

Arcadian has an effective compliance program that demonstrates its commitment to compliance, integrity, and ethical values as demonstrated by having the seven essential program elements prescribed by CMS for Medicare Advantage compliance programs. These elements include:

•••• Written policies, procedures, and standards of conduct that articulate Arcadian’s commitment to comply with all applicable Federal and State standards;

•••• The designation of a compliance officer and compliance committee that are accountable to senior management;

•••• Effective training and education between the compliance officer and Arcadian’s employees;

• Effective lines of communication between the compliance officer, Arcadian’s employees, and Medicare Advantage-related contractors that at a minimum, includes a mechanism for employees or contractors to ask questions, seek clarification, and report potential or actual noncompliance without fear of retaliation;

•••• Enforcement of standards through well-publicized disciplinary guidelines;

•••• Provision for internal monitoring and auditing that includes a risk assessment process to identify and analyze risks associated with failure to comply with all applicable Medicare Advantage compliance standards; and

•••• Procedures for ensuring prompt response to detected offenses and development of corrective action initiatives relating to Arcadian’s Medicare Advantage contract.

Reporting Compliance Concerns

Arcadian has established a reporting hotline available to all employees, members, contracted vendors and providers. The hotline is available 24 hours a day, 365 days per year. Concerns related to compliance, privacy, information security, and fraud waste and abuse should be directed to this line. The Compliance Department has an immediate follow up process designed to ensure confidentiality, integrity, and objectivity for prompt investigation and resolution of all reported concerns. To report concerns or ask compliance related questions, employees, members, vendors, providers, and any other party doing business with Arcadian, may do any of the following:

•••• Call the Compliance Hotline, 1-888-861-6038;

•••• Send and e-mail to reports@lighthouse-services.com

•••• Report Medicare Part D related incidents to the MEDIC directly at 1-877-772-3379; and/or

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•••• Mail written correspondence marked confidential to:

Arcadian Health Plans, Compliance Department in care of the Chief Performance Officer

500 12th Street. Suite 350, Oakland, CA 94607 It is Arcadian’s policy that neither retribution nor retaliation for reporting a compliance violation, in good faith, will be tolerated. Efforts will be made to protect the identity of the individual to the extent allowable by law. Any officer, director, manager, employee or Provider contractor who is involved in any act of retaliation, retribution or any form of harassment against a person who reports suspected non-compliance or Fraud, Waste and Abuse (either by committing the act or condoning it), will be subject to disciplinary action or contract action, up to and including termination.

Contracted Provider Responsibilities

As a physician or other healthcare provider of services to Arcadian Members:

• You may not discriminate against Members in any way based on health status.

• You must allow Members to directly access screening mammography and influenza vaccination services.

• You may not impose cost-sharing on Members for influenza vaccine or pneumococcal vaccine.

• You must provide female Members with direct access to a women’s health specialist for routine and preventive health care services.

• You must ensure that Members have adequate access to covered health services.

• You must ensure that your hours of operation are convenient to Members and do not discriminate against Members and that medically necessary services are available to Members 24 hours a day, 7 days a week as applicable. Primary Care Physicians must have backup for absences.

• You may not distribute Medicare Advantage marketing materials or forms to Members without CMS approval of the materials or forms.

• You must provide services to Members in a culturally competent manner, taking into account limited English proficiency or reading skills, hearing or vision impairment and diverse cultural and ethnic backgrounds.

• You must cooperate with our procedures to inform Members of health care needs that require follow-up and provide necessary training to Members in self-care as appropriate.

• You must document in a prominent part of the Member’s medical record whether the Member has executed an advance directive.

• You must provide covered health services in a manner consistent with professionally recognized standards of health care.

• You must ensure that any payment and incentive arrangements with subcontractors are specified in a written agreement, that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards.

• You must cooperate with our processes to disclose to CMS all information necessary for CMS to administer and evaluate the Medicare Advantage Program, and all information determined by CMS to be necessary to assist Members in making an informed choice about Medicare coverage.

• You must cooperate with our processes for notifying Members of network participation agreement terminations.

• You must comply with our medical policies, quality improvement programs and medical management procedures.

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• You must cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance and other indicators, as specified by CMS.

• You must cooperate with our procedures for handling grievances, appeals and expedited appeals.

• You must provide for the protection and maintenance of each Member’s medical records, whether in paper or electronic format, against loss, destruction, tampering or unauthorized use.

Regulatory Requirements

Although contracted providers are not expected to be experts in all legal or regulatory matters, it is their responsibility to understand and comply with applicable rules, regulations and laws that directly pertain to the patient care they provide and related responsibilities undertaken on behalf of Arcadian. Contracted providers need to understand applicable policies and exercise good judgment in the following areas:

• The Stark Self-Referral Prohibitions: The Federal Physician Self-Referral Law, commonly referred to as the “Stark Law”, generally prohibits a physician’s referral of a Medicare patient to an entity for the provision of certain designated health services (DHS) if the physician has a financial relationship with the entity.

• The Anti-Kickback Statute: Individuals and companies are prohibited from offering kickbacks to others or accepting kickbacks from anyone doing business with the government. Prohibited acts include accepting or granting gratuities (gifts) to secure favorable treatment for or from Arcadian; granting direct or indirect improper rewards (giving anything of value) to a representative of government or private business with whom Arcadian does business; or accepting or granting kickbacks or bribes.

• Office of Inspector General (OIG) Exclusion: The OIG was established to identify and eliminate fraud, waste, and abuse and to promote efficiency and economy in Department of Health and Human Services (DHHS) operations. The OIG has been given the authority to exclude from participation in Medicare, Medicaid and other federal health care programs individuals and entities who have engaged in fraud or abuse. The effect of an OIG exclusion from federal health care programs is that no federal health care program payment may be made for any items or services (1) furnished by an excluded individual or entity, or (2) directed or prescribed by an excluded physician. Any items and services furnished by an excluded individual or entity are not reimbursable under federal health care programs. This prohibition applies even when the federal payment itself is made to another provider, practitioner or supplier that is not excluded.

• Federal False Claims Act: Impose penalties on anyone who knowingly submits a false or fraudulent claim to the government or who makes or uses a false record to get a claim paid. A false claim is any attempt to obtain money from the federal government by knowingly presenting false or misleading information relating to payment from the government. Health care providers who violate the federal False Claims Act can be subject to civil monetary penalties for each false

claim submitted. In addition to this civil penalty, providers can be required to pay three times the amount of damages sustained by the U.S. Government. The law also allows private citizens or ‘whistleblowers’ to bring an action against a party on behalf of the government and receive a percentage of the monies recovered.

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Claims Processing Arcadian has established its policies and protocols in regard to claims payment in conjunction with CMS guidelines. Updates and revisions to CMS claims payment guidelines will be adopted by Arcadian and the effective date(s) will coincide with CMS’s effective date. Timely Filing

Claims are to be submitted according to the timely filing limits specified in the Provider’s contract with Arcadian. Timely filing is considered the receipt of a clean claim submitted and payable by Arcadian within the parameters of the contract. Clean Claim

A clean claim is a claim for Covered Services submitted by Provider which is complete and includes all of the information reasonably required by CMS standard data transaction sets, and as to which request for payment there is no material issue regarding Arcadian’s obligation to pay under the terms of a Managed Care Plan or Arcadian’s Medical Management Program. Submission of Claim

Arcadian accepts claims submitted in the form of paper or electronic (EDI). Standard CMS 1500 or UB-04 billing forms are accepted. Claims requiring an authorization number must reference the number on the claim, or attach the authorization form. The authorization number can be found listed as “Tracking Number” on the authorization approval letter for the services you are billing. Electronic Claim submission:

Claims Payer ID: 77045 Electronic Claims Formats Accepted NEIC/Envoy/WebMD:

- ANSI X12 837 - National Standard Format (NSF), v3.1 - UB04

Paper Claim submission – mail claims to: Arcadian Health Plans, Inc. Regional Claim Processing Center P.O. Box 4946 Covina, CA 91723 Claim Inquiry

If you have questions regarding the status of a claim, you have two options:

1) Call Arcadian’s Community Care Health Plan - (800) 573-8597 option 3 for the Provider Service Line option 1 for status of a claim or

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2) Arcadian Online System – AOS (if not currently utilizing our on-line system, contact your designated Provider Relations Representative for access to AOS) www.arcadianhealth.com; select Health Plans Type in User Name and Password Select “Eligibility”, and look up the member Select “View claims”

Claim Denial and Appeal

All Providers will be accorded the right to appeal a claim according to Arcadian’s agreement with CMS. If Provider is in receipt of an EOB stating that the claim has been denied, Provider may appeal this denial. Please submit the claim, a Resolution Request form (your provider relations representative may supply this form and it is also available on AOS), the appropriate medical notes indicating the service or procedure and reason, and fax to (866) 784-1004. Alternately, you may mail the appeal to: Arcadian Health Plan

P.O. Box 5020 Covina, CA 91723

Arcadian will determine if the denial will be upheld or overturned. A subsequent EOB will be submitted to the Provider stating our decision. If the claim is overturned, the claim will be reprocessed and reimbursement will be enclosed in the EOB. Recoupment of Overpayment

If Arcadian believes they have overpaid a claim, a recoupment letter will be sent to the Provider. One recoupment letter will be sent for each overpayment. Provider will have 30 days in which to reimbursement Arcadian. Thereafter, recoupment will be made in the form of reduction in reimbursement of further claims until amount of recoupment is satisfied. Underpayment by Arcadian Health

If the Provider feels they have not been paid in full for the claim, they may submit an Appeal.

• Note: getting the appropriate authorizations can greatly save time with claims issues Medicaid and Coordination of Benefits

Arcadian has entered into agreements with several states in which it conducts business, and a plan has been devised for Members who also qualify for Medicaid. In these situations, Medicaid would act as a secondary payor and applicable coordination of benefit rules would apply. If this is the case within the Provider’s state, the Provider is to accept payment from Arcadian as payment in full except for any copay or coinsurance remaining. The Provider would then be responsible for coordinating the collection of the remaining copay or coinsurance which may be submitted to Medicaid for reimbursement. The Member will not be responsible for any fees, except for non-covered services.

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Electronic Payment and Reporting

Arcadian is able to pay Provider by an electronic deposit directly into Provider’s savings or checking account. Provider would complete the Electronic Payment and Reporting form, and fax to (909) 971-6884 along with a voided check. Please contact your Provider Relations Representative to obtain this form. Provider may also elect to have EOBs either faxed or emailed, and in a text file or data file.

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Utilization Management / Medical Management Purpose

The Medical Management Program is designed to monitor, evaluate, and manage the cost and quality of healthcare services delivered to all members of Arcadian. This assures that all CMS requirements for implementing Medicare benefits and Medicare standards for quality of care are met through the consistent application of standards, evidence-based guidelines, and criteria for coverage. Clinical Review Criteria

Utilization Management criteria are based on reasonable medical evidence and are used to make decisions pertaining to the utilization of services. Arcadian involves actively practicing practitioners in the development and approval of the criteria. All services authorized by Arcadian staff are evaluated to determine medical necessity based on approved standard criteria (InterQual, evidence based medicine, and/or specific CMS requirements as required per benefit limits). The criteria are available upon request to all participating Providers, Members, and the public, accompanied by the following notice: the

materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons

with similar illnesses or conditions. Specific care and treatment may vary depending on individual need

and benefits covered under your contract.

Authorization Process

The scope of the Arcadian program includes, but is not limited to the following types of review:

• Prospective Review for inpatient and outpatient services • Provisional and Admission Review and tracking of acute hospital/SNF, LTAC, and acute

inpatient rehabilitation admissions and re-admissions • Discharge Planning • Retrospective Review • Home Health/DME • Skilled Nursing Facility (SNF) Review • Out of Network Review • Case Management/Rehabilitation/Transplant Management • Behavioral Health • Specialty Authorization Management

Arcadian staff follows the approved process for reviewing and authorizing requested services. Authorizations and/or adverse determinations are based on medical necessity and will reflect appropriate when necessary, as mandated by state regulations, a physician, an Arcadian medical director or his/her designee, will review every adverse determination based on medical necessity. Information is clearly documented and appropriately available for review. All authorization requests are approved or denied. If a determination cannot be made within the required timeframe and needs to be pended due to the need for additional clinical information or consultation by an expert reviewer, the Provider will be notified in writing.

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All authorization requests are followed by written notification to the Member and Provider (PCP and specialist provider) of the determination within the appropriate time frames. Approved and modified requests will include an authorization number for the specific services authorized. The name and phone number to reach Arcadian’s Senior Medical Director to discuss a denial or modification will be included on all Provider letters. In determining medical appropriateness, Arcadian considers characteristics of the local delivery system, such as the availability of hospitals, physicians, SNF, sub-acute or home care in the service area. All authorization requests are submitted to licensed personnel who are responsible for completing the authorization process. Licensed clinical professionals (RNs, LVN/LPNs) apply approved criteria and practice guidelines. If the criteria or guidelines are not met, the Resource Nurse/Case Manager will forward the request to the Arcadian’s Senior Medical Director or Resource Physician, who has the authority to deny any services based on medical necessity. Approved requests will include an authorization number for the specific services authorized. Both Member and Provider are notified of the determination. If an adverse determination is made, the notification will include service denied, denial reason, criteria used in making the decision as well as its availability upon request, alternate care options, and appeal rights information. Prospective Review

Prospective Review of authorization requests will include specialty consultations, selected outpatient medical treatments and services, hospital admissions, transfers, rehabilitative and ancillary services, home care and hospice services and out-of-plan authorizations.

Provisional Authorization and Admission Review

The Utilization Management Department issues provisional authorizations for acute inpatient services at the time of admission for services that are not prior authorized. Provisional authorizations are also issued for non-acute inpatient services (SNF, LTAC, acute inpatient rehabilitation) at the time of admission if no prior authorization has been obtained. Provisional authorizations are issued to ensure members are receiving medically necessary care without disruption associated with ‘pending authorizations’ due to delay/failure by the provider to submit appropriate clinical information. Facilities may submit via facsimile a daily census sheet which documents the previous days’ admission, a face sheet documenting the specific admission information or the facility may contact Member Services. The Intake Coordinator contacts the facility requesting an admission review. Three (3) telephonic attempts within three (3) working days are made by the Intake Coordinator requesting medical records. Authorization requests remain in provisional status until medical records are received. The Resource Nurse/Case Manager reviews admissions with accompanying medical records within one (1) working day of submission applying AHP accepted clinical criteria either approving the admission or referring those requests not meeting criteria to the Senior Medical Director for determination. Discharge Planning

Member needs are anticipated prior to admission and documented for the hospital discharge planner. Relevant clinical information is obtained and the treating physician is consulted as appropriate. The

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Resource Nurse/Case Manager and the case management/discharge planning staff from the facility work closely with the attending physician who is ultimately responsible for overseeing the planning and discharge of the member from the hospital. The discharge planning process is in place at the time of the member’s admission and is an integral part of the management of the member’s care. Special services, follow-up visits at the provider office, home health care and SNF/hospice referrals are arranged as appropriate. Members being discharged from acute inpatient medical/behavioral health, observation, acute inpatient rehabilitation, skilled nursing facility, or long term acute care setting receive a Welcome Home call from a member of the Utilization Management team. Members are contacted via telephone within 24-48 hours of their discharge. Members having a diagnosis of Congestive Heart Failure (CHF) and/or Chronic Obstructive Pulmonary Disease (COPD) are contacted by the Nurse Case Manager. The purpose of the Welcome Home call is to ensure the member has an understanding of their discharge process, medications prescribed to them, follow up care with their physician and ensure any ancillary services such as home health care and DME have been initiated. Members are identified for potential case management intervention during this call. Retrospective Review

Retrospective Review is performed for those services performed less than fourteen (14) calendar days at the time of the retrospective request. Requests for retrospective authorization are processed against the same clinical criteria that prior authorization requests are reviewed against. Retrospective services rendered greater than fourteen (14) calendar days and not previously authorized are to be submitted to Claims with the standard CMS 1500 or UB-04 and clinical information to Arcadian Health Plan, P.O. Box 5020, Covina, CA 91723. The Clinical Claims Review Nurse conducts retrospective review of cases that were not previously authorized and of claims that require authorization for payment. Cases not meeting clinical criteria are referred to the Senior Medical Director or Resource Physician for approval/denial determination. Home Health and Hospice Care

The Resource Nurse/Case Manager assists in the management of the Member’s care in the home environment in order to promote the delivery of cost-effective healthcare services by reducing periods of unnecessary hospitalizations and facility placement, and by preventing unnecessary admissions and/or re-admissions. When necessary, evaluations by a social worker are authorized for assessment and recommendation of community services use as appropriate. Hospice care reverts back to original Medicare. Eligible Members are informed of the availability of hospice care and hospice care providers in their service area that are certified under Medicare benefits. At a minimum of two (2) calendar days prior to the anticipated Home Health discharge, the Notice of Medical Non-Coverage (NOMNC) letter is presented to the Member or to the Member’s authorized representative, followed by the Detailed Explanation of Non Coverage (DENC) should there be a dispute regarding the timing of the discharge. DME

The Resource Nurse/Case Manager assists in the process of evaluating and authorizing durable medical equipment (DME) to Members for the purpose of providing necessary and comprehensive healthcare services. The Resource Nurse/Case Manager will evaluate a Member’s illness, injury, degree of

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disability and medical needs for the proper and timely authorization of durable medical equipment. The Resource Nurse/Case Manager monitors the necessity and appropriateness of DME and supply usage by Members according to the Member’s eligibility, benefit coverage and the consistent and appropriate application of Medical Management decision making criteria. Typically, authorizations are made for up to two (2) months at a time, but can be extended on a case-by-case basis. The Resource Nurse/Case Manager conducts bi-monthly assessments of the Member’s eligibility and benefits and of the cost of the equipment (to ensure that rental cost does not exceed purchase price). Skilled Nursing Facility (SNF) Review

In the process of working with the healthcare team, particularly the PCP, and hospital discharge planners the Resource Nurse/Case Manager will encourage the appropriate transfer of patients to the lower level of care at the appropriate point in their hospitalization. The Resource Nurse/Case Manager will assist in the placement of Members into skilled nursing facilities (SNF) based on the Member’s eligibility, schedule of benefits and approved UM decision-making criteria, which are clearly documented. Contracted SNFs, when available, are utilized in this process. Upon admission to a SNF, admission review is completed every week at a minimum, or more often as needed to ensure the patient continues to meet SNF level of care and to assist in the discharge planning needs. At a minimum of two (2) calendar days prior to the anticipated discharge, the Notice of Medical Non-Coverage (NOMNC) letter is presented to the Member or to the Member’s authorized representative, followed by the Detailed Explanation of Non Coverage (DENC) should there be a dispute regarding the timing of the discharge.

Provider Authorization Process Direct Access Services

Arcadian Members may directly access services from the Member’s PCP or from the approved NOTIF from the PCP to the Specialist Provider for the following medical services: � Women’s Health Specialist

• Gynecologist (for well-woman exams and routine gynecological services such as pap tests, pelvic exams and mammograms (if recommended)

• Certified nurse midwife • Other qualified health care provider

� Annual Screening Mammography Arcadian Members may self-refer within the contracted Arcadian network, for an annual screening mammography. Arcadian will provide Members with a list of contracted mammography facilities annually. � Flu and Pneumonia Vaccine

Arcadian Members have direct access to a contracted Provider for an annual flu and pneumonia vaccine. The Member’s PCP should educate Member about annual flu shot clinics and the availability of flu and pneumonia shots through his/her PCP. In addition, the Provider cannot impose cost-sharing on the Member for influenza or pneumococcal vaccine.

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Authorization Requests

Please see Addendum I – Authorization Guide for a listing of services and procedures requiring authorization. Notification requests may be submitted via fax or Arcadian’s Online System (AOS). Arcadian does not require prior authorization from PCPs for services that are within the scope of the PCP office setting and that meet Medicare benefit guidelines. Arcadian’s Health Services Department will provide copies of the authorization determination to the following:

• Member’s Primary Care Physician (PCP) • Referred to provider(s) • Member

Possible authorization determinations include:

• Authorized as requested – no changes • Authorized as modified – authorization approved, but the requested provider or treatment

plan was modified • Delayed – need additional information, will include specific information required • Denied - will include the reason for denial and a suggested alternative treatment plan

If the Member persists in requesting treatment when the PCP suggested an alternative treatment plan, Provider must submit an authorization request to Arcadian. This will provide the Member formal documentation of the adverse determination and notify the Member of his/her appeal rights in case of a modification or denial. Arcadian Health Services Department provides verification of all notification requests. The Health Services Department reviews and authorizes, pends, or denies all notification requests according to CMS Guidelines. The process works very smoothly and the usage of the online system (AOS) significantly reduces the amount of time the Providers spend on the phone and dealing with faxes. Online notification has many benefits to both Members and Providers:

• Verifies member eligibility • Ensures member is being referred to a network provider • Provides notification to specialist that member is not ‘self referring’ and prevents claim

issues • Pre-screening for benefit coverage • Provides member and provider with written approval of notification

If the Provider is not set up to use AOS, contact your Provider Relations Representative to obtain a password and instructions on using the AOS system. If the AOS system is not available, notification and authorization requests may be faxed to the market-specific fax line at Arcadian. For Pharmacy Authorizations the Exception Request may be faxed to Arcadian’s Pharmacy Department at 1-866-258-2828. The Arcadian Authorization Form must be used for all faxed authorization requests. Out of Network Services

Out of network services are managed by the Resource Nurse/Case Manager in order to bring the Member back into the care of contracted Providers at contracted facilities as soon as it is appropriate.

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Out of network is defined as any Provider outside of the Arcadian approved counties for conducting Arcadian business that is not an in-network, contracted Arcadian Provider.

• The Resource Nurse/Case Manager may initially be notified of an out of network emergency room visit and/or hospitalization.

• The Resource Nurse/Case Manager will manage and track member care and arrange for transfer to an in-plan hospital.

• The Senior Medical Director has substantial involvement in the implementation of the out of network Utilization Management process and board certified physicians from appropriate specialty areas may assist in making determinations of medical appropriateness of care that the Member may be receiving.

Out of Network Providers

Requests to out of network Providers are redirected to Arcadian contracted Providers unless there is a medical reason/continuity of care issue that requires the patient to be seen by the out of network Provider. The Resource Nurse/Case Manager will contact the PCP to confirm there are no medical reasons for the patient to see an out of network Provider. On agreement with the PCP that the Member can safely be seen by a network Provider, an authorization will be issued redirecting the Member to a network Provider. If the Member refuses to see the network Provider, the request for the Member to see the out of network Provider is entered into the system and referred to the Senior Medical Director or Resource Physician for review and determination. If it is determined that the Member must be authorized to see out of network Provider, the authorization is issued within the appropriate timeframe for the Member’s medical condition.

Emergency Services

Arcadian has a process that ensures Members can obtain required emergency services. This requires coverage of emergency services to screen and stabilize the Member without prior approval where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. Additionally, the process requires coverage of emergency services if an authorized representative, acting for the organization, has authorized the provision of emergency services, in network, or out of network.

• Prior authorization requirements are not applied to emergency services for network or out of network Provider.

• An emergency-screening fee (Medical Screening Exam) is paid timely for all emergency room claims where clinical data supporting a higher level of pay is not available.

• Non-contracted Providers are paid for the treatment of the Emergency Medical/Behavioral Health Condition including medically necessary services rendered to a Member until the Member’s condition has stabilized sufficiently to permit discharge, or to refer and transfer the Member to a contracted facility.

• Members will receive adequate follow-up care through their PCP, when non-emergency care is needed and emergency services are denied in the emergency department following a Medical Screening Exam.

Authorizations/Adverse Determination

The Utilization/Case Management staff follows Arcadian’s authorization process for reviewing requested services. Both favorable and adverse determinations are based on medical necessity using

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nationally recognized criteria and guidelines. All adverse determinations are based on medical necessity, are made by Arcadian’s Senior Medical Director or his/her designee, with current unrestricted license to practice medicine. Clinical guidelines used in making the determination are available for review upon request. Arcadian’s Director, also with current unrestricted licensure, supervises the UM processes and works in collaboration with the Arcadian’s Senior Medical Director. Arcadian clearly documents and communicates the reasons for each denial of health care services to Providers and Members. Providers are provided an initial notification of denial within twenty-four (24) hours via fax that includes the name and telephone number of the Medical Director or Resource Physician making the adverse determination. This enables the Provider the opportunity to discuss the adverse determination with the Medical Director or Resource Physician. Required timeframes are met for Member and Provider notification. Adverse determination letters to the Member and Provider contain information regarding the appeals process and the availability, upon request, of the criteria used in making the adverse determination.

Appeals

Arcadian has a policy and process in place to facilitate the timely, thorough, and appropriate resolution of appeals for Members and Providers if they were denied health care services through the authorization process.

Provider Termination and Continuity of Care

Provider contracts require at least 60 days prior notice for termination without cause. In the case of any Provider termination, Arcadian will insure continuity of care for Members when a Provider has terminated their contract with Arcadian. Examples of possible continuity of care issues include, but are not limited to current treatment of acute or serious chronic conditions where changing treating a Provider may endanger the health care of the Member, second and third trimester pregnancy, or high risk pregnancy. Arcadian will make its best effort to notify affected Members of termination of a Provider within 15 days of Arcadian’s receipt or knowledge of such Provider’s termination notice to the plan.

New Technologies

Arcadian continually reviews and assesses existing and improved technology for health care services benefit applications. This includes medical and behavioral health procedures, pharmaceuticals as well as devices. Arcadian criteria may change and/or expand because of these revisions. This information is submitted to the Clinical Care Committee (CCC) for further review and reflected in Arcadian’s policy and procedure changes. Arcadian’s Senior Medical Director is available to Providers for discussion of individual cases that may benefit from improved technological changes. Additionally, Arcadian may receive referral requests from Providers regarding new technology, which would be submitted to the Arcadian’s Senior Medical Director for review and determination of benefit applications.

Availability of Arcadian Staff

Utilization/Case Management staff will be available to Providers and Members at least 40 hours per week during normal business hours for the local time zone to discuss patient care and allow response to

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telephone requests. After hour calls are recorded and responded to within two working days. Arcadian’s message during business hours directs the caller to 911 in the case of a life- threatening emergency.

Hospital Services

Prior Authorization

The Prior Authorization process is designed to provide for a prior assessment of requested services to determine if the requested services, such as hospitalization, diagnostic testing, specialty notification and authorization, physical, occupational, and speech therapy, home health, etc., are medically necessary and appropriate for the Member, and if the service is covered by the plan.

Acute and Skilled Admissions and Outpatient Hospital Services

Prior Authorization is required for all non-emergent admissions, inpatient admissions, skilled nursing admissions, acute inpatient rehabilitation, long term acute care (LTAC), and specified outpatient hospital services. Prior Authorization provides the requesting Provider and/or hospital an opportunity to prospectively assure that:

• The patient is an eligible Arcadian Member • The benefit is a covered service available under the Member’s health plan Evidence of

Coverage (EOC) • All covered services (e.g., test, procedures) within the Provider’s scope of practice have been

provided and evaluated thoroughly prior to specialist or hospital involvement in order to: • Avoid unnecessary consultations or admissions • Avoid delays in services • Determine if the requesting Provider can provide the service • Provide the receiving specialists and hospital the required medical information to

evaluate a Member’s condition • Consultation requests are directed to a Provider and/or facility that has been contracted,

credentialed, and/or approved by Arcadian

Notification Requirements for Hospital Admissions

Hospitals are required to provide Arcadian notification of all admissions to verify eligibility, authorize care, including Level of Care (LOC), and initiate admission review and discharge planning, in accordance with the Health Services Program. Initial Notification Process

All hospital services require authorization. If the admission was prior authorized, Arcadian Health Services will fax a copy of all prior authorizations to the hospital and requesting Provider.

• Upon admission, hospitals are requested to notify Arcadian Health Services Department within one (1) business day. This may be done by either faxing the Member’s face sheet or a daily census sheet to Arcadian fax number.

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• Notification may also be accomplished via Arcadian’s Online System (AOS) using the email function. If the Hospital is not set up to use AOS, please contact the Provider Relations Representative to obtain a password and instructions on how to use the AOS system.

Case Management Program

The purpose of Arcadian Case Management program is to ensure that coordination of medically necessary care and applicable available resources is delivered in the most cost efficient setting for Members who require extensive or ongoing services. Operating within HIPAA regulations, the Health Plan analyzes Members’ health status using available data systems and clinical data sources.

Case Identification and Access to Case Management

1. Members are identified for potential case management through various notification, authorization and data sources. Sources used for identification of potential case management Members include, but is not limited to:

• Claim or encounter data such as: Interim Claims report, 2 day length of stay or less report, AHP 20K paid report, Claims exceeding threshold report, ER frequent flyer report, 75K report

• Hospital discharge data such as that identified on the Monthly Utilization Management report (MUM)

• Pharmacy data • Data collected through the utilization management process

Daily Welcome home report Daily ER report

Monthly readmission report Automatic referral for dx: CHF or COPD Complex health care needs Complex health care coordination needs Post transplant Self referral/family/caregiver referral Provider referral via the Provider Assistance Line(PAL)or case management fax line Members identified via the Health Risk Assessment Medicare Risk Score (RAF score)

2. Arcadian has multiple access points for Members to be considered for case management services including:

• Health Risk Assessment (HRA) • Discharge Planner Referral • Utilization Management Referral • Member Self-Referral • Practitioner Referral Identification of cases through Behavioral Health

Care Plan and member profile Family and member interviews Provider interviews Pharmacy

Claims Interdisciplinary Care Team (ICT) referral

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3. Case Management Instructions for Providers The Arcadian Health Plan case manager clinically and administratively identifies, coordinates, and evaluates the services delivered to those members with complex, acute and chronic needs, on a case-by-case basis. The purpose of effective Case Management (CM) is to ensure coordination of medically necessary care in a “culturally sensitive” manner, and requires that health care services being delivered to members in the most cost-efficient setting. CM also ensures members’ access to community resources based on their identified needs. CM includes the coordination of care for members at any level of care, inpatient, outpatient, home, rehabilitation, hospice, etc. Contracted providers may refer members requiring specialized coordination of health care needs to the Arcadian Case Management program in two ways:

1. Providers may submit a request via AOS email to the local resource nurse or case management nurse by clicking on the email link located on the AOS main menu 2. Providers may call the Provider Assistance Line (PAL) at 800-998-3057 and request a member be added to case management. The PAL representative will complete the request via Arcadian’s internal MAGS system and forward to the Health Services Department. All provider requests submitted to the case management department will be evaluated by the appropriate nurse and members meeting case management criteria will be contacted to determine their willingness to participate in the program. Members accepted into the program receive assistance from the nurse, including but not limited to: Monitoring/Education

a. The member's self-management of the condition – including family/care giver b. Preventive health issues – including appointment follow up c. Understanding relevant medical test results for their medical condition d. Mental health issues – with attention to “sad/blue” or isolation e. Community Resources f. Treatment options Managing

a. Co morbidities b. Lifestyle issues c. Medication – usually coordinated with the pharmacy staff Coordinating Care with PCP and Specialists a. Authorizations/referrals b. Hospitalization concurrent review c. Home Health concurrent review d. Urgent Care issues – facilitates appointment Advance Care Planning a. Advance Directives b. Alternative care options/hospice 3. Providers may also fax a referral directly to the Case Management department Monday to Friday using the Case Management toll free e-fax number 888-909-2201.

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Special Needs Plan (SNP)

Model of Care

Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization Act (MMA) of 2003. This type of Medicare managed care plan focuses on certain vulnerable groups of Medicare members. Arcadian Health Plan offers a Special Needs Plan (SNP) for members who have Medicare Parts A and B and Qualified Medicare Beneficiaries (QMB’s) Medicaid eligibility. These members are referred to as ‘dual eligible’, and is the targeted population for the Arcadian Health Plan SNP Model of Care. Arcadian Health Plan is required by the Centers for Medicare and Medicaid Services (CMS) to administer a Model of Care Plan. The SNP Model of Care Plan is the framework for case management policy, procedures, and operational systems.

Goals and Objectives

• To promote the Medical Home by placing the member’s PCP in a ‘navigator’ role encouraging a partnership between the member and PCP to improve the coordination of care and services

• To enhance and improve members health status including safety, productivity, satisfaction and quality of life

• To assist members in achieving an enhanced level of health and to maintain wellness and function by facilitating timely and appropriate health services

• To assist members in receiving appropriate and affordable access to care including medical, behavioral, social and ancillary services

• To assist members to appropriately self direct care, self advocate, and make informed healthcare decisions to the best of their ability

• To promote utilization of available resources appropriately to achieve clinical and financial outcomes

• To ensure the utilization management process is used to provide seamless transition of care.

• To improve clinical and quality of life outcomes of members care by ongoing monitoring

Interdisciplinary Care Team (ICT)

Interdisciplinary Care Teams are composed of clinical and non clinical participants and are located regionally to ensure community resources are incorporated when addressing the medical and psychosocial needs of the member. The composition of the team varies based on the needs of the member. Participants may include, but not be limited to, the member’s Primary Care Physician (PCP), Case Manager (facility and AHP), Specialty Provider, Social Worker, and AHP Senior Medical Director.

Individualized Care Planning

Nurse Case Managers develop individualized plan of care for members in Case Management using a variety of data elements such as the HRA, UM Data, Claims Data, PCP information, and Member Services information. The member is contacted and encouraged to assist in the development of their individualized care plan. The essential elements incorporated in the plan include results of the health risk assessment, the member’s clinical history including the disease onset, hospitalizations, medication

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usage, member’s ability to perform activities of daily living, member’s mental health status, cognitive functioning, ability to communicate, understand instructions and process information about their disease process, advanced directives and durable power of attorney, any language or educational barriers that may prevent the member from understanding their disease process, member’s family/social resources, including the member’s living arrangements and caregiver requirements. Also included in the plan are the goals and objectives, outcomes measures, any add-on benefits, and specific services to assist vulnerable members. Depending on the member’s health status, the plan of care is reviewed and revised by the member’s PCP and/or case manager in collaboration with the member as their health status warrants changes. The plan of care is documented and maintained in a software database (e.g. Arcadian Online System - AOS). The PCP acts as the Navigator setting the course for the member’s care and is responsible for communicating that plan of care to the member. For services required outside the PCP office the PCP is responsible for communicating the plan to the Nurse Case Manager to assist in the seamless coordination and transition of care to pertinent network providers. This is communicated via a variety of options; telephonic intervention, AOS, and business fax.

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Arcadian Online System (AOS) AOS is Arcadian’s internet portal which offers the following services.

• Verify eligibility • Enter and view authorizations • Check claim status • Pharmacy history and authorizations • Access to helpful Arcadian documentation such as Summary of Benefits and Formulary • E-mail Arcadian representative

To gain access, a Provider’s office must first obtain a User Name and Password from your local Provider Relations Representative (see Contacting Arcadian Health Plan for your local office). You will need to provide your e-mail address and physician practice information. A Provider’s office can also access an AOS request form by navigating to www.arcadianhealth.com and clicking on Health Plans in the top right corner. Verifying Eligibility

• Click on Eligibility under Inquiry • Enter member’s Plan ID or Last Name to locate Member • Select Member • Member’s information is listed including PCP, effective date, copays, etc. • Ability to access authorizations, claims, and also a member snapshot that your provider

representative can allow you access to.

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Authorizations for Medical Services and Procedures

An authorization is required and can be made by the servicing physician for any office or facility based procedure defined in Addendum I. The process for an Authorization is as follows.

• Under Input Authorizations (left column of AOS Home Page), click on Office Visits and PCP

Notifications, Outpatient Visits, Inpatient Visits or Pharmacy Authorizations as approprieate. • Select Member by clicking on blue box; enter member’s last name or Plan ID • Select appropriate provider in Referred from field • Select appropriate provider in Referred to field • Select the appropriate type of Referral in the Category field • Complete all other required fields • Submit the Referral

Authorizations are approved are approved generally within the CMS standard timelines if all necessary information and documentation has been submitted. All Providers involved in the care of the Member can access AOS to view the approval, denial, or request for additional information regarding a specific referral.

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Addendum I – Authorization Guide

General Services Needing Prior Authorization

• Inpatient Admissions (Acute/Rehab/Psych/SNF/LTAC) • MRI/MRA, PET, CT (all types)

• Outpatient Surgeries & Select Procedures (Hospital OP and ASC)

• Select Office-Based Procedures (see below grids by specialty for detail)

• High Cost Injectables • Self-injectable Drugs

• Transplant Services • Out-of-Network Referrals

• Alcohol/Drug Abuse Detox OP Services • Any Experimental/Investigational Services

• Home Health ● Home Infusion Therapy

• Prosthetic & Orthotics • Genetic Testing and unlisted procedures

• Ambulance - Non-emergent transport (Codes A0120, A0130, A0426, A0428)

• Referral to Hospice

• DME & Supplies (except canes, commodes, CPAP supplies, crutches, diabetic shoes, diabetic supplies, insulin pump supplies, nebulizers/nebulizer medication (except Xopenex), ostomy/urostomy supplies & walkers)

• Outpatient Rehab Services (PT, OT, ST) (Codes: PT-97001, 97110; OT-97003; 97004; ST-92506; 92507, 92508) Maximum 12 visits per authorization; therapy services subject to Medicare caps. 2011 cap is $1,870 for PT & ST and $1,870 for OT services. Caps do not apply to services billed by hospitals.

Office-Based Services Requiring Prior Authorization

An authorization is required for any office based procedures performed in a facility Procedure Code

Cardiology

Nuclear Medicine – MUGA 78494; 78472; 78473; 78481; 78483; 78494; 78496

ENT/Pulmonary

Sleep Studies 95800-95811; G0398-G0400

Dermatology

Moh's chemosurgery 17311-17315

Actinotherapy (ultraviolet light) 96900

Photochemotherapy 96910-96913

Laser treatment for inflammatory skin disease (psoriasis) 96920-96922

Neurology

Nerve conduction, amplitude & latency/velocity, per nerve 95900-95904

Electromyography studies 95860-95872

Ob/Gyn

Abortions 59812-59857

Sterilization 58600; 58611; 58670

D & C after delivery 59160

All OB & Delivery Care 59400; 59510; 59610; 59618 and related codes

Oncology

All chemotherapy codes require initial authorization and, depending on treatment plan, additional authorizations may be needed. Exception: the Generic Chemo Code Program will auto-approve. Please contact your local provider relations representative for more information.

Oral Surgery All procedure codes

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Office-Based Services Requiring Prior Authorization

An authorization is required for any office based procedures performed in a facility Surgery

Remove Maxilla Cyst Complex 21048

Excis Uppr Jaw Cyst W/Repair 21049

Repair Cleft Lip/Nasal 40702

Radiation Onc/Nuclear Med

Radiation treatment 77400-77499

Facility-Based Outpatient Services Requiring Prior Authorization The following procedures require authorization when provided in an outpatient facility.

All elective outpatient surgeries require prior authorization The following informational grid is arranged by medical specialty. We understand that certain procedures may be performed by multiple medical specialties. Please locate the specific procedure on the grid for guidance.

Audiology

Hearing screenings (except Dx 389 series) 92551 with other diagnosis

Cardiology

PTCA 92980-92998

Intravascular Ultrasound (Coronary Vessel or Graft) 92978-92979

Catheterization 93451-93464; 93503-93505; 93530-93533; 93561-

93562; 93563-93568

Angiograms 93571-93572

Cardiac Electrophysiology 93600-93662

Other Procedures 93024-93025; 93268-93278; 93580-93581; 93701-

93790

Nuclear medicine procedures 78414-78499

Cardiac Rehab 93797-93798

Stress Treadmill with J code 93015-93018; Includes J Code

Cardiovascular Surgery

Procedures 33010-33926; 33960-33980; 34001-37790

ENT

Sleep Studies 95800-95811; G0398-G0400

Dermatology

Moh's chemosurgery 17311-17315

Actinotherapy (ultraviolet light) 96900

Photochemotherapy 96910-96913

Laser treatment for inflammatory skin disease (psoriasis) 96920-96922

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Facility-Based Outpatient Services Requiring Prior Authorization**

The following procedures require authorization when provided in an outpatient facility.

All elective outpatient surgeries require prior authorization Gastroenterology

Procedures

91000-91030; 91034-91040; 91065; 91110-91122; 91132-91299

Codes within the range of 40000-49999, excluding those below*

* Exclusion List, these procedures do NOT need prior authorization when performed in an ASC

44388-44394; 44397; 45355; 45378; 45379-45387; 45391; 45392; G0105; G0121

Nephrology

Dialysis 90935; 90945-90997

Procedures 50010-50135; 50200-50290

Neurology

Nerve conduction, amplitude & latency/velocity, per nerve 95900-95904

Electromyography studies 95860-95872

Neurosurgery

Procedures 61000-64999; 77371-77372

Ob/Gyn

Abortions 59812-59857

Sterilization 58600; 58611; 58670

D & C after delivery 59160

All OB & Delivery Care 59400; 59510; 59610; 59618 and related codes

CVS studies 59015; 76945

Procedures 59100-59160

Oncology

All chemotherapy codes require initial authorization and, depending on treatment plan, additional authorizations may be needed. Exception: the Generic Chemo Code Program will auto-approve. Please contact your local provider relations representative for more information.

Bone Marrow Colony Stimulating Agents J0881-J0886; J1440-J1441; J2505; J2820

Other related drugs including Palonosetron, Zoledronic Acid (Zomeltra, Reclast) and other chemotherapeutic drugs

J2469; J3487; J3488

Ophthalmology

Trabeculoplasty by laser surgery 65855

Iridotomy/iridectomy by laser surgery 66761

Extracapsular cataract removal (CPT Code 66982 ONLY) 66982

Post cataract glasses V43.1

Blepharoplasty 15820-15823

Oral Surgery

TMJ Treatment Limited under Medicare to Dx: 524.6 series

Procedures 21025-21070, 21116, 21100, 21110

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Facility-Based Outpatient Services Requiring Prior Authorization**

The following procedures require authorization when provided in an outpatient facility.

All elective outpatient surgeries require prior authorization Orthopedics

Carpal Tunnel 64721; 29848

Espi/Synvisc injection J7322; J7325

Pain Management

Epidural Injections 62310-62319

Injection for Sacroiliac Joint 27096

Pain Management services 64400-64449; 64450-64455; 64479-64484; 64490-64495; 64505; 64508-64517; 64520; 64530-64565;

64622-64623

Application of surface neurostimulator 64550

Physiatry

Procedures 51784-51785; 62310-62311; 62318-62319; 64479-64484

Plastic Surgery Blepharoplasty 15820-15823

Pulmonary

Procedures 32035-32225; 32310-32405; 32420-32540; 32601-

32665; 32900-32960

Sleep Studies 95800-95811; G0398-G0400

Rehab G0424

Radiation Onc/Nuclear Med

Radiation treatment 77400-77499

Stereotactic Radiosurgery 61796-61800; 63620-63621; G0339-G0340

Rheumatology

Hyalgan/Supartz J7321

Synvisc or Synvisc One J7322; J7325

Reclast J3488

Infliximab J1745

Surgery

Bariatric Procedures 43770; 43644-43645; 43845-43847

Urology

Urologic needle electromyography studies (EMG) 51785

Urologic stimulus evoked response 51792

Voiding pressure studies, intra-abdominal 51797

Sterilization – Vasectomy 55250

Procedures

50010-51080; 51500-51597; 51605-51610; 51715-51720; 51784; 51800-51992; 51999; 52010; 52214-52260; 52317-52318; 52327; 52332-52334; 52353-52649; 53000-53025; 53085; 53210-53220; 53400-

53605; 53665; 55250

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Facility-Based Outpatient Services Requiring Prior Authorization** The following procedures require authorization when provided in an outpatient facility.

All elective outpatient surgeries require prior authorization Wound Care

Hyperbaric Oxygen Therapy 99183; C1300

Wound Vac(s) (1 auth for entire treatment plan) 97605-97606; A6550; E2402

Allograft 15300-15321

Apligraf Q4101

Effective 5/1/2011

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Addendum II - State Addendums States with state agreements (Dual Plus for Special Needs Program or SNP) for cost-sharing

purposes:

Arkansas Georgia Missouri South Carolina Arizona Louisiana New York Texas California Maine Oklahoma Washington Arcadian assures that its contracts with the Providers contain provisions that require such Providers to accept MaineCare payment and, if appropriate, enrollee cost sharing as payment in full. Arkansas

• The state of Arkansas has an obligation to pay cost sharing for Dual Eligible’s. Provider may access our website at http://www.arcadianhealth.com/Arkansas.php

• The following information and more regarding cost sharing can be found at https://www.medicaid.state.ar.us/Download/provider/amprcd/Manuals/MEDX/MEDX_II.DOC

The Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of Medicare claims for “physician” services furnished to individuals who are eligible for Medicare and Medicaid, including those eligible as Qualified Medicare Beneficiaries (QMBs). According to Medicare regulations, “physician” services, for the purpose of this policy, are services furnished by physicians, dentists, optometrists, chiropractors and podiatrists.

Item 1-C. of the “Contract To Participate In The Arkansas Medical Assistance Program Administered By The Division Of Medical Services Title XIX (Medicaid)” further requires acceptance of assignment under Title XVIII (Medicare) in order to receive payment under Title XIX (Medicaid) for any applicable deductible or coinsurance that may be due and payable under Title XIX (Medicaid). Services furnished to an individual enrolled under Medicare who is also eligible for Medicaid, including Qualified Medicare Beneficiaries (QMB) may only be reimbursed on an assignment related basis.

Medicare Advantage Plans (like HMOs and PPOs) are health plan options that are available to beneficiaries, approved by Medicare, but run by private companies. These companies bill and pay directly for benefits that are a part of the Medicare Program, as well as offering enhanced coverage provisions to enrollees. Since these claims are paid through private companies and not through the original Medicare plan directly, these claims will not automatically cross to Medicaid and the provider must request payment of Medicare covered services coinsurance and deductible amounts through Medicaid according to the instructions in Section III, 330.000, after the Medicare plan pays the claim.

Louisiana

• The process for participating with Louisiana Medicaid can be found on our website at http://www.arcadiancommunitycare.com/Louisiana.php or on the Louisiana state website at http://www.dhh.louisiana.gov/offices/?ID=92.

• Arcadian assures that its contracts with the Providers contain provisions that require such Providers to accept Medicaid payment and, if appropriate, enrollee cost sharing as payment in full.

Texas

• The process for participating with Texas Medicaid can be found on our website at www.texascommunitycare.com or on the Texas state website at http://www.hhsc.state.tx.us/medicaid.

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• Participating skilled nursing facilities (SNF) are encouraged to electronically submit to the Texas Medicaid claims administrator a resident transaction notice within 72 hours after the Dual Eligible member is admitted or discharged from the SNF.

• Arcadian has entered into an agreement with the Texas Health and Human Services Commission (THHSC) for the Dual Plan and Dual Plus Plans for Members who also qualify for Medicaid. Under this Agreement, Arcadian receives monetary payment via capitation from THHSC for Dual Plus Plan members meeting criteria for Medicaid eligibility. Provider is to accept payment from Arcadian as payment in full, inclusive of copayments or coinsurances. Due to a three month eligibility lag in the eligibility file from THHSC, the Provider would need to be cognizant of non-billing of remaining copayments or coinsurances under this time frame. The Member will not be responsible for any fees, except for non-covered services.

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Appendix 1 – Medicare Advantage Regulatory Requirements

ARCADIAN HEALTH PLAN

MEDICARE ADVANTAGE REGULATORY REQUIREMENTS APPENDIX 1

The CMS regulatory provisions contained in this “Appendix” are made part of the Agreement between Health Plan and Provider, Hospital, Facility, Ancillary Provider, Network or Network Provider, hereafter referred to as “Provider.” Provider has agreed to provide services to Medicare beneficiaries receiving coverage under Medicare Advantage agreements between the Centers for Medicare and Medicaid Services (“CMS”) and Health Plan.

SECTION 1 – APPLICABILITY

This Appendix applies to the Covered Services Provider provides to Medicare Advantage Beneficiaries. In the event of a conflict between this Appendix and other appendices or any provision of the Agreement, the provisions of this Appendix shall control except as required by applicable law.

SECTION 2 – DEFINITIONS

For purposes of this Appendix, the following terms shall have the meanings set forth below. 2.1 Benefit Plan: A certificate of coverage, summary plan description, or other document or agreement, whether delivered in paper, electronic, or other format, under which Health Plan is obligated to provide coverage of Covered Services for a Member. 2.2 CMS Agreement: A contract between the Centers for Medicare & Medicaid Services (“CMS”) and Health Plan for the provision of Medicare benefits pursuant to the Medicare Advantage Program under Title XVIII, Part C of the Social Security Act. 2.3 Cost Sharing: Those costs, if any, under a Benefit Plan that are the responsibility of the Member, including deductibles, coinsurance, and copayments. 2.4 Covered Service: A health care service or product for which a Member is entitled to receive coverage from Health Plan, pursuant to the terms of the Member’s Benefit Plan with Health Plan. 2.5 Dual Eligible Member: A Health Plan Member who is: (a) eligible for Medicaid; and (b) for whom the state is responsible for paying Medicare Part A and B Cost Sharing. 2.6 Medicare Advantage Benefit Plans: Benefit Plans sponsored, issued or administered by Health Plan as part of the Medicare Advantage program or as part of the Medicare Advantage program together with the Prescription Drug program under Title XVIII, Part C and Part D, respectively, of the Social Security Act. 2.7 Member: A person eligible and enrolled to receive coverage from Health Plan for Covered Services.

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SECTION 3 - PROVIDER REQUIREMENTS

3.1 Data. Provider shall cooperate with Health Plan’s efforts to report to CMS all statistics and other information related to its business, as may be required or requested by CMS, including but not limited to risk adjustment data as defined in 42 CFR 422.310(a). Provider shall send to Health Plan, all risk adjustment data and other Medicare Advantage program-related information as may be requested by Health Plan in a form that meets Medicare Advantage program requirements. Provider represents to Health Plan, and upon Health Plan’s request Provider shall certify in writing, that the data is accurate, complete, and truthful. 3.2 Policies. Provider shall cooperate and comply with Health Plan’s policies and procedures. 3.3 Member Protection. Provider agrees that in no event, including but not limited to, nonpayment by Health Plan, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Health Plan Member for services provided pursuant to the Agreement or for any other fees that are the legal obligation of Health Plan under the CMS Agreement. This provision does not prohibit Provider from collecting from Health Plan Members allowable Cost Sharing. This provision also does not prohibit Provider and a Health Plan Member from agreeing to the provision of services solely at the expense of the Member, as long as Provider has clearly informed the Member, in accordance with applicable law, that the Member’s Benefit Plan may not cover or continue to cover a specific service or services. In the event of Health Plan insolvency or other cessation of operations or termination of Health Plan’s agreement with CMS, Provider shall continue to provide Covered Services to a Member through the later of the period for which premium has been paid to Health Plan on behalf of the Member, or, in the case of Members who are hospitalized as of such period or date, the Member’s discharge. This provision shall be construed in favor of the Member, shall survive the termination of the Agreement regardless of the reason for termination. 3.4 Dual Eligible Members. Provider agrees that in no event, including but not limited to, non-payment by a State Medicaid Agency or other applicable regulatory authority, other state source, or breach by Health Plan of the Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Dual Eligible Member, person acting on behalf of the Dual Eligible Member, Health Plan (unless notified otherwise) for Medicare Part A and B Cost Sharing. Instead, Provider will either: (a) accept payment made by or on behalf of Health Plan as payment in full; or (b) bill the appropriate state source for such Cost Sharing amount. If Provider imposes an excess charge on a Dual Eligible Member, Provider is subject to any lawful sanction that may be imposed under Medicare or Medicaid. This provision does not prohibit Provider and a Dual Eligible Member from agreeing to the provision of services solely at the expense of the Dual Eligible Member, as long as Provider has clearly informed the Dual Eligible Member, in accordance with applicable law, that the Dual Eligible Member’s Benefit Plan may not cover or continue to cover a specific service or services. 3.5 Eligibility. Provider agrees to immediately notify Health Plan in the event Provider is or becomes excluded from participation in any Federal or state health care program under Section 1128 or 1128A of the Social Security Act. Provider also shall not employ or contract for the provision of health care services, utilization review, medical social work or administrative services, with or without

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compensation, with any individual or entity that has been excluded from participation in any Federal or state health care program under Section 1128 or 1128A of the Social Security Act. 3.6 Laws. Provider shall comply with all applicable Federal and Medicare laws, regulations, and CMS instructions, including but not limited to: (a) Federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse, including but not limited to, applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. §3729 et seq.), and the anti-kickback statute (§1128B of the Social Security Act); and (b) HIPAA administrative simplification rules at 45 CFR Parts 160, 162, and 164. 3.7 Federal Funds. Provider acknowledges and agrees that Health Plan receives Federal payments under the CMS Agreement and that payments Provider receives from or on behalf of Health Plan are, in whole or in part, from Federal funds. Provider is therefore subject to certain laws that are applicable to individuals and entities receiving Federal funds. 3.8 CMS Agreement. Provider shall perform the services set forth in the Agreement in a manner consistent with and in compliance with Health Plans’ contractual obligations under the CMS Agreement. 3.9 Records.

(a) Maintenance, Privacy, Confidentiality and Member Access. Provider shall maintain records and information related to the services provided under the Agreement, including but not limited to Health Plan Member medical records and other health and enrollment information, in an accurate and timely manner. Provider shall maintain such records for at least ten (10) years or such longer period as required by law. Provider shall safeguard Members privacy and confidentiality, including but not limited to the privacy and confidentiality of any information that identifies a particular Member, and shall comply with all Federal and state laws regarding confidentiality and disclosure of medical records or other health and enrollment information. Provider shall ensure that Members have timely access to medical records and information that pertain to them, in accordance with applicable law. (b) Government Access to Records. Provider acknowledges and agrees that the Secretary of Health and Human Services, the Comptroller General, or their designees shall have the right to audit, evaluate and inspect any pertinent books, contracts, medical records, patient care documentation and other records and information belonging to Provider that involve transactions related to the CMS Agreement. This right shall extend through ten (10) years from the later of the final date of the CMS Agreement period in effect at the time the records were created or the date of completion of any audit, or longer in certain instances described in the applicable Medicare Advantage regulations. For the purpose of conducting the above activities, Provider shall make available its premises, physical facilities and equipment, records relating to Members, and any additional relevant information CMS may require. (c) Health Plan Access to Records. Provider shall grant Health Plan or its designees such audit, evaluation, and inspection rights identified in subsection 3.9(b) as are necessary for Health Plan to comply with its obligations under the CMS Agreement. Whenever possible, Health Plan will give Provider reasonable notice of the need for such audit, evaluation or inspection, and will conduct such audit, evaluation or inspection at a reasonable time and place. 3.10 MA Organization Accountability; Delegated Activities. Provider acknowledges and agrees that Health Plan oversees and is accountable to CMS for any functions and responsibilities described in the CMS Agreement and applicable Medicare Advantage regulations, including those that Health Plan may sub-delegate to Provider. If Health Plan has sub-delegated any of its functions and responsibilities under

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the CMS Agreement to Provider pursuant to the Agreement, the following shall apply in addition to the other provisions of this Appendix: (a) Provider shall perform those delegated activities specified in the Agreement, if any, and shall comply with any reporting responsibilities as set forth in the Agreement. (b) If Health Plan has delegated to Provider any activities related to the credentialing of health care providers, Provider must comply with all applicable CMS requirements for credentialing, including but not limited to the requirement that the credentials of medical professionals must either be reviewed by Health Plan or its designee, or the credentialing process must be reviewed, pre-approved and audited on an ongoing basis by Health Plan or its designee. (c) If Health Plan has delegated to Provider the selection of health care providers to be participating providers in the Health Plan’s Medicare Advantage provider network, Health Plan retains the right to approve, suspend or terminate the participation status of such health care providers. (d) Provider acknowledges that Health Plan or its designee shall monitor Provider’s performance of any delegated activities on an ongoing basis. If Health Plan or CMS determines that Provider has not performed satisfactorily, Health Plan may revoke any or all delegated activities and reporting requirements. Provider shall cooperate with Health Plan regarding the transition of any delegated activities or reporting requirements that have been revoked by Health Plan. 3.11 Subcontracts. If Provider has any arrangements, in accordance with the terms of the Agreement, with affiliates, subsidiaries, or any other subcontractors, directly or through another person or entity, to perform any of the services Provider is obligated to perform under the Agreement that are the subject of this Appendix, Provider shall ensure that all such arrangements are in writing, duly executed, and include all the terms contained in this Appendix. Provider shall provide proof of such to Health Plan upon request. Provider further agrees to promptly amend its agreements with subcontractors, in the manner requested by Health Plan to meet any additional CMS requirements that may apply to the services. 3.12 Off shoring. Unless previously authorized by Health Plan in writing, all services provided pursuant to the Agreement that are subject to this Appendix must be performed within the United States, the District of Columbia, or the United States territories.

SECTION 4 – OTHER

4.1 Confidentiality of Protected Health Information (HIPAA). Health Plan and Provider each acknowledge that it is a “Covered Entity,” as defined in the Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164) pursuant to the Health Insurance Portability and Accountability Act of 1996 (the “Privacy Rule”). Each party shall protect the confidentiality of Protected Health Information and shall otherwise comply with the requirements of the Privacy Rule and with all other State and Federal Laws governing the confidentiality of medical information.

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4.2 Prompt Payment. Health Plan or its designee shall promptly process and pay or deny Provider’s claim within thirty (30) calendar days following receipt of a Clean Claim by Health Plan. If Provider is responsible for making payment to subcontracted providers for services provided to Health Plan Members, Provider shall pay them no later than thirty (30) days after Provider receives request for payment for those services from subcontracted providers.

4.3 Regulatory Amendment. Health Plan may unilaterally amend this Appendix to comply with applicable laws and regulations and the requirements of applicable regulatory authorities, including but not limited to CMS. Health Plan shall provide written or electronic notice to Provider of such amendment and its effective date. Unless such laws, regulations or regulatory authority(ies) direct otherwise, the signature of Provider will not be required in order for the amendment to take effect.