Provider Manual TABLE OF CONTENTS INTRODUCTION Aspirus Arise is pleased to welcome you as a partner! Introduction...... 3 The Aspirus Arise Provider Manual is designed and produced for Aspirus Arise Contact Aspirus Arise...... 4 providers to promote a clear understanding of our policies and procedures, About Aspirus Arise...... 5 including provider services, outpatient prior authorization, claims, and eligibility. Product and Benefit Plans...... 6 The purpose of this manual is to answer some of the questions you may Member Primary Care Access Model...... 7 have regarding Aspirus Arise operations. As changes occur, this manual will be updated on a routine basis. Aspirus Arise reserves Appointment Scheduling Guidelines...... 8 the right to revise or alter the material and information detailed in Medical Record Requirements...... 9 this manual at any time. Medical Management...... 10-11 Medical Management Program...... 12 Medical Management Definitions...... 13-14 Prior Authorization...... 15-16 Prior Authorization Determination...... 17 Special Programs/Provider Responsibility...... 18 Vision Management...... 18-20 Concurrent Review Decisions...... 21 Post-Service Determination...... 22 Case Management...... 23-24 Chronic Disease Management ...... 25 Behavioral Health Management...... 26-28 Chiropractic Care Management...... 29 Pharmacy Management...... 30-31 Drug Prior Authorization...... 32 Technology and Incentives...... 33 Resources/Tools...... 34-35 Medical Policy Guidelines...... 36 Quality Improvement Program...... 37 Urgent and Emergent Care...... 38-39 Telemedicine...... 40 Member Rights and Responsibilities...... 41 Member Grievance Procedures...... 42 Claims Procedures...... 43-45 Provider Rights to Pertaining Credentialing...... 46 Continuity of Care...... 47 Provider Contracting...... 48

2 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 3 CONTACT ASPIRUS ARISE ABOUT ASPIRUS ARISE On Jan. 27, 2016, Aspirus and WPS Health Solutions announced the creation of a new health insurance company, Corporate Aspirus Arise Health Plan of Wisconsin, Inc., known publicly as Aspirus Arise, in north-central Wisconsin. Aspirus Phone 715-972-8140 Arise offers individual marketplace, small group, large group, and self-funded plans for 2017 effective dates. Email [email protected] Aspirus is a non-profit, community-directed health system based in Wausau, Wisconsin. With more than 7,000 Website AspirusArise.com employees, Aspirus serves communities throughout 16 counties in northern and central Wisconsin, as well as Mailing Address Aspirus Arise the western Upper Peninsula of Michigan. The integrated system includes four hospitals in Michigan and four P.O. Box 395 hospitals in Wisconsin, 50 clinics, more than 400 physicians, home health and hospice care, pharmacies, critical Wausau, WI 54402 care and helicopter transport, medical goods, nursing homes, and high-quality affiliated physicians.

Electronic Claim Submission WPS Health Solutions is a nationally regarded government contractor and a leading Wisconsin not-for-profit The WPS Electronic Data Interchange (EDI) department has a dedicated staff whose primary function is to consult health insurer. The WPS Health Insurance division offers affordable individual health insurance, family health and service providers on electronic processes. Our staff is experienced in dealing with a variety of provider insurance, high-deductible health insurance, and short-term health plans, as well as flexible and affordable group specialties, billing services, and software vendors. plans and cost-effective benefit plan administration for businesses. The WPS Government Health Administrators division administers Part A and B Medicare benefits for millions of seniors in multiple states, and the WPS Military Phone 608-221-7115 and Veterans Health division serves millions more who are active in the U.S. military, veterans, and their families. Toll-Free 800-782-2680 In 2017, the International Ethisphere® Institute named WPS one of the World’s Most Ethical Companies® for the Email [email protected] eighth straight year. For more information about WPS, visit wpsic.com. Hours Monday–Thursday, 7 a.m. to 10 p.m. Friday, 7 a.m. to 4:30 p.m. Saturday, 8 a.m. to noon Claim Submission Aspirus Arise SERVICE AREA P.O. Box 21684 Eagan, MN 55121 Medical Management Phone 920-490-6901 Toll-Free 800-332-3297 (follow prompts 2, 4, 2) Fax 920-490-6943

Contact Medical Management for: · Pharmacy management · Medical policies · iExchange electronic prior authorization request · Outpatient prior authorization guidelines · Inpatient prior authorization guidelines (inpatient hospital or skilled nursing facility)

Network Management, Provider Relations, and Provider Credentialing Phone 715-972-8140 Email [email protected] Hours Monday–Friday, 8 a.m. to 4:30 p.m.

Contact Network Management, Provider Relations, and Provider Credentialing for: · Provider additions, terminations, and changes · Fee schedule questions · Assistance with provider issues · Provider directory/website listings · Credentialing questions

4 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 5 PRODUCT AND BENEFIT PLANS ID CARDS Aspirus Arise offers a broad range of insurance products to meet the needs of our group and individual customers, from traditional Health Maintenance Organization (HMO) and Point-of-Service (POS) plans, to self- funded administration and consumer-driven options. Aspirus Arise is a Qualified Health Plan Issuer in the Health Insurance Individual Marketplace and SHOP (Small Business Health Options Program), offering its plans on- and off-Marketplace.

INDIVIDUAL AND FAMILY PLANS Aspirus Arise also offers a wide variety of individual products providing exceptional flexibility and value for individuals. Individuals can choose from POS plans and HMO plans, as well as consumer-driven options that include Health Savings Account (HSA)-qualified high-deductible health plans. These plans are offered on and off the Health Insurance Individual Marketplace.

SMALL GROUP PLANS Aspirus Arise offers a wide variety of small group products providing exceptional flexibility for employers with fewer than 50 employees. Employers can choose from POS plans and HMO plans, as well as consumer-driven options that include Health Savings Account (HSA)-qualified high-deductible health plans. These plans are offered on and off the SHOP Marketplace (Small Business Health Options Program).

PLAN FEATURES Our Individual and Small Group products feature free preventive care; $0 copays on select preventive drugs that target common conditions such as high blood pressure, cholesterol, heart conditions, and asthma; telehealth services offered through Teladoc®; and $10 copays at convenient care clinics.

LARGE GROUP PLANS MEMBER PRIMARY CARE ACCESS MODEL Aspirus Arise offers large group health plans to employers with 51 or more employees. These plans are available with our Aspirus Arise network. Aspirus Arise network providers are selected for their commitment to high- Primary Care Practitioners (PCPs) are the core of Aspirus Arise. The objective of our Primary Care Model of quality, cost-efficient health care. Aspirus Arise is available with HMO and POS plans with both regular and HSA- Care is to guide members into an ongoing relationship with a PCP. The PCP is the individual responsible for eligible options. coordinating medical care for each member. We define PCPs as: • Family Practice SELF-FUNDED GROUP PLANS/ADMINISTRATIVE SERVICES ONLY (ASO) • General Practice Aspirus Arise contracts with employers or other group entities to administer benefit plans under an ASO • Internal Medicine arrangement. Our ASO business is administered under the name Aspirus Arise Administrators. Under an ASO arrangement, an employer hires a third party like Aspirus Arise Administrators to deliver employee benefit • Obstetrics/Gynecology administrative services to the employer. These services typically include health claims processing, billing, and • Pediatrics medical management. The employer bears the risk for health care expenses under an ASO plan. We believe this PCP model provides members with medical services within a time frame that allows safe What does this mean for our contracted providers? ID cards for this business will use Aspirus Arise treatment of emergency and emergent conditions and maintains effective preventive health care practices. Administrators’ name and logo. Claims can be remitted to the same address used for Aspirus Arise claims. For A list of PCPs is available for the member on our website and in our provider directory. It is important for plans administered under an ASO arrangement, no withhold will be taken if your contract includes withhold members to always identify themselves as Aspirus Arise members whenever they are making an appointment language. with a provider.

Note: Some ASO business may require a prior authorization, while others may not. Please call 715-972-8140 to Members will have reasonable access to care and services with respect to Aspirus Arise’s service area and verify if the member needs a prior authorization for any services. geographic location, hours of operation, and waiting times. Aspirus Arise will contract with a sufficient number of PCPs, specialists, and other health care providers in the geographic service area to meet the medical needs of our plan members.

6 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 7 APPOINTMENT SCHEDULING GUIDELINES MEDICAL RECORD REQUIREMENTS Member requests appointment for care. Aspirus Arise has adopted medical record documentation guidelines that are designed to provide consistent, current, and complete information regarding the care of our members. Clinic receptionist, nurse, or specified person determines type of care (if unable to determine type of care or patient/member has additional concerns, the situation is referred to the nurse or physician). The medical record documentation guidelines include the following requirements: • PREVENTIVE CARE–Involves asymptomatic patient/member; visit is for wellness, annual exam, • Patient’s name or ID number on each page. scheduled immunization, or other non-illness/injury-related issue. • Patient’s demographic information to include the home address, primary and secondary phone numbers, • ROUTINE PROBLEM–Involves patient/member with stable, non-urgent symptoms or conditions that: employer, and marital status. are not likely to change in the next 48 hours; do not cause concern about an illness or injury; do not • A problem list to indicate significant illnesses/medical conditions. interfere with normal daily activities. • Documentation of any known anaphylactic reaction and allergic trigger. All medication allergies and • URGENT PROBLEM–Involves patient/member with active symptoms or condition that: are likely adverse reactions or documentation of no known allergies. to escalate in the next 48 hours; cause concern about an illness or injury; interfere with normal • A medication list. daily activities. • An immunization record, if primary care. • EMERGENT PROBLEM–Involves severe active symptoms or conditions that: are life-threatening; will • A patient history record to include medical history, surgical history, and social history. become life-threatening if not treated; require medical care immediately or within the next two hours. • The medical recordkeeping system is organized, as evidenced by easily identifiable, retrievable, Clinic receptionist schedules appointment and strives to meet the following standards. individualized records. All entries must be dated and contain the author’s identification. Author’s identification may be a handwritten signature, unique electronic identifier, or initials. Type of Medical Appointment Preventive Care Routine Urgent Problem Emergent Problem • Documentation of clinical findings and evaluation for each visit. Working diagnoses are consistent with Problem findings. Max time from patient request to 30 days 7 days Same-day Immediate access • Treatment plans are consistent with diagnoses. appointment date access • There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure. Type of Behavioral Care Routine Care Urgent Non-Life-Threatening Emergency • A written medical record policy that addresses the ease of retrieval, timeliness of completion, release, Appointment Care and retention of medical records. Max time from patient request to 10 business days 48 hours 6 hours appointment date • To protect the confidentiality of medical records and guard against unauthorized disclosure of patient information, provider practices will have written policies/procedures that address confidentiality and storage of medical records in an area not accessible to the public. A consult is an appointment made at the request of the PCP. The clinic schedules a consult appointment based on the same guidelines set forth for Preventive Care, Routine Problem, and Urgent Information filed in medical records includes, but is not limited to: Problem as defined above. • All services provided directly by a PCP If the PCP or consulting physician cannot see the • All ancillary services and diagnostic tests ordered by a practitioner patient within the time frames indicated by the • All diagnostic and therapeutic services for which a member has been referred by a practitioner, such as: clinic and Aspirus Arise guidelines, an appointment will be offered with an alternate physician/same • Home health nursing reports site, or, if unavailable, with an alternate physician/ • Specialist reports different Aspirus Arise site. The patient may decline • Hospital discharge reports the alternate arrangement and accept a delayed appointment with the PCP. • Physical therapy reports

8 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 9 MEDICAL MANAGEMENT The scope of the Medical Management Program consists of the following components: • Primary Care Model of Care The Medical Management Program is designed to monitor the appropriateness of all medically necessary and covered services for prior care, concurrent review, and post-service care delivered to Aspirus Arise members. • Prior Authorization Determination of Medical Services • Concurrent Review Decisions The program has been developed in collaboration with Aspirus Arise contracted health care providers and the Aspirus Arise Medical Management team. Promoting optimal practice while being sensitive to the current • Post-Service Decision Determination structure of the local delivery systems is the strategy of our Medical Management Program. All components of • Complex Care Management Program the program comply with federal and state regulations and strive to meet the nationally recognized utilization • Chronic Disease Management Program standards of the National Committee for Quality Assurance (NCQA). The program is designed to make utilization decisions affecting the health care of members in a fair, impartial, and consistent manner. The main goal of the • Behavioral Health Management Program Medical Management Program is to oversee and ensure the quality of relevant care while promoting appropriate • Chiropractic Care Management Program utilization of medical services and plan resources. • Pharmacy and Specialty Drug Management Program • Emergency Services THE OBJECTIVES OF THE MEDICAL MANAGEMENT PROGRAM ARE TO: • Technology Assessment Provide a structured process to continually monitor and evaluate the delivery of health care and services to our members by: • Affirmative Statement on Incentives • Establishing system-wide health management processes across the continuum of care. • Reporting • Establishing a process for provider feedback regarding utilization. • Grievances and Appeals • Monitoring indicators to detect possible under- and over-utilization. • Radiology Benefit Management Program • Periodic auditing of denial decision timeliness. • Satisfaction with the UM Process • Conducting inter-reviewer reliability audits of all integrated care managers and the Medical Director. The Medical Management Program is supported by the following resources/tools: Improve clinical outcomes through: • Nationally published and locally developed Utilization Management Criteria • System-wide collaboration to identify, develop, and implement clinical practice guidelines and programs, • Clinical Practice Guidelines which address key health care needs of the members. • Policies and Procedures • Implementation of clear, consistent Medical Management requirements and key indicators of success. • Clinical Experts • Implementation of Behavioral Health management processes. • Literature • Development of mechanisms to measure and implement actions to improve under- and over-utilization. • External Review • Collaboration with the Quality Improvement (QI) Committee/department, Medical Director, and Manager • Definitions from the Certificate of Coverage of Medical Management to assess and implement actions to improve continuity and coordination of care. • Conference/Seminars

The Medical Management Department collects data on practitioner satisfaction with the Utilization Management Improve practitioner and member satisfaction by: process and reports this information to the Quality Improvement Committee for review and action, as they deem • Assessing practitioner and member satisfaction with Medical Management policies and procedures. necessary. • Promoting appropriate utilization of Aspirus Arise resources through efficiency of service.

Follow established quality standards by: • Complying with NCQA standards for the accreditation of Managed Care Organizations. • Measuring program performance in accordance with the Healthcare Effectiveness Data and Information Set (HEDIS) specifications.

10 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 11 MEDICAL MANAGEMENT PROGRAM MEDICAL MANAGEMENT DEFINITIONS Aspirus Arise operates under a Primary Care model of health care. The Primary Care model provides high-quality The definitions below are taken from Aspirus Arise, which may vary depending upon the type of plan. health care by increasing opportunities for continuity of care; coordinating care among multiple providers; and effectively using the services of PCPs, specialty physicians, and other providers. Experimental/Investigational/Unproven: As determined by our Corporate Medical Director, any health care service or facility that meets at least one of the following criteria: • Aspirus Arise members must select a PCP upon enrollment in the Health Plan. • It is not currently recognized as accepted medical practice; • PCPs may practice the following specialties: Family Practice, Pediatrics, General Practice, Internal Medicine, or Obstetrics/Gynecology. • It was not recognized as accepted medical practice at the time the charges were incurred; • Members have direct access to participating plan PCPs and specialists. • It has not been approved by the United States Food and Drug Administration (FDA) upon completion of Phase III clinical investigation; • Specialists may refer to another specialist upon concurrence with the member’s PCP. The member is responsible for having the PCP or specialist submit a written prior authorization request to Aspirus Arise • It is being used in a way that is not approved by the FDA or listed in the FDA-approved labeling (i.e., for all non-participating providers and tertiary care specialists/facilities. Specialists who see a member off-label use, except for off-label uses that are accepted medical practice); through prior authorization are accountable for communicating the results of the consultation and • It has not successfully completed all phases of clinical trials, unless required by law; recommended treatment to the member’s PCP. • It is based upon, or similar to, a treatment protocol used in ongoing clinical trials; • Participating Specialists performing a procedure or providing a service, which requires a prior decision, • Prevailing peer-reviewed medical literature in the United States has failed to demonstrate that it is safe are responsible for notifying Aspirus Arise and discussing the member’s care with the member’s PCP. and effective for your condition; • The PCP is responsible for assessing, directing, and coordinating the member’s need for specialty care. • There is not enough scientific evidence to demonstrate or make a convincing argument that (a) it can The Medical Management Program is developed and revised by the Medical Management Department. The measure or alter the sought-after changes to your illness or injury or (b) such measurement or alteration program is reviewed and approved annually by the Quality Improvement Committee. will affect your health outcome; or support conclusions concerning the effect of the drug, device, procedure, service, or treatment on health outcomes; The Medical Director is responsible for the key aspects of the Medical Management program, such as setting • It is associated with a Category III CPT code developed by the American Medical Association. policies, reviewing cases, and participating in a variety of Medical Management Committees and the Quality Improvement Committee meeting. The Medical Director oversees the inpatient case management program, The above list is not all-inclusive. ambulatory case management program, and the pharmacy benefit management program. The Medical Director A health care service or facility may be considered experimental/investigational/unproven even if the health makes the final decision for all medical necessity denial decisions for inpatient, concurrent, prior, and post- care provider has performed, prescribed, recommended, ordered, or approved it, or if it is the only available service care. procedure or treatment for the condition.

All activities and initiatives within Medical Management are coordinated within the framework of the Quality We have full discretionary authority to determine whether a health care service is experimental/investigational/ Improvement Program. The Medical Director is the Chair of the Quality Improvement Committee. unproven. In any dispute arising as a result of our determination, such determination will be upheld if it is based The Medical Director may consult with an appropriate board-certified specialist if a medical necessity review is on any credible evidence. If our decision is reversed, your only remedy will be our provision of benefits in outside of the Medical Director’s scope of expertise. accordance with the Policy. You will not be entitled to receive any compensatory damages, punitive damages, or attorney’s fees, or any other costs in connection therewith or as a consequence thereof. Aspirus Arise has a participating behavioral health practitioner involved in the Behavioral Health Program in conjunction with the Medical Director. His/her role is to oversee and provide professional expertise to continually References used in the evaluation include, but are not limited to: The American Cancer Society, The American improve the Behavioral Health Program. The Medical Director consults with this practitioner on an as-needed Medical Association, FDA, U.S. Department of Health & Human Services, MCG guidelines, National Library basis regarding behavioral health issues/reviews. of Medicine Search, National Institutes of Health, Pubmed (Medicine), The Hayes Directory of New Medical Technologies, Cochrane Library, National Comprehensive Cancer Network, National Guidelines Clearinghouse, and/or the American Academies or Colleges of various Physician specialties. MEDICAL MANAGEMENT CONFIDENTIALITY Member health information that is identifiable, including medical records, claims, benefits, and administrative data, obtained in connection with the performance of duties in utilization management, shall not be revealed or disclosed in any manner or under any circumstance, except to a member’s attending physician.

Information required to study and evaluate the quality of care, and/or policies or services focused on members, shall be made available only to the persons directly involved in presenting, reviewing, evaluating, or acting upon the information.

Program descriptions, manuals, forms, and all related documentation are considered proprietary business information, and shall be treated as confidential.

12 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 13 Medically Necessary: A health care service or facility that we determine to be: PRIOR AUTHORIZATION • Consistent with, and appropriate for, the diagnosis or treatment of your illness or injury; • Commonly and customarily recognized and generally accepted by the medical profession in the United WHAT IS A PRIOR AUTHORIZATION? States as appropriate and standard care for the condition being evaluated or treated; A prior authorization is the process of receiving written approval from Aspirus Arise for services or products prior to being rendered. The prior authorization is requested and submitted by the provider. Services are still subject • Substantiated by the clinical documentation; to all plan provisions including, but not limited to, medical necessity and plan exclusions. • The most appropriate and cost-effective level of care that can safely be provided to you. Appropriate and cost-effective does not necessarily mean the least expensive; When is prior authorization needed? • Proven to be useful or likely to be successful, yield additional information, or improve clinical outcome; Prior authorization is required under our HMO health plans for all non-participating practitioners/providers and • Not primarily for the convenience or preference of the covered person, his/her family, or any health care tertiary care specialists/facilities. Prior authorization is required for specialized services under our HMO and POS provider. health plans including:

A health care service or facility may not be considered medically necessary even if the health care provider has • Elective inpatient stays in a hospital or skilled nursing facility (nursing home) performed, prescribed, recommended, ordered, or approved the service, or if the service is the only available procedure or treatment for your condition. • Transplants • Durable Medical Equipment with a purchase price greater than $1,000 or rental costing more than $750 a Concurrent Care Decision: A decision by us to reduce or terminate benefits otherwise payable for a course of month, and all CPAP purchases and rentals treatment that has been approved by us or a decision with respect to a request by you to extend a course of treatment beyond the period of time or number of treatments that has been approved by us. • Home infusion • Prosthetics over $5,000 Incomplete Claim: A correctly filed claim that requires additional information including, but not limited to, medical information, coordination of benefits questionnaire, or subrogation questionnaire. • New medical or biomedical technology • New surgical methods or techniques Incorrectly Filed Claim: A claim that is filed but lacks information that enables us to determine what, if any, benefits are payable under the terms and conditions of the Policy. Examples include, but are not limited to, claims • Non-emergency ambulance transportation missing procedure codes, diagnosis, or dates of service. • Genetic studies and testing Post-Service Claim: Any claim for a benefit under the Policy that is not a pre-service claim. • Pain management procedures • Services performed as part of a research study or clinical trial Pre-Service Claim: Any claim for a benefit with respect to which the terms of the Policy condition receipt of a benefit, in whole or in part, on receiving prior authorization before obtaining medical care. • Varicose vein treatment, blepharoplasty, or any other procedure that may be considered cosmetic • Sleep studies and recommended aftercare Urgent Claim: Any pre-service claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the • Neuropsychological testing claimant or the ability of the claimant to regain maximum function or in the opinion of a physician with actual • Spinal surgery knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be • Certain pediatric vision services adequately managed without the care or treatment that is the subject of the claim. • High-dollar imaging • Drugs that require prior authorization The above is not an all-inclusive listing of services that may require prior authorization. Please refer to AspirusArise.com and access the provider tab to check on prior authorization requirements.

Before seeking medical services, members should call Aspirus Arise at 715-972-8140 to verify the prior authorization request has been approved.

A prior authorization is not required for: • Services performed by a participating provider, including a participating provider who specializes in obstetrics or gynecology, except for those services noted above or listed on the prior authorization list located on AspiursArise.com. • Emergency care or urgent care at an emergency or urgent care facility • Covered radiologist, pathologist, and anesthesiologist services at a participating facility

14 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 15 Whose responsibility is it to obtain the prior authorization? PRIOR AUTHORIZATION DETERMINATION It is ultimately the member’s responsibility to ensure the prior authorization request is submitted and approved by The Medical Management Program requires prior authorization determination of all services referred to inpatient Aspirus Arise prior to receiving services. facilities (including rehabilitation and skilled nursing facilities). Additionally, our HMO health plans require a prior authorization on all services referred to non-participating practitioners/providers, tertiary care specialist/facilities How will claims be paid if authorized care is received from a non-participating and providers, and for other select services. Our POS health plans in addition require prior authorization for other select services. The prior authorization list is available online at AspirusArise.com. provider? Maximum Allowable fee levels will apply to non-participating providers and services rendered. This means that These services may be reviewed for medical necessity, potential recommendation of an appropriate redirection to the member is responsible for any charge that exceeds the Maximum Allowable fee level for authorized services an appropriate participating practitioner/provider, and/or coordination of care/services. received from non-participating providers. • Requests may be submitted by our website portal via iExchange. If iExchange is unavailable, we will accept To obtain a paper copy of the Prior Authorization Request form, please visit AspirusArise.com. requests submitted by facsimile, phone, or mail. • All data and relevant information is obtained, including, but not limited to, medical records and communications PRIOR AUTHORIZATION PROCESS with practitioner or other consultants. • Call 877-642-0922 or visit RadMD.com. • Relevant information is reviewed using utilization management criteria as described in resources/tools section. • The ordering provider submits the clinical information to NIA. • Inpatient facility care–for example, observation, acute, rehabilitation, and/or skilled nursing care–is reviewed • Relevant information is reviewed using evidence-based criteria. prior to, or within, 24 hours of admission, and then concurrently according to accepted criteria and guidelines.

• Authorization is required for each procedure ordered. The ordering provider may request a peer-to-peer • Determinations for non-urgent authorization decisions are given to the practitioners and members via oral, discussion with a physician reviewer. written, or electronic notification within 15 calendar days of the request. Determinations for non-authorization (denials) in this category (non-urgent) are given within 15 calendar days of the request by written or electronic notification. • Determinations for urgent prior authorization decisions are given to the practitioners and members via oral, written, or electronic notification within 72 hours of the request. Determinations for non-authorization (denials) in this category (urgent) are given within 72 hours of the request via oral, written, or electronic notification. • Prior authorization decision letters for select services are sent to the member, the PCP (if applicable), the practitioner to whom the member is being referred, and the facility, if appropriate. • The Medical Director reviews all potential denials for prior care, based on medical necessity, and he or his designee makes a determination. • Denials are communicated to the practitioner and member by phone or letter. Denial letters are sent to the PCP (if applicable), then referred to practitioner, if applicable, and the member.

Written denial determination notifications include: • The specific reason for the denial. • A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based. • An offer to provide a copy of the actual benefit provision, guideline, diagnosis/treatment codes, protocol, or other similar criterion on which the denial decision was based, upon request. • A description of appeal/grievance rights, including the right to submit written comments, documentation, or other information relevant to the appeal/grievance. • An explanation of the appeal/grievance process, including the right to member representation, and time frames for deciding appeals/grievances. • For urgent prior or urgent concurrent denial, a description of the expedited appeal/grievance. • Notification that expedited external review can occur concurrently with the internal appeal process for urgent care and ongoing treatment. • Notice of the External Review Process, if applicable.

• Contact information for language assistance. 16 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 17 SPECIAL PROGRAMS/PROVIDER RESPONSIBILITY Prior authorization is required for the following services under all Aspirus Arise plans (not just those under age 19): RADIOLOGY BENEFIT MANAGEMENT A. Contact lenses for the following conditions: Aspirus Arise uses National Imaging Associates, Inc. (NIA) (niainc.com), an accredited leader in the management • Keratoconus of outpatient radiology benefits. This program is founded on evidence-based medicine. To view the NIA Matrix, • Pathological myopia please visit AspirusArise.com and click on the Radiology Authorizations section of our Resources page. • Aphakia A separate authorization number is required for each procedure ordered. • Anisometropia Note: Inpatient Emergency Department imaging studies do not require prior authorization. • Aniseiknoia • Aniridia LOW BACK PAIN SURGERY MANAGEMENT • Corneal disorders A prior authorization determination is necessary for low back surgery performed by a participating orthopedic surgeon or neurosurgeon when a regimen of optimal conservative care, as determined by Aspirus Arise, has • Post-traumatic disorders been completed. Prior authorization must be obtained prior to services being rendered. • Irregular astigmatism

Conservative care provided or directed by a non-orthopedic surgeon or neurosurgeon must consist of ALL of the B. Low-vision services including the following: following: • One comprehensive low-vision evaluation every five years • Chronic low back pain with symptoms present for at least three months; AND • Low-vision aids, including only the following: • Medical records include documentation of what functional disability is caused by the pain; AND • Spectacles • Pain is moderate to severe in nature; AND • Magnifiers • Medical records include documentation of pain severity (Oswestry Score, Pain Visual Analog Scale, or • Telescopes other validated measure); AND • Follow-up care of four visits in any five-year period • Failure of at least six weeks of conservative measures with two or more modalities including: prescription C. The following lens options and treatments: pharmaceuticals, such as non-steroidal anti-inflammatory agents, anticonvulsants, and antidepressants; • Ultraviolet protective coating physical and restorative therapies, including spinal manipulation, physical therapy with a home exercise program, and advice to stay active; chiropractic management with a home exercise program and advice • Blended segment lenses to stay active; and injection therapy (epidural steroid injection, intraarticular facet joint injection, and radio • Intermediate vision lenses frequency ablation). • Standard progressives If the symptoms require urgent medical care due to severity, the trial of conservative therapy may be waived by • Premium progressives the treating provider. • Photochromic glass lenses VISION MANAGEMENT • Plastic photosensitive lenses • Polarized lenses PEDIATRIC VISION • Standard anti-reflective coating Based on the Affordable Care Act (ACA), vision benefits are provided for some Aspirus Arise health plans. This • Premium anti-reflective coating mainly affects individuals who purchase their own insurance or who work for small employers with fewer than • Ultra anti-reflective coating 50 employees. The benefit is limited to pediatric vision care for those who are under age 19. If such a product is • Hi-index lenses purchased, the benefits are as follows: Aspirus Arise will cover either prescription eyeglasses or contact lenses Aspirus Arise contracts with Classic Optical Laboratories, Inc., to provide covered eyeglasses and eyeglass • Lens coverage is limited to one pair of single vision, conventional bifocal, or conventional trifocal lenses component parts to Aspirus Arise Members who have a vision hardware benefit. A selection of frames can be per Calendar Year (1/1 through 12/31). Replacement lenses are not covered. viewed and purchased at classicoptical.com. Aspirus Arise does not reimburse this expense. • Frame coverage is limited to one pair of frames from a selection of covered frames per Calendar Year. Through the Classic Optical Laboratories website, providers can place and track orders for covered eyeglasses, Replacement frames are not covered. verify frame availability, and make changes to selection. When ordering online, Classic Optical’s smart ordering form will only allow covered materials and frames to be ordered. • Contact lens coverage is limited to six pairs of contact lenses every three months. Daily disposable and colored lenses are not covered. Contact lenses are provided in lieu of eyeglasses. • Other lens options and treatments will only be covered if determined to be medically necessary.

18 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 19 To access these online options, providers are required to have a username and password, which can be CONCURRENT REVIEW DECISIONS requested in one of two ways: Concurrent review decisions are reviews for the extension of previously approved ongoing care. Examples • Complete and submit an online request form. To access the request form, click New User and then click include the review of inpatient care, observational stays, or ongoing ambulatory care. the Log In button. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care being provided, • Call Classic Optical Laboratories, Inc., at 888-522-2020. and supports the health care provider in coordinating a member’s care across the continuum of health care Without prior authorization, Aspirus Arise will not reimburse eyeglasses and eyeglass component parts services. not provided by the Aspirus Arise contracted vendor. Provider cannot bill the member without prior written • Inpatient concurrent review is done telephonically or via fax by Medical Management staff. acknowledgement and consent of the member. • All data and relevant information is obtained, including, but not limited to, medical records and Contact lenses, provided in lieu of eyeglasses, may be dispensed directly from an Aspirus Arise contracted communications with practitioner or other consultants. optometry/ophthalmology provider’s office. These services should be billed to Aspirus Arise in the same manner • Relevant information is reviewed using utilization management criteria as described in resources/tools as all other services provided and will be reimbursed according to your Provider Agreement. section. • Daily disposable and colored lenses are not covered. • Inpatient concurrent review is continuous for the duration of the inpatient stay. • Lenses billed with V2510-V2531 require review for medical necessity prior to reimbursement. • Urgent concurrent review decisions are made, and the practitioner notified, within 24 hours of receipt of • Prior authorization request forms can be found at AspirusArise.com. the request. Approval decisions are determined by medical management staff and given to practitioners via oral, electronic, or written notification by facility case managers or discharge planner. Denial decisions are given orally or electronically and in writing to practitioner, facility, and member by medical For more information, please call Classic Optical Laboratories at 888-522-2020 available Monday–Friday, management staff. 8 a.m. to 6 p.m. • Concurrent review may include staffing with health care professional and/or home visits with home health care agencies. • Requests to extend a course of previously approved treatment that does not meet the definition of urgent care–for example, prior or post-service and the appropriate time frames followed–will be handled as a new request. • The Medical Director reviews all potential denial decisions based on medical necessity related to concurrent review. A determination will be made by the Medical Director or their designee.

20 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 21 POST-SERVICE DETERMINATION CASE MANAGEMENT Post-service decisions are determinations of medical necessity and/or appropriate level of care when the care Case Management provides a collaborative process that assesses, plans, implements, coordinates, monitors, has already been received, for example, retrospective review. and evaluates the options and services required to meet a member’s health needs, using communications and available resources to promote quality, cost-effective outcomes. Notification of post-service decision denial determinations are given electronically or in writing to the practitioner and member. All data and relevant information is obtained. Relevant information is reviewed using utilization Members may be selected for Case Management based on criteria that address various demographics, management criteria as described in the resources/tools section. including, but not limited to: age, psychosocial and economic status, support systems, diagnoses, and/or complexity of treatment plan. The Medical Director reviews all potential post-service denial decisions based on medical necessity or appropriate level of care, and a determination is made by the Director or his/her designee. Cases may be identified through utilization reports, health promotion activities, claim activity reports, complicated inpatient admissions, and practitioner, provider, or member prior authorizations and referrals for Case Management.

Case Management is conducted in collaboration with the practitioner, supports the practitioner/member relationship, and promotes adherence to an established treatment plan. Members are notified of their selection for case management.

COMPLEX CARE MANAGEMENT PROGRAM Complex Care Management is the coordination of care and services provided to members who have experienced a critical event or have a diagnosis that requires the extensive use of resources and assistance navigating the system to facilitate the appropriate delivery of care and services. The Complex Care Management Program is an opt-in program. This allows all eligible members to choose whether they wish to participate in the program.

1. Evidence used to develop the Complex Care Management Program Complex care management was developed and based upon MCG guidelines and/or nationally recog- nized evidence-based clinical guidelines.

2. Criteria for identifying members who are eligible for the program Currently Aspirus Arise uses the following data sources to identify members for care management:

• Claims or encounter data that utilize a monthly basic stop-loss summary report for members with claims exceeding $100,000, as well as a monthly top-100 utilizer by dollar amount report. • Hospital discharge data: Utilization management of hospital certification and concurrent review for all members allow the opportunity to evaluate the need for coordination of services for members with complex conditions and helps them access needed resources. • Pharmacy data: Ability to collect information on categories such as high-dollar expenditure, therapeutic drug category, and high pharmacy utilization. • Data obtained through utilization management: The prior authorization process affords the ability to identify members with complex conditions and evaluate the need for assistance with coordination of care. • Conditions, diseases, or high-risk groups most frequently managed: Transplants, trauma, and chronic illnesses that result in high utilization. • Data supplied by purchasers, if applicable. • Data supplied by member or caregiver: Ability to pull system reports to identify the referral source on prior authorizations as well as inpatient authorizations. • Data supplied by practitioners: System reports available to identify the referral sources on prior authorizations and inpatient authorizations.

22 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 23 3. Services offered to members CHRONIC DISEASE MANAGEMENT PROGRAM • During the Complex Care Management process, the nurse case manager performs a detailed assessment of the member’s health status specific to identified health conditions and likely Aspirus Arise offers a Chronic Disease Management Program at no additional cost to the patient. The program is co-morbidities, including a clinical history. designed to offer management to members who have been diagnosed with certain chronic conditions. We have • An evaluation of available benefits and review of certificate benefits, as well as assistance with programs for the following chronic diseases: direction to in-network providers. • Hypertension • Facilitation of member referrals to resources, as well as follow-up as needed as to whether the member acted on these referrals. • Diabetes • Assistance with available community resources when appropriate, such as referrals to EAP, Disease • Congestive Heart Failure Management, etc. Members who meet the eligibility criteria to be enrolled in our programs receive educational materials and • Interaction with providers, including the member’s PCP, specialist, DME/infusion company, etc., based newsletters via mail or email attachments to help self-manage and avoid worsening their conditions. Members on the member’s current needs. also have access to our online tools and resources available on our website at AspirusArise.com. Members who • Development and communication of a member self-management plan with the identification of goals qualify for interventions receive: and any barriers to meeting these goals. A schedule for communication with members is created during the CCM process. • Highly trained case managers to answer questions and provide guidance

4. Defined program goals • Case plan follow-up and reminders The purpose of the complex care management program at Aspirus Arise is to help members regain • Medication management optimum health or improved functional capability in the most appropriate and cost-effective care setting to meet their needs. • Referral to wellness coaching, if needed

Aspirus Arise has defined two program goals to measure the achievement of its complex care • Self-management tools management program: • Screening for depression • Achieve member satisfaction of 80% or greater as reflected in the annual member satisfaction survey. • Identify improvement measures to increase its effectiveness. This is measured in two ways: For referrals, additional program information, or questions, please contact the Aspirus Arise Disease Management Team at 715-843-1061 or email at [email protected]. • An annual cost analysis of this population reflected by claims costs per member per month. • An annual analysis of readmission data for this population. • Discharge Planner referral: The nurse case manager and discharge planner evaluate the member’s discharge needs for continued services and determine if there is a need for care management intervention. • Based on the results of these measures, interventions and measurement would be implemented if applicable. • UM referral: Aspirus Arise requires prior authorization for tertiary and non-participating providers, as well as home health care, hospice, durable medical equipment, skilled nursing facility, transplants, prosthetics, inpatient hospitalization, new medical or biomedical technology, new surgical methods or techniques, non- For referrals, questions, or additional program information, please contact the Aspirus Arise Complex Care emergency ambulance transportation, imaging services, and specialty drug management. Through this Management Team at 715-843-1061 or email at [email protected]. process, members with multiple or complex conditions can be identified for possible case management intervention.

• Member or caregiver self-referral and practitioner referral: members, UM department hospital staff, family members, and/or practitioners may initiate care management services.

24 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 25 BEHAVIORAL HEALTH MANAGEMENT Denials are communicated to the practitioner, member, and PCP if applicable, by phone or letter. Denial letters are sent to the practitioner, member, and PCP. The Behavioral Health Management program provides a mechanism to optimize use of the member’s health care benefits while providing high-quality integrated health care to members with mental and/or substance abuse All written denial determination notifications include: disorders. Services include, but are not limited to: • The specific reason for the denial. • Inpatient and concurrent authorization • A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision • Prior request review is based. • Post-service review • An offer to provide a copy of the actual benefit provision, guideline, protocol, diagnosis/treatment codes, or other similar criterion on which the denial decision was based, upon request. • Case management • A description of appeal/grievance rights, including the right to submit written comments, documentation, or other information relevant to the appeal/grievance. The Behavioral Health Management program does not require triage or prior authorization prior to a member contacting or making an appointment with a behavioral health practitioner. It is the practitioner’s responsibility to • An explanation of the appeal/grievance process, including the right to member representation and time provide a treatment plan for Aspirus Arise services. frames for deciding appeals/grievances. • A description of the expedited appeal/grievance process for urgent prior or urgent concurrent denial. The Behavioral Health Management program requires prior authorization determination of all services referred to inpatient facilities (including transitional). In addition, HMO health plans require a prior authorization on • Notice of the External Review Process, if applicable. services provided by non-participating practitioners or providers. These services may be reviewed for medical • Notification that expedited external review can occur concurrently with the internal appeal process for necessity, potential recommendation of an appropriate Aspirus Arise practitioner, and/or coordination of care/ urgent care and ongoing treatment. services. • Contact information for language assistance. BEHAVIORAL HEALTH MANAGEMENT PROCESS Concurrent review decisions are reviews for the extension of previously approved ongoing care. Examples • Requests may be submitted by facsimile, phone, or mail. include the review of inpatient care as it is occurring or ongoing ambulatory care. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care being provided and supports the health care • All data and relevant information is obtained, including, but not limited to, medical records, and provider in coordinating a member’s care across the continuum of health care services. communications with practitioner or other consultants, excluding psychotherapy notes. • Inpatient concurrent review is done telephonically or via fax by Medical Management staff. • Relevant information is reviewed using utilization management criteria as described in resources/tools • All data and relevant information is obtained, including, but not limited to, medical records and section. communications with practitioner or other consultants. • Inpatient facility care (i.e., observation, acute, and rehabilitation) is reviewed prior to, or within, 24 hours of • Relevant information is reviewed using utilization management criteria as described in resources/tools admission, and then concurrently according to accepted criteria and guidelines. section. • Determinations for non-urgent prior approval decisions are given to the practitioners and members via • Inpatient concurrent review is continuous for the duration of the inpatient stay. oral, written, or electronic notification within 15 calendar days of the request. Determinations for non- • Urgent concurrent review decisions are made, and the practitioner notified, within 24 hours of receipt of authorization (denials) in this category (non-urgent) are given within 15 calendar days of the request by the request. Approval decisions are determined by Medical Management staff and given to practitioners written or electronic notification. via oral, electronic, or written notification by facility case managers or discharge planner. Denial decisions are given orally or electronically and in writing to practitioner, facility, and member by Medical • Determinations for urgent prior approval decisions are given to the practitioners and members, via oral, Management staff. written, or electronic notification within 72 hours of the request. Determinations for non-authorization (denials) in this category (urgent) are given within 72 hours of the request via oral, written, or electronic • Concurrent review may include staffing with health care professional and/or home visits with home health notification. care agencies. • Requests to extend coverage for a course of treatment previously approved will be handled as a new • Prior approval decision letters for select services are sent to the member, the PCP (if applicable), the request, and the appropriate time frames followed. However, if the request is for urgent care, the urgent practitioner to whom the member is being referred, and the facility, if appropriate. care deadlines apply. • The Medical Director reviews all potential denials for inpatient and ambulatory care, based on medical • The Medical Director reviews all potential denial decisions based on medical necessity, related to necessity, and a determination is made by him, or in conjunction with consultation of the Associate concurrent review, and a determination made by him, or in conjunction with consultation of the Associate Director of Behavioral Health. Director of Behavioral Health.

26 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 27 Post-service decisions are determinations of medical necessity and/or appropriate level of care after the care CHIROPRACTIC CARE MANAGEMENT already has been received, for example, retrospective review. Notification of post-service decision denial determinations is given electronically or in written form to the practitioner and member, for example, a claim Chiropractors have limited access to specialty imaging services and laboratory testing with appropriate received for out-of-area care that was not prior authorized. The Medical Director reviews all potential post-service authorization. Aspirus Arise chiropractic services are monitored and reviewed by the Director of Chiropractic denial decisions based on medical necessity or appropriate level of care or the Director’s designee makes a Services. The Director of Chiropractic Services works collaboratively with the Medical Director and Medical determination. Management in accordance with appropriate state statute and is able to make chiropractic clinical management decisions autonomously. Aspirus Arise chiropractors are encouraged to collaborate directly with primary care Members may be selected for Behavioral Health Case Management based on criteria that address various and specialty medical services to facilitate the most cost-effective and expeditious authorizations within the demographics, including, but not limited to, age, psychosocial and economic status, support systems, diagnoses, network. and complexity of treatment plan. These services will be reviewed for medical necessity and/or coordination of care/services: Cases may be identified through utilization reports, health promotion activities, claim activity reports, complicated inpatient admissions, and practitioner, provider, or member prior authorization. Case Management • Requests can be submitted by facsimile, phone, mail, or iExchange. is conducted in collaboration with the physician, supports the physician/member relationship, and promotes • All data and relevant information is obtained, including, but not limited to, medical records and adherence to an established treatment plan. Members are notified of their selection for case management. communications with practitioner or other consultants. • Relevant information is reviewed using utilization management criteria as described in resources/tools section. • Determinations for non-urgent prior approval decisions are given to the practitioner and member via oral, written, or electronic notification within 15 calendar days of the request. Determinations for non- authorizations (denials) in this category (non-urgent) are given within 15 calendar days of the request via oral, written, or electronic notification. • Determinations for urgent prior approval decisions are given to the practitioner and member via oral, written, or electronic notification within 72 hours of the request. Determinations for non-authorization (denials) in this category (urgent) are given within 72 hours of the request via oral, written, or electronic notification. • Prior authorization decision letters for chiropractic services are sent to the member and to the practitioner who is providing the requested services. • Requests to extend a previously approved course of treatment that does not meet the definition of urgent care will be handled as a new request, and the appropriate timeframes followed. • The Director of Chiropractic Services and a determination made by him or his designee reviews all potential denial decisions based on medical necessity related to concurrent review.

All written denial determination notification includes: • The specific reason for the denial. • A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based. • An offer to provide a copy of the actual benefit provision, guideline, diagnosis/treatment codes, protocol, or other similar criterion on which the denial decision was based, upon request. • A description of appeal/grievance rights, including the right to submit written comments, documentation, or other information relevant to the appeal/grievance. • An explanation of the appeal/grievance process including the right to member representation and time frames for deciding appeals/grievances. • Notice of the External Review Process, if applicable. • Notification that expedited external review can occur concurrently with the internal appeal process for urgent care and ongoing treatment. • Contact information for language assistance.

Post-service decisions are determinations of medical necessity and/or appropriate level of care when the care has already been received for example, retrospective review. Notification of post-service decision denial determinations is given electronically or in writing to the practitioner and member.

28 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 29 PHARMACY MANAGEMENT COVERED DRUGS Aspirus Arise offers a comprehensive prescription drug program that includes a suitable array of products that In general, the prescription drug benefit covers FDA-approved drugs that, by law, require a prescription from allow practitioners to appropriately manage their patients. a licensed practitioner, and, by certificate, are medically necessary. Insulin and disposable diabetic supplies– which, by law, may not require a prescription–are also eligible for coverage. However, to be eligible for coverage, Aspirus Arise’s Director of Pharmacy and Chief Medical Officer provide program leadership. Aspirus Arise’s Aspirus Arise requires that they must be medically necessary and a prescription must be written. Pharmacy Program is overseen by the Quality Improvement Committee and is administered by Express Scripts. The Pharmacy Management Program is reviewed annually, at a minimum, and updated as needed. Changes to COMMONLY EXCLUDED DRUGS the program are communicated to practitioners via direct mail, email, and/or the internet. • Drugs to treat toenail or fingernail fungus PHARMACY BENEFITS • Drugs used for fertility or whose primary use is fertility Aspirus Arise contracts with Express Scripts to process pharmacy claims. Express Scripts is also Aspirus Arise’s • Compounded medications that do not contain at least one legend ingredient exclusive provider of home delivery pharmacy services. • Non-legend drugs (those available without a prescription) Please note: Not all members receive their drug benefits through Aspirus Arise. Please verify drug benefits by • Investigational drugs checking the member’s ID card. • Drugs from non-participating pharmacies, except for emergencies outside of the geographical service area Aspirus Arise uses a formulary designed and maintained by Express Scripts. It can be accessed via AspirusArise.com. Physicians can use a formulary, or a list of drugs, to identify which drugs offer the greatest • Replacement medications resulting from loss, theft, or damage overall value. It does not guarantee coverage and should be only used as a guide. • Any drug used for weight control The following is a list of common reasons a prescription will not process at a pharmacy. For a specific situation, • Any drug used for cosmetic purposes, or whose use is not medically necessary please call 800-332-3297. • Any specialty compounded hormone prescription • A limited number of formulary drugs must meet specific criteria for use before they will be considered • A covered drug related to a non-covered medical encounter a covered benefit. The practitioner may be required to convey to Express Scripts certain medical • Anabolic steroids, unless prior authorization is obtained information to request prior authorization. This can be done by calling 800-417-8164. The practitioner’s • Any medical supply not noted elsewhere office will then be notified as to whether or not the drug authorization is approved. • Injectable medications except as determined by Aspirus Arise or its designee • If a drug prior authorization request has not been requested, or the authorization has been denied, the pharmacy will not be able to file the drug claim under the member’s prescription benefit, and the member • Drugs used for impotence, or for which the primary use is impotence, or to enhance sexual activity, will be responsible for the entire cost of the prescription. except for Viagra • Some drugs, like migraine medications, are not taken every day. Therefore, the amount per copay is • Any drug without the proper plan authorization as outlined in the certificate limited to what typically would be needed for that condition. If the pharmacy is submitting a quantity larger than what is allowed, the prescription will not process. MEMBER GIVEN GENERIC DRUG WHEN BRAND NAME PRESCRIBED • Retail pharmacies are only able to dispense up to a continuous 30-day supply of medication. The When an FDA-approved generic alternative to a brand name drug is available, Aspirus Arise may limit coverage prescription will not process if the pharmacy is trying to dispense greater than this amount. to the generic form of a drug. The active ingredient(s) in a generic drug are chemically identical to their brand name counterparts. Pharmacists will dispense the generic medication in this situation. If the member requests MEMBER RESPONSIBILITY DETERMINATION the brand, they will be responsible for the appropriate copay/coinsurance plus the difference in cost between the brand and the generic. The most common pharmacy benefit is tiered. The copay/coinsurance levels vary based upon the tiering of the drug prescribed.

• Generic drugs are on the formulary and carry the lowest responsibility (first tier) • Brand name drugs that are on the formulary are the middle responsibility (second tier) • Brand name drugs that are not on the formulary carry the highest responsibility (third tier) Some plans have a fourth tier that is unique for specialty drugs. In this situation, specialty drugs, whether brand name or generic/formulary, or non-formulary, are subject to a specific cost sharing.

Note: High-deductible health plans have a combined medical and pharmacy benefit, which does not incorporate a tiered benefit.

30 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 31 DRUG PRIOR AUTHORIZATION TECHNOLOGY AND INCENTIVES Visit AspirusArise.com to view the drug prior authorization list. TECHNOLOGY ASSESSMENT HOW TO REQUEST DRUG PRIOR AUTHORIZATION Aspirus Arise has a policy that establishes procedures for the assessment of new technologies and new applications of existing technologies, including, but not limited to, medical and surgical procedures, • The list identifies who performs the review for specific drugs: Diplomat, Express Scripts, or Aspirus Arise. pharmaceuticals, and devices. Aspirus Arise has procedures and criteria for the submission and selection of a • Aspirus Arise has engaged Diplomat to assist with specialty drug management. Aspirus Arise requires technology under consideration. The roles of the Medical Policy Committee, Quality Improvement Committee, an approved prior authorization for most specialty drugs. On behalf of Aspirus Arise, Diplomat and Benefits Committee are defined to address whether or not the technology will be incorporated as an Aspirus reviews specialty drug requests for all service settings (e.g., outpatient, office, home) except inpatient. Arise benefit. Treatments subject to this program include, but are not limited to, specialty drugs for cancer, multiple sclerosis, and inflammatory conditions. AFFIRMATIVE STATEMENT ON INCENTIVES • Coverage policies for specialty drugs can be found at: Utilization management decision-making at Aspirus Arise is based only on appropriateness of care and existence http://diplomat.is/files/pdfs/PA_utilizationcriteria.pdf of coverage. Aspirus Arise does not specifically reward practitioners or other individuals for issuing denials of • Specialty drugs dispensed without proper authorization will not be reimbursed. coverage or service. No financial incentive is given to encourage decisions that result in underutilization. • In each situation, when a provider is seeking a review, please call the correct company (phone numbers below). Phone calls are preferred to efficiently identify the necessary clinical information to complete the review. • Diplomat (Specialty Drugs) 888-515-1357 • Express Scripts (Traditional Drugs) 800-753-2851 • Aspirus Arise (Drugs most policies do not cover, e.g., fertility) 715-972-8140 • When calling, please have available the patient’s Aspirus Arise ID number (from his/her card), date of birth, and access to the medical record. • You will be asked questions related to diagnosis, medication history, and other relevant clinical information. • The provider’s office should contact the member regarding the decision.

32 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 33 RESOURCES/TOOLS CLINICAL EXPERTS In addition to the Medical Director, Medical Management has access to clinical experts through Aspirus Arise’s UTILIZATION REVIEW CRITERIA practitioner panel, many of whom participate on various committees at Aspirus Arise and are board certified. Medical necessity decision-making requires the consistent application of utilization criteria. Aspirus Arise Aspirus Arise also purchases a variety of expert services through external vendors. uses both nationally published and locally developed criteria. Input from Aspirus Arise practitioners, including The Medical Director or designee consults with board-certified practitioners, when appropriate, to accommodate department chairs and other practitioners, is solicited. The Medical Policy Committee reviews criteria for the medical necessity review process. Access is also provided to external review agencies that employ board- appropriateness and makes recommendations for approval to the Quality Improvement Committee. The Quality certified practitioners for case review. Improvement Committee makes the final decision to approve criteria for use. Decision-making criteria are reviewed and updated annually or more frequently if significant changes in standards of care are identified. CLINICAL PRACTICE GUIDELINES Criteria are applied consistently to medical necessity decisions, and in a manner that is responsive to individual Clinical Practice Guidelines are designed to assist physicians by providing an analytical framework for the member needs and the characteristics of the local delivery system. At least annually, Aspirus Arise evaluates the evaluation and treatment of patients with specific clinical circumstances. They are not intended to replace consistency with which Case Management Specialists and the Medical Director apply the criteria when making professional judgment or to establish a protocol for patients with a particular condition. A guideline will rarely decisions. A corrective action plan is developed if significant variation is found. establish the only approach to a problem. Practice guidelines have a sound scientific basis, such as clinical literature and expert consensus. The selected guidelines are from nationally recognized organizations and have The following criteria used by Aspirus Arise include, but are not limited to: been reviewed by Advisory Committees. • MCG guidelines for Inpatient and Surgical Care, Ambulatory Care (Medical and Behavioral Health and Practice guidelines are not intended to determine plan benefits and do not reflect coverage. Benefit coverage Chiropractic Care), General Recovery, and Chronic Care varies by group and should be verified prior to services being rendered. • Hayes Medical Technology Directory As a condition of accreditation, The National Committee for Quality Assurance (NCQA), which is the accrediting • Cochrane Collaborative Systemic Reviews, and CCGPP for Low Back Pain (for Chiropractic Care) organization for managed care plans, requires the adoption of Clinical Practice Guidelines. In addition, guidelines • DSM-Criteria (Behavioral Health) are helpful in demonstrating the quality of care we provide to those who purchase our services. • Medical Policy Committee Decisions (Coverage Policy Bulletins) Clinical Practice Guidelines adopted by Aspirus Arise may easily be accessed by visiting the Aspirus Arise • Pharmacy Benefit Criteria (includes clinical data, reference materials, expert physician opinion, FDA- website at AspirusArise.com. Another valuable resource for accessing nationally recognized and supported approved labeling, and/or cost-benefit information) Clinical Practice Guidelines is the National Guideline Clearinghouse produced by the Agency for Healthcare • APTA Guide to Physical Therapy Practice Research and Quality (AHRQ). This site is available at guideline.gov/index. • National Comprehensive Cancer Network (NCCN) • National Guideline Clearinghouse produced by the Agency for Healthcare Research and Quality (AHRQ)

Aspirus Arise practitioners/providers may review Medical Management criteria. A copy of specific criteria used for decision-making is provided to an Aspirus Arise practitioner upon request. This copy is for the practitioner’s own use and may not be released to others without permission from the Aspirus Arise. Aspirus Arise practitioners are informed how to request criteria during practitioner orientation and in the provider newsletter.

The Medical Director or a designee will attempt to contact the attending practitioner prior to making an inpatient medical necessity denial. The Medical Director’s phone number is provided to the ordering practitioner when a medical necessity denial is made for outpatient care.

POLICIES/PROCEDURES Policies are statements that define how Aspirus Arise intends to administer its Medical Management program. Medical Management policies are presented to the Quality Improvement Committee for review. Each department is responsible for development of procedures for functions within its responsibility.

34 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 35 MEDICAL POLICY GUIDELINES QUALITY IMPROVEMENT PROGRAM Practitioners and other providers may obtain the medical policy guidelines used for making medical coverage The Quality Improvement Program is the framework for Aspirus Arise processes and continuous monitoring of determinations for an Aspirus Arise member under their care. Our medical policy guidelines are based on sound our performance according to, or in comparison with, objective, measurable performance standards. The Quality medical and clinical evidence and adopted with the involvement of appropriate medical specialists. If you have Improvement Program ensures identification and evaluation of issues that impact our ability to continually better received a determination and would like to review the medical policy guidelines used in that determination, you our performance and improve the health care and administrative services we provide to our customers. may contact us. The scope of the Quality Improvement Program includes all aspects of services provided by health plan To obtain medical policy guidelines for a specific subject through the Medical Management Department, please practitioners, providers, and staff. Aspirus Arise arranges for the provision of comprehensive health care delivery submit your request via phone, fax, or in writing to: through a network of primary care and specialty practitioners, behavioral health practitioners and clinicians, ancillary care providers, hospitals, and other health care facilities. The scope of the Quality Improvement Aspirus Arise Program encompasses all care delivered by these practitioners and providers. All Aspirus Arise departments Attn: Medical Management Department participate in the Quality Improvement Program. All components of the process are interrelated. The review and P.O. Box 11625 evaluation of the components shall be directed by the Quality Improvement Committee and is initiated at the end Green Bay, WI 54307-1625 of each calendar year. Phone: 920-490-6901 The scope of the Quality Improvement Program incorporates components as outlined below. A description of Fax: 920-490-6943 each aspect is found in the Program Components section that follows:

Note: If applicable, please include the patient name and member number along with the subject (procedure/ • Regulatory and professional compliance service/treatment) for which you are requesting the medical policy guidelines. The medical policy guidelines are • Credentialing and re-credentialing an informational resource and not an authorization, an explanation of benefits, or a contract to provide benefits. • Medical management By following the medical policy guidelines, payment of health insurance benefits is not guaranteed. • Behavioral health care Receipt of benefits is subject to satisfaction of all terms and conditions of the member’s contract in effect at the • Chronic disease management time services are rendered. Medical technology is constantly changing, and we reserve the right to review and update our medical policy guidelines as necessary. • Pharmacy management • Quality of care and service • Member diversity • Patient safety Aspirus Arise is dedicated to delivering high-quality services to members. The following goals are major areas of focus or priority.

The objectives include the major plan-wide initiatives that will be undertaken to ensure achievement of each goal. Our guiding principle is to provide services with the following characteristics outlined by the Institute of Medicine:

• Safe • Timely • Effective • Efficient • Patient/member-centered • Equitable

STRUCTURE The structure and resources needed to achieve the goals of the Quality Improvement (QI) Program are reviewed at least annually through the Quality Improvement Committee.

36 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 37 URGENT AND EMERGENT CARE Emergency Room and Urgent Care Coverage–College Students • In the event of a medical emergency, the member is covered regardless of where medical care CONVENIENT CARE CLINIC is received. A medical clinic that: (1) is located in a retail store, supermarket, pharmacy, or other non-traditional, convenient, • After receiving emergency care, the member should call Aspirus Arise and their PCP on the following and accessible setting; and (2) provides covered health care services performed by nurse practitioners, physician business day or when they are able. assistants, or physicians acting within the scope of their respective licenses. • If the member is admitted to the hospital, the member should call Aspirus Arise within two days of URGENT CARE the admission. Care received for an illness or injury with symptoms of sudden or recent onset that require medical care the • If the member is away at college and a medical problem develops, the member should call his/her PCP same day. first. If the PCP cannot handle the member’s problem, and the member has an HMO health plan, the PCP should refer the member to a participating provider or initiate a prior authorization for services from a EMERGENCY MEDICAL CARE non-participating provider. Prior authorizations must be approved by Aspirus Arise prior to the member receiving services on a non-emergent basis. If the PCP cannot handle the member’s problem and the Health care services to treat your medical emergency. member has a POS health plan, the PCP should refer the member to the college’s health center, a local physician’s office, or an urgent care center. MEDICAL EMERGENCY A medical condition involving acute and abnormal symptoms of such severity (including severe pain) that a • If additional services are needed, the member will need a prior authorization from their PCP and approval prudent and sensible person who possesses an average knowledge of health and medicine would reasonably from Aspirus Arise’s Medical Director if covered by a HMO health plan. The member may need to return conclude that a lack of immediate medical attention will likely result in any of the following: home to receive treatment from a participating provider. • Serious jeopardy to a person’s health or, with respect to a pregnant woman, serious jeopardy to the • If the member requires ongoing medical care, the member will need a prior authorization from their PCP health of the woman or her unborn child; and approval from Aspirus Arise’s Medical Director if covered by a HMO health plan. • Serious impairment to a person’s bodily functions; or • Some out-of-area medical facilities not in Aspirus Arise’s participating provider network may require the • Serious dysfunction of one or more of a person’s body organs or parts. member to pay for their care at the time it is given. To arrange for reimbursement, send itemized bills and proof of payment within 90 days to:

EMERGENCY ROOM AND URGENT CARE COVERAGE Aspirus Arise In the event of a medical emergency, hospital care is covered wherever it is received. However, if a member is P.O. Box 21684 admitted, Aspirus Arise and the PCP must be notified within 48 hours of being medically able. Eagan, MN 55121

When urgent care is needed for a non-life-threatening illness or injury, members should contact their PCP prior to • The member will be responsible for out-of-area charges that exceed the maximum allowable fee. Routine seeking care for direction to the appropriate medical facility. care should be received from a participating PCP when the member is in Aspirus Arise’s service area. Aspirus Arise provides, arranges, or otherwise facilitates needed emergency services or instructs the members to call 911. Aspirus Arise will not deny coverage for emergency services for a member without prior authorization when:

• Such care is received to screen and stabilize the member where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. • An authorized representative, acting for the organization, has authorized the provision of emergency services. Aspirus Arise will provide coverage for emergency services rendered during the treatment of an emergency medical condition by a non-participating provider as though a participating provider provided the services. Aspirus Arise will also provide coverage if the enrollee cannot reasonably reach a participating provider, or as a result of the emergency is admitted for inpatient care subject to any restriction, which may govern payment to a participating provider for emergency services.

Aspirus Arise shall pay the non-participating provider at the rate the insurer pays a participating provider after applying any copayments, coinsurance, deductibles, or other cost-sharing provisions that apply to participating providers.

38 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 39 TELEMEDICINE MEMBER RIGHTS AND RESPONSIBILITIES The Member Rights and Responsibilities listed below set the framework for cooperation among covered persons, TELEMEDICINE (also referred to as telehealth) practitioners, and Aspirus Arise. The delivery of clinical health care services via telecommunications technologies, including, but not limited to, telephone, email, and interactive audio and video conferencing. Telemedicine does not include teleradiology. MEMBER RIGHTS Telemedicine services provided by a health care provider at a distant site to a covered person at an originating • You have the right to be treated with respect and recognition of your dignity and right to privacy. site via interactive audio-visual telecommunication. The originating site and the distant site must be: • You have the right to a candid discussion of appropriate or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage. • A physician’s office or the office of another health care provider such as a nurse practitioner, physician assistant, certified nurse-midwife, or psychologist; • You have the right to participate with practitioners in making decisions about your health care. • A convenient care clinic; • You have the right to receive information about us, our services, our network of health care practitioners and providers, and your rights and responsibilities. • A hospital; or • You have the right to voice complaints or appeals about us or the care we provide. • A skilled nursing facility. • You have the right to make recommendations regarding the members’ rights and responsibilities policies. Interactive audio-visual telecommunication is telecommunication that allows medical information to be communicated in real-time via interactive audio and video communications. The real-time audio and video communication is between the patient and a distant physician or health care provider furnishing the health care MEMBER RESPONSIBILITIES services. The patient must be present and participating throughout the communication. Telephone calls do not • You have the responsibility to supply information (to the extent possible) that we and our practitioners qualify as interactive audio-visual telecommunication because they are non-face-to-face medical discussions that and providers need in order to provide care. do not include direct, in-person contact between the patient and the health care provider. • You have the responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible. The following services are not considered telemedicine: • You have the responsibility to follow the treatment plan and instructions for care that have been agreed • Telemedicine services that do not include direct, in-person contact between the health care provider and on with your practitioners. the covered person. • Telephone evaluation and management services. • Transmission fees. • Website charges for online patient education material. • Online medical evaluations.

TELEHEALTH SERVICES FROM TELADOC® Phone and internet consultations are available by our approved telehealth board-certified physicians. Telehealth services from Teladoc® are used to treat minor health conditions, 24/7/365. For more information, visit Teladoc.com, call 800-Teladoc, or call the Customer Service phone number listed on your ID card.

40 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 41 MEMBER GRIEVANCE PROCEDURES CLAIMS PROCEDURES This section includes the appeal rights and the grievance procedure for covered persons of plans that are governed by the Employee Retirement Income Security Act of 1974 (ERISA) and the ACA (45 CFR 147.136). ELECTRONIC CLAIM SUBMISSIONS Members of ERISA plans have the right to file a civil action under Section 502 (a) of ERISA if a health plan fails to Aspirus Arise strongly recommends submitting claims electronically in order to expedite claim processing. This establish or follow claims procedures, or after all appeals outlined in this section have been completed. submission format is available for situations in which Aspirus Arise is the primary as well as the secondary carrier.

A grievance is any dissatisfaction with the administration, claims practices, or provision of services by Aspirus The Electronic Data Interchange (EDI) department has a dedicated team whose primary function is to consult and Arise that is expressed in writing to Aspirus Arise, by, or on behalf of, a covered person. The Grievance assist providers with the EDI process. Our team is experienced in dealing with a variety of provider specialties, Committee is composed of Aspirus Arise representatives, including a clinical representative and an enrollee. The billing services, and software vendors. Committee convenes every other week to review grievances. If you currently send your claims through ClaimsNet clearinghouse, you may continue to do so, and ClaimsNet Any covered person who files a grievance will be notified of their right to appear in person before the Grievance will forward them to Aspirus Arise. Committee. The covered person, or his/her authorized representative, may present written or oral information If you will be submitting your claims through an existing WPS EDI Trading Partner (i.e., clearinghouse) who has an and ask any questions relating to the grievance. Aspirus Arise will send the covered person written notice of established Submitter ID on our WPS Trading Partner System, you may continue to use the same Submitter ID for the time and place the covered person may appear before the Grievance Committee at least seven calendar Aspirus Arise business, or you may elect to receive a new Submitter ID. days prior to the appearance date. Following a thorough review of the case, the grievance committee votes on the resolution. A resolution letter is sent within 10 calendar days. Grievances are generally resolved within 30 If you prefer to submit EDI claims directly to WPS (without using a clearinghouse), you will need to complete calendar days, although there are a few plans that allow the covered person to give permission for a 30-day a self-registration process on the WPS Trading Partner System (WTPS) to prepare for transaction testing and extension. If the person’s medical condition warrants, the grievance may be expedited and resolved within 72 production claim submission. WTPS is located at https://corpws.wpsic.com/apps/wtps-web/unauth/wtps.do. hours. Providers will be required to complete an EDI enrollment agreement prior to submission of Aspirus Arise EDI INDEPENDENT REVIEW transactions to WPS. If you have elected to use a clearinghouse to submit your claims, you will still need to complete the EDI provider agreement. Once we have processed your agreement, we will contact you and The covered person, or their authorized representative, may request and obtain an independent review of an your clearinghouse (if this is your chosen option) with approval to begin submitting test or production files. It is adverse determination, including an experimental treatment determination by calling 800-332-3297. normally not required to test when submitting through an approved clearinghouse. The agreement can be found on the WPS EDI webpage at wpsic.com/edi/tools.shtml. RECONSIDERATIONS In addition, a practitioner has the opportunity to appeal an adverse determination (denial) by submitting any CONTACT EDI additional information orally and/or in writing with a request for reconsideration. Providers interested in becoming an EDI trading partner with Aspirus Arise should call our EDI Marketing staff at 800-782-2680 or visit the EDI section of the Aspirus Arise website.

PAPER CLAIM SUBMISSION If you choose to submit paper claims, the claim must be submitted using industry-standard formats, on industry standard forms, using the required specific code set as promulgated by HIPAA. The claim submission must communicate all of the following required elements to ensure accurate and timely claim payment:

§ Who was treated and why § Services provided § Amount billed for those services § Where those services were rendered § Who rendered those services The above data is also essential for state, national, and accrediting body reporting requirements.

CLAIM SUBMISSION Paper claims should be submitted to the following address: Aspirus Arise P.O. Box 21684 Eagan, MN 55121

42 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 43 CLAIM EDITING (CES) Fee Schedule Reimbursement Aspirus Arise uses Clinical Editing Software (CES) software to automatically review claim submissions for · 100% of the fee schedule amount for the costliest endoscopy CPT (based on the fee schedule, not the appropriate claim coding. This includes edits for procedures that are age-specific, bundling/unbundling, global billed amount) billing and follow-up services, and thresholds for billed units. CES reviews may result in an adjustment of the claim and/or payment as a result of the rules contained within the CES software. · For each less costly endoscopy CPT, reimbursement will be calculated by taking the fee schedule amount for each less costly endoscopy, less the fee schedule amount of the base code for the corresponding Aspirus Arise provides an online tool for providers to simulate code combinations and the capability to view edit endoscopy family results and rationale. Providers are able to enter procedure codes, modifiers, diagnosis codes, date of service, patient gender, date of birth, and place of service parameters to review results specific to the procedure codes being billed. The results and rationale will be displayed and can be downloaded as a PDF. This online tool allows for greater transparency of the code combination edits applied by Aspirus Arise.” Check to make sure text is all Corrected Claims the same color. First paragraph looks black compared to second. A corrected claim is any claim that has a change to the original submittal. Procedure to follow when filing a corrected claim: MODIFIERS · Provider must clearly indicate that the submittal is a corrected claim and what they are requesting to For processing claims for contracted providers, Aspirus Arise follows industry standards relating to standard change billing modifiers and coding similar to those established in UB-04 and CMS’s Medicare Database. · Changes made to diagnosis, CPT/HCPCS, or modifiers require the submission of medical records

DEFINITIONS · Corrected claims must be sent with a cover sheet. You can find a copy of this cover sheet at Maximum Allowable Fee AspirusArise.com under the Resources tab The maximum amount of reimbursement allowed for a covered health care service. For a covered health care · Corrected claims must be submitted to the following address: service provided by a participating provider, the maximum allowable fee is the rate negotiated between us and the participating provider. For a covered health care service provided by a non-participating provider, the Aspirus Arise maximum allowable fee is the maximum out-of-network allowable fee. P.O. Box 21684 Upon written or oral request from the member for our maximum allowable fee for a health care service and if Eagan, MN 55121 they provide us with the appropriate billing code that identifies the health care service (for example, CPT codes, ICD 10 codes or hospital revenue codes) and the health care provider’s estimated fee for that health care service, we will provide the member with any of the following:

1. A description of our specific methodology, including, but not limited to, the following:

· Source of the data used (such as claims experience, an expert panel of health care providers, or other sources)

· Frequency of updating such data

· Geographic area used

· Percentile used by us in determining the maximum allowable fee (if applicable)

· Any supplemental information used by us in determining the maximum allowable fee

2. The maximum allowable fee determined by us under our guidelines for a specific health care service provided to the member. That may be in the form of a range of payments or maximum payment.

Multiple Endoscopies Reimbursement for multiple endoscopies will be made by Aspirus Arise using the following methods:

Billed Charges Reimbursement

· 100% of the contracted fee for the procedure listed with the highest value (primary procedure) · 10% of the contracted fee for multiple endoscopies beyond the primary procedure

44 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 45 PROVIDER RIGHTS TO PERTAINING CREDENTIALING CONTINUITY OF CARE Under certain circumstances, if a covered person’s PCP or specialist leaves our network, the covered person may continue to receive care from that practitioner. Credentialing of practitioners is upon initial contracting of practitioners and every three years thereafter. Practitioners undergoing the credentialing process have the following rights: We will continue to provide coverage for services from a practitioner who terminates from Aspirus Arise under the following circumstances: • You have the right to review a summary of outside information obtained by the Credentialing Department • The practitioner continues to practice within the geographical service area. for the purpose of evaluating your application. • Requests to review a file shall be made to the Credentialing Manager. The review will take place • The practitioner did not terminate with the health plan due to misconduct. on site during normal office hours. • We represented that the practitioner was, or would be, participating in Aspirus Arise marketing • Providers shall not have access to references from other practitioners/health care facilities, materials available to the covered person at the time of their initial enrollment, most recent coverage recommendations, or peer-review protected information received as part of the credentialing renewal, or most recent open enrollment period, whichever is later. process. • If the practitioner is the covered person’s PCP at the time of termination, we will continue to cover • Providers may receive a copy of only those documents provided by or addressed personally to services provided by that practitioner until the end of the plan year. the provider. A written summary of all other information shall be provided to the practitioner by the Medical Director or his/her designee. • If the covered person is undergoing a course of treatment with a specialist who terminates, we will continue to cover non-maternity services from that specialist for the following period of time: • You will be promptly notified of information that varies significantly from the information you have o For the remainder of the course of treatment or for 90 days after the specialist’s participation provided and be given the opportunity to submit updated/additional documentation or corrections to the terminates, whichever is shorter. Credentialing Department. The correction of erroneous information must be done, in writing, within ten (10) days of being notified of the varying information. The Credentialing Department is not obligated to o Certain groups cover specialty services until the end of the current plan year for which it was reveal the source of information if disclosure is prohibited by law. represented that the specialist was, or would be, participating.

• You have the right, upon request, to be informed of the status of your application at any time. Requests • If the covered person is receiving maternity care from a practitioner other than the covered person’s shall be directed to the Credentialing Manager. The Credentialing Manager shall promptly provide PCP, and the covered person is in the second or third trimester of pregnancy when the practitioner’s applicant with information regarding date of application receipt, general category of items outstanding, participation terminates, we will continue to cover practitioner’s services from that provider until the and target approval date. completion of postpartum care for the mother and infant.

• You will be notified of the Credentials Committee decision regarding your application via written letter within 60 calendar days of the committee’s credentialing or re-credentialing decision. Notification to Members Affected by the Termination of a Specialist or PCP Aspirus Arise takes responsibility for notifying affected members of specialist or PCP terminations and options For questions or more information, please contact: for receiving continued care. Notification is not done if the specialist or PCP moves outside the service area, is terminated for cause, retires, or is no longer caring for patients in the same manner of their prior practice. Phone: 715-972-8140 Email: [email protected] PLEASE NOTE The above are a general level of benefits, and not a guarantee of benefits. All benefits and services are subject to the terms and limitations of the policy and subject to medical necessity.

46 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 47 PROVIDER CONTRACTING Are you a provider who is interested in participating in the Aspirus Arise Network? Please send a letter of intent to [email protected].

Please include the following information: • Your name and address • The services you provide • If you provide any unique services or treatments • All participating doctors at your location • If you are treating any of our existing members

CONTRACTED PROVIDERS: PROVIDER CHANGES • Please contact [email protected] for notification of any provider changes, including staff additions or terminations, and use of Locum Tenens, along with time frames. • Note: If you leave your current practice and open or join a new practice, it is possible that your new practice does not have a contractual agreement with Aspirus Arise.

PROVIDER/PATIENT RELATIONSHIPS Aspirus Arise providers may freely communicate with patients about treatment options available to them, including medication treatment options, regardless of benefit coverage limitations.

COMPLIANCE WITH PROGRAM/PROVIDER MANUAL Aspirus Arise providers agree to participate, cooperate, and comply with materials outlined in the Provider Manual, including quality improvement activities. Provider agrees to allow Aspirus Arise to use performance data, such as, but not limited to, WCHQ, WHIO, etc., for analysis and peer comparison. Such data may be used to develop and evaluate quality improvement activities. Results may be shared via public reporting methods and other methods, including, but not limited to, web-based tools.

©2017 Aspirus Arise Health Plan of Wisconsin, Inc. All rights reserved. 29641-080-1703 JO4155