Policy & Procedure

Provider Network

2015‐2018 Table of Contents I. Provider Network Participation ...... 2 II. Access to Care ...... 2 III. Availability and Hours of Operation ...... 2 IV. Practice Change Notifications ...... 3 V. Provider Database ...... 3 VI. Adding Sites & Services ...... 4 VII. Provider Credentialing ...... 4 A. Behavioral Health Network ...... 4 1. Facilities ...... 4 2. Physicians Providers (refer to Medical in Section 4) ...... 5 3. Non‐physician Providers ...... 5 4. Certification Programs ...... 6 B. Dental Provider Network ...... 8 C. Medical Provider Network ...... 9 VIII. Re‐Credentialing ...... 9 IX. Delegated Credentialing ...... 9 X. Billing Workers ...... 13 XI. Provider Claims Appeal…………………….…………………………..……………………………………………………………………………………….13

XII. Provider Auhorization Process..……….…………………………..……………………………………………………………………………………….13

I. Provider Network Participation

A “participating provider” is an individual practitioner, private group practice, licensed outpatient agency, or facility that has been credentialed by EZ Comp Care (referred to as “EZ”) and has signed a provider services agreement (PSA) with EZ providers agree to provide services to injured workers, to accept reimbursement directly from EZ according to agreed upon fee schedule, and to adhere to all other terms in the PSA including provider manual, providers who maintain approved credentialing status remain active network participants unless the PSA is terminated in accordance with the terms and conditions set forth therein.

II. Access to Care

Providers are required to offer injured workers reasonable access to care. Below reflects the required timelines:

Type of Care Appointment Must Be Offered: Routine/non‐urgent services Within 14 calendar days Urgent Care Within 48 hours Emergency services Immediately, 24 hours per day, 7 days per week

III. Availability and Hours of Operation

Provider shall maintain a system of 24‐hour on‐call services for injured workers and shall ensure that all injured workers are aware of how to contact the treating or covering provider after‐hours and during provider vacations.

Crisis intervention services must be available 24 hours per day, 7 days per week. Outpatient facilities, physicians and practitioners are expected to provide these services during operating hours. After hours, providers should have a live telephone answering service or an answering machine that specifically directs a worker in crisis to a covering physician, agency‐affiliated staff, crisis team, or hospital emergency room.

In addition, outpatient providers should have services available Monday–Friday, 9 a.m.–5 p.m.at a minimum; evening and/or weekend hours should also be available at least two days per week.

Notice to EZ is required for any material changes in practice, any access limitations, and any temporary or permanent inability to meet the appointment access standards. All notifications of practice changes and access limitations should be submitted 90 days before their planned effective date or as soon as the provider becomes aware of an unplanned change or limitation.

Changes or limitations in appointment access for the practice or any clinician, including but not limited to:

 Change in hours of operation  Is no longer accepting new patients  Is available during limited hours or only in certain settings  Has any other restrictions on treating members  Is temporarily or permanently unable to meet EZ standards for appointment access  Change in address or telephone number of any service  Addition or departure of any professional staff  Change in linguistic capability, specialty or program  Discontinuation of any covered service  Change in licensure or accreditation of provider or any of its professional staff

Notice of changes and/or access limits should be submitted to: [email protected] or fax at 855‐339‐ 0612

V. Provider Database

EZ maintains a database of provider information as reported to us by providers. The accuracy of this database is critical to EZ, for such essential functions as:  Identifying and referring members to providers who are appropriate and have available services to meet their individual needs and preferences

 Network monitoring to ensure member access to a full continuum of services across the entire geographical service area  Network monitoring to ensure compliance with quality and performance standards including appointment access standards.

Provider‐reported hours of operation and availability to accept new members are included in EZ’s provider database, along with specialties, licensure, language capabilities, addresses and contact information. This information i is the primary information source for EZ staff when assisting customers with referrals. In addition to contractual requirements pertaining to appointment access, up‐to‐date practice information is equally critical to ensuring appropriate referrals to available appointments.

The PSA is specific to the services for which the provider originally contracted with EZ to add a site, service or program not previously included in the PSA, the provider should notify EZ in writing (email to [email protected] is acceptable) of the location and capabilities of the new site, service or program. EZ will determine whether the site, service or program meets an identified geographic, cultural/linguistic and/or specialty need in the network and will notify the provider of its determination. If EZ agrees to add the new site, service or program to its network, we will advise the provider of applicable credentialing requirements. In some cases, a site visit by EZ will be required before approval, in accordance with EZ’s credentialing policies and procedures. When the credentialing process is complete, the site, service or program will be added to EZ’s database under the existing provider identification number.

VII. Provider Credentialing

EZ conducts a rigorous credentialing process for network providers based on NCQA (National Committee for Quality Assurance) guidelines. All providers must be approved for credentialing by EZ in order to participate in any of EZ’s provider network, and must comply with re‐credentialing standards by submitting requested information within the specified time frame. Private solo and group practice clinicians are individually credentialed, while facilities are credentialed as organizations.

To be credentialed by EZ, practitioners must be licensed and/or certified in accordance with state licensure requirements and the license must be in force and in good standing at the time of credentialing or re‐credentialing. Practitioners must submit a complete practitioner credentialing application with all required attachments. All submitted information is primary‐source verified by EZ; providers are notified of any discrepancies found and any criteria not met, and have the opportunity to submit additional, clarifying information. Discrepancies and/or unmet criteria may disqualify the practitioner for network participation

Once the practitioner has been approved for credentialing and contracted with EZ as a solo provider or verified as a staff member of a contracted practice, EZ will notify the practitioner or the practice’s credentialing contact of the date on which he or she is active on the network.

The next section provides specific credentialing criteria by specialty.

A. Behavioral Health Network

1. Facilities EZ credentials and re‐credentials facilities and licensed outpatient agencies as organizations. Facilities that must be credentialed by EZ as organizations include:  Licensed outpatient clinics and agencies including hospital‐based clinics

 Freestanding Inpatient Mental Health facilities, freestanding and within general hospital

 Inpatient Mental Health units at general hospitals

 Inpatient Detoxification facilities

 Other diversionary mental health and substance abuse services including

4 | Page – Provider Network Policy & Procedure Copyright ©2015‐ 2017 – EZ Comp Care reserves all rights o Partial hospitalization o Day treatment o Intensive outpatient o Community based acute treatment o Community support services for substance abuse

In order to be credentialed, facilities must be licensed or certified by the state in which they operate, and the license must be in force and in good standing at the time of credentialing or re‐credentialing. If the facility reports accreditation by The Joint Commission (TJC), (formerly the Joint Commission on Accreditation of Healthcare Organizations), Council on Accreditation of Services for Family and Children (COA), Council on Accreditation of Rehabilitation Facilities (CARF), or, such accreditation must be in force and in good standing at the time of credentialing or rec‐credentialing of the facility.

The credentialed facility is responsible for credentialing and overseeing its clinical staff as EZ does not individually credential facility‐based staff. Master’s level mental health counselors are approved to function in all contracted hospital‐based, agency/clinic‐based and other facility services sites. Behavioral health program eligibility criteria include the following:

 Master’s degree or above in a mental health field (including but not restricted to counseling, family therapy, psychology, etc.) from an accredited college or university  An employee or contractor within a hospital or mental health clinic licensed in the state in which they’re practicing, and which meets all applicable federal, state and local laws and regulations  Supervised in the provision of services by a licensed independent clinical social worker, a licensed psychologist, a licensed master’s level clinical nurse specialist, or licensed psychiatrist meeting the contractor’s credentialing requirements  Is covered by the hospital or mental health/ substance abuse agency’s professional liability coverage at a minimum of $1,000,000/$3,000,000  Absence of Medicare/Medicaid sanctions

The Contractor shall use, and shall require its Providers to use, the OIG List of Excluded Individuals Entities (LEIE) upon initial hiring or contracting and on an ongoing monthly basis to screen employees and contractors, including providers and subcontractors, to determine if any such individuals or entities are excluded from participation in federal health care programs. The Contractor shall notify EOHHS of any discovered exclusion of an employee or contractor. Once the facility has been approved for credentialing and contracted with EZ to participate in the network, all licensed or certified behavioral health professionals listed may treat injured workers in the facility setting.

2. Physicians Providers (refer to Medical in Section 4)

3. Non‐physician Providers

Below represents credentialing criteria by non‐physician provider.

a) Clinical Social Worker A Clinical Social Worker must have a master’s degree in social work from an accredited graduate program. Trained to make diagnoses, provide individual and group counseling, and provide case management and advocacy; usually found in the hospital setting.

b) Mental Health Counselor A Mental Health counselor must have a master’s degree and several years of supervised clinical work experience. Trained to diagnose and provide individual and group counseling. 5 | Page – Provider Network Policy & Procedure Copyright ©2015‐ 2017 – EZ Comp Care reserves all rights c) Nurse Psychotherapist A registered nurse must be trained in the practice of psychiatric and mental health nursing; and trained to diagnose and provide individual and group counseling.

d) Professional Counselor A counselor must have a master’s degree in psychology, counseling or a related field; and trained to diagnose and provide individual and group counseling.

e) Psychiatric or Mental Health Nurse Practitioner A registered nurse practitioner must have a graduate degree and specialized training in the diagnosis and treatment of mental and emotional illness.

f) Clinical Psychology A psychologist must have a doctoral degree in psychology from an accredited/designated program in psychology. Psychologists are trained to make diagnoses and provide individual and group therapy.

4. Certification Programs All the providers above may have various certifications of training to further assist injured workers. Below represents the certifications that may be applied to a to chronic pain claim

a) Cognitive Behavioral Therapy CBT certifications must be endorsed by the National Association of Cognitive Behavioral Therapists to participate in the network. Below represents the four certifications and qualification criteria:

(1) Diplomate in Cognitive‐Behavioral Therapy ‐ The DCBT is the highest credential awarded by the NACBT.

Requirements for NACBT Diplomate Status

1. Masters or doctoral degree in psychology, counseling, social work, psychiatry, or related field from a regionally accredited university. 2. Ten years of post‐graduate experience at providing cognitive‐behavioral therapy. This experience must be verified by a supervisor or supervisors. 3. Three letters of recommendation from mental health professionals who are familiar with the applicant’s cognitive‐behavioral skills. 4. Successful completion of a certification program (all levels) in cognitive‐behavioral therapy that is recognized by the NACBT, such as Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, or Cognitive Therapy.

Maintenance of Diplomate Status

1. Certification is effective for five (5) years. To re‐certify, a member must submit at the end of the five years proof of continuing education received during the five‐year certification period. The total number of contact hours for the five years is twenty‐five (25). If a member fails to meet the continuing education requirements at the end of the five‐year certification period, he or she may take the certification examination to re‐certify. 2. Diplomates must publish one article every year that is closely related to CBT. This can include submitting an article for publication in the NACBT’s monthly newsletter, Rational News. 3. Diplomates must serve as an Associate on the NACBT Advisory Board and must exercise their voting privilege with the board.

The Certified Cognitive‐Behavioral Therapist (CCBT) Credential Requirements

Mental health professionals, regardless of specialization, who professionally qualify are permitted to apply for the credential of “Certified Cognitive‐Behavioral Therapist.” The following criteria are required for certification:

1. Masters or doctoral degree in psychology, counseling, social work, psychiatry, or related field from a regionally accredited university. 2. Six years of post‐graduate experience at providing cognitive‐behavioral therapy. This experience must be verified by a supervisor or supervisors. 3. Three letters of recommendation from mental health professionals who are familiar with the applicant’s cognitive‐behavioral skills. 4. Successful completion of a primary or introductory certification program in cognitive‐behavioral therapy that is recognized by the NACBT, such as the Primary Certificate Program in REBT, the Level‐One Certification in Rational Behavior Therapy program, or Level‐One Certification in Rational Living Therapy.

CCBT Re‐Certification

Certification is effective for five (5) years. To re‐certify, a member must submit at the end of the five years proof of continuing education received during the five‐year certification period. The total number of contact hours for the five years is twenty‐five (25). If a member fails to meet the continuing education requirements at the end of the five‐year certification period, he or she may take the certification examination to re‐certify.

(3) Certified Cognitive‐Behavioral Group Therapist (CBGT)

Requirements: Successful completion of the home study program and Masters Degree or higher in a mental health profession.

(4) Certified Cognitive‐Behavioral Group Facilitator (CBGF)

Requirements: Successful completion of the home study program and high school diploma or equivalent.

B. Dental Provider Network

Dental providers must meet the following criteria:

 Dental professional license must be clear, active, and without obligations  Dental professional license must be clear of probation, suspension, disciplinary action, and/or malpractice claim for the past 5 years  Dental professional license must not have been placed on probation for 3 or more years within a lifetime  Provider can have no wrong site surgery malpractice claim/disciplinary action within a lifetime  Provider can have no DUI, and/or criminal convictions within a lifetime  Provider cannot have 3 or more malpractice claims/disciplinary actions within a lifetime  Provider cannot have 2 or more malpractice claims that settled for $250k within a lifetime  Provider cannot be listed in the Office of Inspector General’s (OIG) Exclusions Database  D.E.A. registration‐ if applicable  Professional liability insurance policy in amounts in accordance with state requirements or if amounts are not established by the state one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate.  Provide all liability and malpractice claims history  Provide copy of curriculum vitae‐if applicable  Provide education and training locations and dates  Provide work history from time of graduation  Completed, signed provider application  Current, State Controlled Substance Registration/Certificate if applicable  W9

Medical providers must meet the following criteria:

 Medical professional license must be clear, active, and without obligations  Medical professional license must be clear of probation, suspension, disciplinary action, and/or malpractice claim for the past 5 years  Medical professional license must not have been placed on probation for 3 or more years within a lifetime  Provider can have no wrong site surgery malpractice claim/disciplinary action within a lifetime  Provider can have no DUI, and/or criminal convictions within a lifetime  Provider cannot have 3 or more malpractice claims/disciplinary actions within a lifetime  Provider cannot have 2 or more malpractice claims that settled for $250k within a lifetime  Provider cannot be listed in the Office of Inspector General’s (OIG) Exclusions Database  D.E.A. registration‐ if applicable  Professional liability insurance policy in amounts in accordance with state requirements or if amounts are not established by the state one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate.  Provide all liability and malpractice claims history  Provide copy of curriculum vitae‐if applicable  Provide education and training locations and dates  Provide work history from time of graduation  Completed, signed provider application  Current, State Controlled Substance Registration/Certificate if applicable  W9  Board certification  Letter from hospital confirming privileges

VIII. Re‐Credentialing

All practitioners and organizational providers are reviewed for re‐credentialing within 24 months of their last credentialing approval date. They must continue to meet EZ’s established credentialing criteria and quality of care standards for continued participation in EZ’s provider network. Failure to comply with re‐credentialing requirements, including timelines, may result in removal from the network.

IX. Delegated Credentialing

1. Purpose The purpose of this policy is to establish guidelines for the delegation of credentialing and recredentialing activities and to ensure that delegated credentialing and recredentialing activities are performed in accordance with EZ Comp’s approved policies and procedures.

2. Definitions

9 | Page – Provider Network Policy & Procedure Copyright ©2015‐ 2017 – EZ Comp Care reserves all rights A. Delegation means a formal process by which an organization gives another entity the authority to perform certain functions on its behalf. B. Oversight means monitoring and directing a set of activities, resulting in desired outcome. C. Delegation Audit means an annual evaluation of a delegate’s capacity to perform delegated credentialing activities using criteria established by the organization’s approved policies and procedures. The audit findings may warrant a correction action to improve compliance. D. Primary Source verification means verification by the original source of a specific credential.

3. Procedures A. The delegated group is responsible for the credentialing activities of all practitioners requesting participation with EZ Comp. This includes, but is not limited to: Doctors of Dentistry (DDS’s / DMD’s), Doctors of Medicine or Osteopathy (MD’s/DO’s), Podiatrists (DPM’s) Chiropractors (DC’s), Behavioral Health Practitioners, Mid‐Levels, and any other licensed independent practitioner with whom the delegated entity contracts or who provides care to EZ Comp claimants.

B. Responsibilities of the Delegated Entity include: 1. Collection of applications and credentialing data 2. Primary source verification 3. Ongoing review and evaluation of qualifications 4. Reporting of credentialing and recredentialing decisions 5. Reporting of practitioner’s credentialing and demographic information to EZ Comp 6. Maintaining written policies and procedures for credentialing and recredentialing activities

C. Responsibilities of EZ Comp include: 1. Prior to delegation, and annually thereafter, EZ Comp conducts an audit of credentialing and recredentialing activities to ensure that the Delegated entity is in accordance with EZ Comp’s approved policies and procedures. 2. EZ Comp reports the outcome of all audits to the delegated entity, as applicable. 3. EZ Comp notifies the Delegated Entity, in writing, of any changes to EZ Comp’s Credentialing and Recredentialing Policy and/or outside regulatory requirements that impact the Delegated Entity’s responsibilities. 4. EZ Comp retains final authority to ratify credentialing and recredentialing decisions for each individual practitioner. 5. EZ Comp maintains authority to suspend, limit, or terminate the participation of any practitioner who does not meet EZ Comp’s participation requirements or fails to comply with EZ Comp’s operating procedures.

D. Delegated Activities for Initial Credentialing: The delegated entity conducts credentialing activities in a non‐ discriminatory manner and performs with EZ Comp’s verification time limit of 180 days and includes the following: 1. Obtains a current verified attestation statement regarding physical and mental health, chemical dependency/substance abuse, loss of license and/or felony conviction history of loss or limitation of privileges or disciplinary action, current malpractice insurance with acceptable amount of coverage and work history, and application completeness and correctness. 2. Reviews, evaluates and verifies the following credentials through an accepted primary source:

10 | Page – Provider Network Policy & Procedure Copyright ©2015‐ 2017 – EZ Comp Care reserves all rights a) Hospital privileges are valid, current, unrestricted and in good standing at EZ Comp contracted hospital, or have an EZ Comp approved admitting arrangement. b) Valid, current, unrestricted license to practice in the State in which they practice and DEA certification, if applicable c) Board certification status, as applicable. d) Absence of gaps in work history or Curriculum Vitae that exceeds six (6) months. e) Reasons for inability to perform the essential functions of the position, with or without accommodation. f) Current malpractice insurance if amounts are not established by State laws, professional liability insurance in the minimum amounts of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate. g) Professional liability claims history of the prior five years, including malpractice suits, arbitration and settlements. h) National Practitioner Data Bank (NPDB) and Healthcare Integrity and Protection Data Bank (HIPDB) reports i) History of disciplinary actions affecting applicant’s professional license, Drug Enforcement Administration (DEA) certificate or other required certification. j) History of denial, suspension, restriction or termination of hospital privileges. k) Sanctions by State and Federal regulatory agencies l) Graduation from a dental/medical/professional school. m) Highest level of education defined as graduation from dental/medical school or appropriate professional school, residency, specialty training, board certification.

E. Delegated Activities for Recredentialing: The delegated entity ensures recredentialing activities are conducted in a non‐discriminatory manner and in accordance with EZ Comp’s verification time limit of 180 days and includes, at a minimum, the following: 1) Reviews, evaluates and verifies initial credentialing activities identified in 4.D.2. 2) Review and evaluation of the following additional items: a) Member complaints and grievances b) Quality Improvement activities

F. Sub‐Delegation: If a delegated entity sub‐delegates any or all of the delegated credentialing or recredentialing functions to a Credentials Verification Organization (CVO), the delegated entity provides EZ Comp with the following: 1. Written description of the delegated activities, and 2. Documented oversight of pre‐contractual and annual evaluation of the sub‐delegated activities in accordance with EZ Comp standards, and 3. Delegated group’s audit results.

G. The Delegated Entity Reporting Requirements:

11 | Page – Provider Network Policy & Procedure Copyright ©2015‐ 2017 – EZ Comp Care reserves all rights 1. The delegated group provides a roster of initial and recredentialed practitioners to EZ Comp within thirty (30) days of approval. The roster must include at a minimum, the specific data elements outlined below: a) Practitioner’s Full Name (Last Name, First Name, Middle Name) b) Degree/Title c) Gender and date of birth d) Address(es) of Practitioner’s practice e) Social Security Number f) Professional License number and expiration date g) Malpractice Insurance Carrier h) Group/IPA i) Medical/Professional School; Residency/Fellowship training j) Board Status for each Specialty k) Residency completion status for each Specialty l) DEA Number and expiration date, when applicable m) Taxpayer Identification name and number n) Language(s) spoken o) Hours of practice p) Hospital admitting privileges or admitting arrangement q) Date of Peer Review and Credentialing Committee Approval r) National Practitioner Identifier Number (NPI)

2. The Delegated Entity provides written notification of Subsequent Actions or Changes in Practitioner Status including but not limited to: a) The Delegated entity notifies EZ Comp within ten (10) days of becoming aware of any changes in an individual practitioner’s credentialing status, including but not limited to changes in demographic information, changes in hospital privileges, loss or restriction of any state license, loss or limit of DEA certificate, ineligibility or exclusion from any federal program or disciplinary action taken against a practitioner. b) The Delegated entity provides EZ Comp, within 90 days, any written notification of termination of participation by any individual practitioner.

3. Credentialing Decisions: a) The Delegated entity adheres to EZ Comp standards to ensure the same criteria, qualification standards and participation terms and conditions set forth in EZ Comp’s Credentialing Policy & Procedure. The Delegate’s policy and procedures include the Practitioner’s right to appeal according to applicable laws. b) All delegated credentialing decisions are reported to EZ Comp within 30 days, for final action. EZ Comp retains the right to approve or reject each individual practitioner and/or practitioner sites and to terminate, suspend and/or limit participation of individual practitioners. 3. Ongoing Oversight and Renewal of Delegation Agreement: a) EZ Comp conducts oversight audits with the delegated entity on an annual basis, and submits written results of to the delegated entity, including a corrective action if deficiencies are noted. If a Corrective Action is required refer to Compliance’s policy entitled Provider Corrective Plan Policy Process.

12 | Page – Provider Network Policy & Procedure Copyright ©2015‐ 2017 – EZ Comp Care reserves all rights b) EZ Comp may, per terms of the contract, revoke or amend the Credentialing Delegation Agreement and assume responsibility for all or part of credentialing functions.

X. Billing Workers

Unless otherwise instructed by EZ, EZ is the payer on claims in connection with referrals channeled to network providers. Workers or their affiliated work comp carrier may not be billed for any covered service or any balance after reimbursement by EZ except workers may be billed for any applicable copayment, in states where Work Comp Regulations apply copayments.

Providers may provide and obtain payment for non‐covered services as agreed upon by EZ, worker and worker’s work comp carrier only and only if the provider has obtained prior written acknowledgment from the member that such services are not covered and the member will be financially responsible.

XI. Claim Appeals

If a provider disagrees with EZ’s decision of denial or reimbursement of a claim, the provider can file an appeal for reconsideration within 30 days of receiving Explanation of Review. All provider appeals must be received in writing.

All Provider Appeals must include:

 Provider’s tax identification number  Provider’s contact information  A clear identification of the appeals item  A concise explanation for which the provider believes the payment amount, request for additional information, or other of EZ’s action is incorrect  The claimant name and date of service

If a provider appeal does not include all required information listed above it will be returned to provider for completion. If the same appeal is not returned with the required information within 30 days the appeal will be closed.

Provider must submit their request to EZ Comp Care P.O. Box 6787 Brandon, FL 33508, [email protected], or fax to 1‐855‐939‐2668.

XII. Authorization Process

EZ Comp Care requires prior authorization to evaluate or treat an injured worker. Pre‐authorization requests may be made by calling EZ Comp Care at 1‐855‐939‐2667.

If it is determined the injured worker requires services other than the pre‐approved services, the provider is responsible to contact EZ Comp Care with concurrent review information (prior to additional services being rendered) in order for the additional services to be considered for payment. The following written information is necessary to secure authorization.

 Why does the patient require the additional services?  What additional services are necessary  The length of time the additional services will take to deliver

Once EZ Comp Care receives notification and concurrent review information, they will give the provider or facility a determination whether the additional services can be approved. Approval is dependent upon benefit plans and medical/dental necessity determination.

For approved services, the provider will receive a written authorization from EZ Comp Care that will include:

 EZ Comp Care name and logo  Injured Worker’s name  List of approved services requested with corresponding ADA and/or CPT codes

A copy of the authorization and corresponding medical/dental records should accompany the claim for services to ensure your payment is processed within 30 days.