1199SEIU PROVIDER MANUAL HOME | TABLE OF CONTENTS | APPENDICES 1199SEIU Benefit Funds Provider Manual | 1 | | National Benefit Fund • Health Care Employees Pension Fund Greater New York Benefit Fund • Greater New York Pension Fund Home Care Employees Benefit and Pension Funds • Home Health Aide Benefit Fund 330 WEST 42ND STREET | NEW YORK, NY 10036-6977 | WWW.1199SEIUFUNDS.ORG October 2013 Dear 1199SEIU Provider: Welcome to the 1199SEIU Benefit Funds Provider Manual. Inside you’ll find a helpful overview of our members’ covered health services. We understand that the 1199SEIU Benefit Funds’ extensive network of talented providers is integral to the quality of service we’re able to provide. We’re delighted that you are part of our network, and we are committed to working with you to ensure our members receive quality care. The advantages that you will enjoy while participating in the 1199SEIU Benefit Funds’ network include: • Participation in a provider network of 80 hospitals and over 30,000 providers; • A dedicated Provider Relations Department to handle your questions or concerns; • Lower administrative costs with electronic claims processing; • No deductibles and no co-payments for participants in the 1199SEIU National Benefit Fund for Health and Human Service Employees, and minimal co-payments for participants in the 1199SEIU Greater New York Benefit Fund and the 1199SEIU National Benefit Fund for Home Care Employees; • Automated eligibility verification and claims status 24 hours a day, seven days a week, through our Interactive Voice Response (IVR) system, and through our online provider portal, NaviNet, at www.NaviNet.net; • Speedy credentialing and re-credentialing; and • Regular updates, notices and alerts via our Provider Connections newsletter. Because we regularly update our list of services requiring prior authorization, please check our website at www.1199SEIUFunds.org regularly for the most current information and read our Provider Connections newsletters, specially created to serve your needs. We look forward to working with you and your staff. Our Provider Relations staff is always here to answer any of your questions – just call (646) 473-7160 or email [email protected]. Sincerely, Mitra Behroozi Executive Director 1199SEIU Benefit Funds FOR BENEFIT AND PENSION FUNDS (646) 473-9200 | FOR RETIREES (646) 473-8666 | FOR PROVIDERS (646) 473-7160 BENEFITS ARE SUBJECT TO EACH FUND’S SUMMARY PLAN DESCRIPTION (SPD) AND THE DISCRETION OF THAT FUND | TABLE OF CONTENTS Introduction ........................................................................................................................ 8 1199SEIU Provider Quick Reference Guide ................................................... 9 Section I: Provider Resources .............................................................................. 12 1.1 Provider Manual ................................................................................................... 12 1.2 Provider Relations Department ............................................................................. 13 1.3 Provider Connections Newsletter and Notices ...................................................... 13 1.4 1199SEIU Benefit Funds’ Website........................................................................ 13 Section II: Summary of Covered and Non-Covered Services ........... 14 2.1 Covered Services ................................................................................................. 15 2.1.1 Hospital and Facility Services ............................................................................... 15 2.1.2 Medical Services .................................................................................................. 15 2.1.3 Medical Services Co-Payments ............................................................................ 16 2.1.4 Ancillary Services ................................................................................................. 16 2.1.5 Dental Services .................................................................................................... 16 2.1.6 Prescription Drug Services ................................................................................... 17 2.2 Non-Covered General Services ............................................................................ 18 2.2.1 Non-Covered Medical Services ............................................................................ 18 2.2.2 Non-Covered Dental Services .............................................................................. 19 2.2.3 Non-Covered Prescription Drug Services ............................................................. 19 Section III: Member Eligibility ............................................................................... 20 3.1 Identifying an 1199SEIU Benefit Funds Member ................................................... 20 3.2 Automatic Eligibility Verification – Interactive Voice Response (IVR) System and NaviNet ............................................................................................ 21 3.3 Eligibility Verification for Emergency Services ........................................................ 22 3.4 Retroactive Eligibility ............................................................................................. 22 3.5 Coordination of Benefits ....................................................................................... 22 3.6 When the 1199SEIU Benefit Funds Are Primary or Secondary ............................. 22 3.7 Spouse and Dependent Coverage ....................................................................... 23 3.8 HMO, Paid-in-Full or Prepaid Plan Coverage ........................................................ 23 3.9 Medicare Eligibility ................................................................................................ 23 3.10 Member Choice ................................................................................................... 24 | Section IV Participating Providers and Networks .................................... 26 4.1 Credentialing Process .......................................................................................... 27 4.2 Credentialing Criteria ............................................................................................ 27 4.3 Application Process ............................................................................................. 29 4.4 Incomplete Applications ....................................................................................... 30 4.5 Re-Credentialing .................................................................................................. 30 4.6 Delegated Credentialing ....................................................................................... 30 4.7 Facility and Ancillary Provider Credentialing .......................................................... 31 Section V: Participating Provider Roles and Responsibilities .......... 32 5.1 Participating Provider Requirements ..................................................................... 32 5.2 Member Choice Primary Care Provider ................................................................ 33 5.3 Member Choice Specialists .................................................................................. 34 5.4 Provider Changes ................................................................................................ 34 Section VI: Preferred Providers ........................................................................... 36 6.1 Laboratory Services ............................................................................................. 36 6.2 Approved In-Office Tests ...................................................................................... 37 6.3 Pharmacy Services .............................................................................................. 37 6.4 Radiology Services ............................................................................................... 37 6.5 Durable Medical Equipment (DME) Services ......................................................... 38 Section VII: Care Management Programs .................................................... 40 7.1 Utilization Management Overview ......................................................................... 40 7.2 Outpatient and Home Care Services That Require Prior Authorization .................. 41 7.3 Prescription Drugs Requiring Authorization........................................................... 43 7.4 Medical Management of Hospital Services ........................................................... 47 7.5 Selected Outpatient and Ambulatory Surgical Procedures that Require Pre-Certification .............................................................................. 48 7.6 Hospital Discharge Notifications ........................................................................... 48 7.7 Utilization Review Procedural Guidelines ............................................................. 48 7.8 Hospital Appeal and Dispute Resolution Program ................................................ 50 7.8.1 First-Level Hospital Appeals – Inpatient/Outpatient/Ambulatory Surgery ............... 50 7.8.2 Second-Level Hospital Appeals – Inpatient Services Only .................................... 51 7.8.3 External Third-Level Hospital Appeals – Inpatient Services Only ........................... 52 7.9 Focus Diagnosis Related Groups (DRG) Validation Program and the Related Appeals Process ...................................................................................