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Network Health Insurance Corporation — Provider Manual

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  I. GENERAL INFORMATION
  II. CREDENTIALING
  III. CARE MANAGEMENT
  IV. CLAIMS
  V. EVIDENCE OF COVERAGE




  I. GENERAL INFORMATION
  A. NHIC CONTACT LIST
  B. PRODUCT HISTORY
  C. MEDICARE ADVANTAGE PLANS
  D. DISCLOSURE OF QUALITY AND PERFORMANCE INDICATORS TO CMS
  E. CONSIDERATION OF LINGUISTIC AND CLUTURAL NEEDS OF MEMBERS
  F. PRIVACY AND CONFIDENTIALITY OF MEMBER INFORMATION AND RECORDS
  G. BUSINESS INFORMATION PROTECTION
  H. FRAUD WASTE AND ABUSE
  I. PROHIBITION OF HEALTH SCREENING PRIOR TO ENROLLMENT
  J. NHP/NHIC – ACCESS – PRACTITIONER / PLAN STANDARDS
  K. MEDICAL RECORDS REVIEW PROCESS
  L. MEDICARE REQUIRED DISCLOSURE OF INFORMATION TO BENEFICIARIES
  M. TERMINATION OF PROVIDER SERVICES
  N. GRIEVANCE RESOLUTION POLICY AND PROCEDURE FOR NETWORK PLATINUMPLUS
  O. NETWORK HEALTH PLAN / NETWORK HEALTH INSURANCE CORPORATION’S GRIEVANCE PROCESS
  P. MEDICARE ADVANTAGE PLANS FINANCIAL AFFAIRS AND BENEFICIARY PROTECTIONS

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  II. CREDENTIALING
  A. CREDENTIALING PROCESS
  B. RECREDENTIALING PROCESS
  C. CREDENTIALING RECREDENTIALING POLICIES AND PROCEDURE REVIEW
  D. SITE VISIT AND MEDICAL RECORDKEEPING PRACTICES
  E. HIGH VOLUME SPECIALISTS DETERMINATION POLICY AND PROCEDURE
  F. FAIR HEARING AND APPELLATE REVIEW PROCESS
  G. RANGE OF ACTIONS TO IMPROVE PERFORMANCE / ALTERING THE CONDITIONS OF PARTICIPATION
  H. REPORTING TO THE PROPER AUTHORITIES
  I. INITIAL AND ONGOING ASSESSMENT OF ORGANIZATIONAL PROVIDERS
  J. PROCESS FOR ONGOING MONITORING OF SANCTIONS, COMPLAINTS AND QUALITY ISSUES
  K. CREDENTIALS COMMITTEE MEMBERSHIP AND RESPONSIBILITY
  L. DELEGATION AND OVERSIGHT POLICY AND PROCEDURE

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  III. CARE MANAGEMENT
  A. INCENTIVE POLICY / AVAILABILITY OF UTILIZATION MANAGEMENT CRITERIA / ACCESS TO NHP/NHIC
CARE MANAGEMENT STAFF
  B. SERVICES REQUIRING AUTHORIZATION FOR PLATINUM PLUS PPO AND PLATINUM PREMIER
  C. PLATINUM PLUS PPO – SPECIALTY CARE ACCESS
  D. CLINICAL CRITERIA FOR UTILIZATION DECISIONS
  E. MEDICAL POLICY DEVELOPMENT
  F. POLICY ON INCENTIVES FOR UTILIZATION DECISIONS
  G. CM STAFF ACCESSIBILITY TO MEMBERS AND PRACTITIONERS
  H. NOTICE OF NON-COVERAGE OF INPATIENT HOSPITAL CARE
  I. NOTICE OF DISCHARGE AND MEDICARE APPEAL RIGHTS
  J. TERMINATION OF PROVIDER SERVICES
  K. NOTICE OF MEDICARE NON-COVERAGE FORMS
  L. NETWORK HEALTH PLAN OUTPATIENT TREATMENT REPORT FOR BEHAVIORAL HEALTH FORM
  M. NETWORK HEALTH PLAN OUTPATIENT TREATMENT REPORT FOR AODA SERVICES – INITIAL FORM
  N. NETWORK HEALTH PLAN OUTPATIENT TREATMENT REPORT FOR AODA SERVICES – CONCURRENT FORM

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  IV. CLAIMS
  A. CMS-1500 PROFESSIONAL CLAIM INFORMATION
  B. UB-04 UNIFORM BILLING CLAIM IMPLEMENTATION
  C. CLAIMS MAILING ADDRESS
  D. CLAIMS PAYMENT FOR NHP SELECTCHOICE
  E. PROVIDER CLAIMS APPEAL PROCESS

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  V. EVIDENCE OF COVERAGE
  A. Network PlatinumPlus
  B. Network PlatinumPlus Pharmacy
  C. Network PlatinumPremier
  D. Network PlatinumPremier Pharmacy

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Site Last Updated November 18, 2008