Stay Healthy. In the Know. Screenings you and your family need. Protect yourself against health care fraud.

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YO U R FA ST T R A C K TO L I V I N G W E L L FA L L 2 0 1 5 YO U R FA ST T R A C K TO L I V I N G W E L L FA L L 2 0 1 5

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Stay Healthy

Screenings you and

your family need

In the Know

Protect yourself against

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DEPARTMENT HOURS

PHONE

NUMBERS

INQUIRIES AND

CONCERNS

AultCare

Customer Service Monday-Friday 7:30 a.m.-5:00 p.m. • 330-363-6360• 1-800-344-8858 • TTY: 330-363-2393* • Claim Status • Benefits • Eligibility • Status of Referrals • Pre-certifications • Prior Authorizations Utilization

Management Monday-Friday 8:00 a.m.-4:30 p.m. • 330-363-6360• 1-800-344-8858 To Request: • Referrals • Pre-certifications • Prior Authorizations Case/Disease

Management Monday-Friday 7:30 a.m.-4:30 p.m. • 330-363-6360• 1-800-344-8858 • Inquiries and Referrals to Case or Disease Management Programs

Too busy to call? You may also e-mail us 24 hours a day, seven days a week at www.aultcare.com by clicking on the “Contact Us” link at the top of the website homepage. You will receive a response within one business day of your inquiry.

*We understand that some of our members have special communication needs. We will provide a translator or hearing impaired services (TTY) to those members who are in need. If you require these services, please contact our service center at the numbers provided and we will gladly assist you (for hearing impaired members, please use the TTY number indicated for Customer Service).

W

hether you are new to AultCare or have been with us for a while, we want your feedback. The New Enrollee Survey allows new members to provide feedback on their enrollment experience and the Member Satisfaction Survey allows all members to provide feedback on their overall satisfaction with AultCare.

You can access our surveys by visiting www.aultcare.com and

logging in to your account. If you do not already have an account, click on the “create login” link and follow the instructions. Once logged in, click on the link at the bottom of your screen titled either “Member Satisfaction Survey” or “New Enrollee Survey.” Tell us about your experience. Your responses will provide us with beneficial information to aid in our goal of delivering the best service to all of our members.

AULTCARE CONTACT INFORMATION

TELL US

HOW WE ARE DOING

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Information

You Can

Find on Our Website

I

f you have questions, you may be able to find the answers at www.aultcare.com. We continue to enhance the information available to you on our website. Here’s a list of the information, documents and services available on our website:

- Member Guide, which includes

information on:

1 How to obtain language/interpreter

services

1New Technology Assessment/Evaluation 1Pharmacy Program Information

1 Information for obtaining a Primary Care

Physician or specialist for your care

1 Information for obtaining emergency/

urgent care services whether in or out of the network and during or after normal business hours, including inpatient admittance

1 Information on how and when to submit

an appeal or complaint, including the independent appeals process

1 Information on how to submit a claim

for covered services

1 Information on services excluded from

your coverage

1 Information on our 24-hour Nursing

Healthline

- Provider Directory: Our searchable provider

directory includes information about our network health care professionals. You can search by network, specialty, name, hospital affiliation, languages spoken, gender, ZIP code, county and whether or not they are accepting new patients

-Health and Wellness Tools: Access to

management tools, and information about the Emmi® Education programs

- Eligibility, Benefit and Claims Payment

Information(requires log-in)

- Quality Management Programs,

Evaluations and Outcomes: Including HEDIS® and CAHPS® outcomes, and Quality Management Program Evaluation

-Care Coordination Services: Information

regarding our Utilization, Case and Disease Management programs

-Pharmacy Information: Access to the

pharmacy directory, formularies, recall information and prior authorization/step therapy/quantity limit information

- Enrollee Rights and Responsibilities -Notice of Privacy Practices

- Pre-certification/Utilization Review policy

-Health Care Reform

You can find all of this useful information by visiting our website at www.aultcare.com or by contacting our AultCare Customer Service Center. To request a written copy of any of the information mentioned above, please call our Service Center (contact information on page 2). HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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Care

Coordination

Services

UTILIZATION, CASE AND

DISEASE MANAGEMENT

SERVICES

AultCare offers a Care Coordination program that helps you receive the information and community services you need. Our team of registered nurses, licensed practical nurses, licensed social workers and pharmacists are available by phone to help. Services include:

- Community resource information to

provide assistance with prescriptions, utilities and transportation if you are having financial difficulties

- Phone calls with a nurse who

specializes in managing care for health conditions

- Educational materials to supplement

information your physician has provided

- Informative mailings and handouts

about your condition

- Equipment such as the Cardiocom

Telescale® (CHF monitoring program) and GlucoCom Telemonitoring System (Diabetes Monitoring Program) to help you manage your condition from the convenience of your home

- Staff to help you work with your doctors

to improve your health

- Reliable referrals to service agencies and

resources in the community

- Assistance with the referral process to

out-of-network specialists

- Help with transitioning your care to

panel providers, if appropriate

You may benefit from our Care Coordination services if you:

- Have questions about your health

status or health care

- Are in need of a transplant

- Have been newly diagnosed with cancer - Are experiencing complex medical issues - Are receiving specialty care outside of

the network

UTILIZATION

MANAGEMENT

DECISIONS ARE BASED

ON MEDICAL NECESSITY

- Utilization Management decisions are

based on the appropriateness of care and services, as well as eligibility and coverage of requested services.

- AultCare does not reward practitioners

44

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or other individuals for issuing denials of coverage or service of care. There are no financial incentives that result in underutilization.

- The specific criteria used in decisions are

available at no cost to you by contacting the Care Coordination department.

- A physician, nurse or pharmacist

reviewer is available to discuss Utilization Management denial decisions by contacting the Care Coordination department.

UTILIZATION MANAGEMENT

STAFF AVAILABILITY

- Utilization Management staff members

are available from 8:00 a.m. to 4:30 p.m. Monday through Friday for inbound calls regarding Utilization Management issues and questions regarding the Utilization Management process.

can receive inbound communication regarding Utilization Management issues after normal business hours via voicemail or fax.

- Utilization Management staff can send

outbound communication regarding Utilization Management inquiries during normal business hours.

will identify themselves by name, title and organization when initiating or returning calls regarding Utilization Management issues.

UTILIZATION MANAGEMENT

EVALUATION OF NEW AND

EXISTING TECHNOLOGY

AultCare investigates all requests for coverage of new technology using a medical technology assessment company as a guideline. If additional information is needed, AultCare utilizes sources including, but not limited to Medicare and Medicaid policies and Food and Drug Administration releases of any current medical peer review literature. This information is reviewed and evaluated by AultCare’s Medical Director and other physician advisors in order to determine if a

new technology is appropriate for coverage under your AultCare plan. Members may request that a certain new technology be investigated for coverage by contacting the Utilization Management department. Contact information for the Utilization, Case and Disease Management departments can be found on page 2.

be found on page 2.

Appeal

Rights

Did you know that when AultCare denies coverage or payment, you have appeal rights? AultCare communicates these rights in many ways to ensure that each member understands their appeal rights. Your plan documents, your Explanation of Benefits and a benefit denial letter all describe your appeal rights as an AultCare member. Every member is afforded the same first-level appeal rights or an internal review. If you initiate a first-level appeal and we uphold our original decisions, you will receive a resolution letter outlining additional appeal rights, which may include external review rights. Your rights vary depending on state and federal laws. For more information on your appeal rights, review your plan document, Explanation of Benefits or Member Guide (all available by logging into your account at www.aultcare. com), your benefit denial letter or appeal resolution letter, or contact the AultCare Service Center (contact information on page 2).

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Protect Yourself

Against

Fraud

T

o protect yourself against fraud, you can do your part by being on the lookout for fraudulent schemes that often include people calling you or asking you for your health plan information.

AultCare encourages you to:

- Never give out your Social Security, health

plan number, date of birth or banking information to someone you don’t know

- Carefully review your plan statement or

explanation of benefits to ensure that all the information is correct

- Know that free services DO NOT require

you to give your health plan numbers to anyone

It has come to AultCare’s attention that at health fairs and county fairs, exhibitors or medical companies may be asking individuals to perform high-cost genetic tests.This may include:

- Checking for signs of a disease

- Determining if you have an increased risk of

developing a disease

- Providing a general prediction of health

These companies are asking for health plan information. AultCare encourages you to not give out your health plan information to these companies.

Did you know that identity theft can lead to higher health care costs?

Be on the lookout for:

- People using your health plan number for

services you never received

- People calling to ask for your health

plan numbers

- People trying to bribe you to use a doctor to

receive a service you may not need

Did you know many legitimate businesses engage in telemarketing, but criminals can also use live or recorded calls to try to steal your identity? AultCare WILL NOT ask you for your banking information or Social Security number.

To protect yourself:

- Hang up on recorded messages - Do not press any keys or numbers when

prompted (even if it is to take your name off of their list)

- Write down suspicious numbers and

report them

Did you know that AultCare DOES NOT sell or mail medical supplies? If you receive medical supplies that you or your doctor did not order, you might be the target of a fraud scheme.

Take action to protect your AultCare benefits:

- Refuse medical supplies you did not order - Return unordered medical supplies that are

shipped to your home

- Report companies that send you these items

Did you know that you are one of the first lines of defense against fraud? Do your part and report services or items that you have been billed for, but did not receive.

Review your plan statement or explanation of benefits and:

- Make sure you received the services or

items billed

- Check the number of services billed - Ensure the same service has not been billed

more than once

If you suspect that you are the target of a fraudulent scheme, report it to AultCare.

- Fraud Hot Line—866-307-3528

- Website—http://aultcarepthp.alertline.com

G O O D F O R Y O U

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T O T H E S O U R C E

PREVENTIVE SCREENINGS

Screening, test,

preventive service

Who should

receive the services?

How often?

Flu Vaccination All individuals 6 months

and older Annually Cholesterol Screening All individuals 20 years

and older Every 5 years or more often as recommended by your physician

Blood Pressure Check All individuals 18 years

and older Every 1-2 years, more often if high risk Blood Glucose Test All individuals 18 years

and older Every 3 years, more often if high risk Colorectal Cancer

Screening All individuals 50 years and older One of the following tests:• Colonoscopy every 10 years

• Fecal Occult Blood Test once a year

• Flexible Sigmoidoscopy every 5 years

• Double Contrast Barium Enema every 5 years Breast Cancer Screening Women 40 years and

older should have a mammogram

Annually Cervical Cancer Screening Women 21-65 years Every 3-5 years Osteoporosis Screening

•

Postmenopausal women

50-69 years with a high-risk factor profile.

•

Men 50-69 years with a high-risk factor profile.

•

All individuals 50 years and older who have had an adult age fracture.

Evaluated for testing every 1-2 years or more often as recommended by your physician

I

t is recommended that you visit your Primary Care Physician annually. It is important to know that not everyone

needs the same tests. Be sure to talk to

your doctor about your individual needs for testing. Below is a list of recommended tests and preventive screenings/services that we encourage our members to have.

This information is intended for educational purposes only. It is not meant to take the place of your doctor's medical advice. Please be advised that we cannot guarantee that your plan provides total coverage for these services. If you have questions about coverage, please contact Customer Service at the phone numbers on page 2.

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BET TER EV ERY DAY

T

he goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not. This process includes ensuring that high-quality, developmentally appropriate health care services are available in an uninterrupted manner as the person moves from adolescence to adulthood.1

Changing doctors is never easy. When you’re a teenager new to advocating for your own health care, or one who has a chronic illness like diabetes or cystic fibrosis, it can be even more challenging to make the transition.

Ideally, children should transition to adult-oriented health care between the ages of 18 and 21. For adolescents seeing a

pediatrician, the transition will involve choosing a new physician, transferring medical records, and communicating treatment histories and insurance information. Although adolescents seeing a family physician may stay in the same practice, they may still need to transfer specialty care to adult subspecialists.2

Your pediatrician is a good resource and can help you with this transition. It is important to discuss your specific needs with your physician. We understand this process can be overwhelming for some and that’s why we are here to help. If you would like additional information about transitioning adolescents to adult health care, contact your pediatrician or AultCare for more information.

Pediatric to Adult Care

1 Pediatrics, Vol. 128 No. 1, July 1, 2011; p.182

2 American Academy of Pediatrics, "Helping Adolescents Transition to Adult Health Care," June 27, 2011

.

The information in this publication is intended to complement—not take the place of—the recommendations of your health care provider

. Consult your physician before making major

changes in your lifestyle or health care regimen. Manifest makes no endorsements or warranties regarding any of the products and services included in this publication or its articles. _GHR

P RSR T S TD U .S . POS TA G E PA ID Av M ed He al th P la ns

2600 Sixth Street SW Canton, OH 44710 330-363-6360 1-800-344-8858 www

.aultcare.com