SELECT NETWORK
Provider Manual
TABLE OF CONTENTS
GUNDERSEN HEALTH PLAN COMMERCIAL PROVIDER MANUAL
SECTION 1: INTRODUCTION 1.1 Mission Statement
1.2 Using the Provider Manual
1.3 Provider Responsibilities – Gundersen Health Plan’s Expectations of Providers
1.4 Gundersen Health Plan Responsibilities – Providers’ Expectations of Gundersen Health Plan 1.5 Gundersen Health Plan Service Area
SECTION 2: STAFF AND SERVICES
2.1 Hours, Location, Mailing & Internet Addresses 2.2 Telephone Directory
2.3 Gundersen Health Plan Marketing
2.4 Culturally and Linguistically Appropriate Services (CLAS)
SECTION 3: MEMBER RELATED INFORMATION
3.1 Introduction to Gundersen Health Plan Customer Service Representatives 3.2 Eligibility and Effective Dates
3.3 Termination of Coverage
3.4 Practitioner/Provider Responsibility for Verification of Eligibility 3.5 Member Identification Cards
3.6 Member Grievance Process 3.7 Member Complaint Process 3.8 Advance Directives
3.9 Member Rights and Responsibilities
3.10 Emergency Room/Urgent Care – Access Standards 3.11 Confidentiality
SECTION 4: BENEFIT INFORMATION 4.1 Benefit Information
4.2 Coordination of Benefits 4.3 Subrogation
4.4 Workers Compensation
SECTION 5: PHARMACY
5.1 Introduction to Pharmacy Department Services 5.2 Prescription Drug Formulary
5.2a Non-Covered Drugs 5.2b Generic Dispensing Policy 5.2c Restrictions/ Limitations 5.3 Utilization Management Process
SECTION 6: PROVIDER RIGHTS AND RESPONSIBILITIES 6.1 Identification of Members
6.1a Prohibition of Interference - Advice to Members 6.2 Provider Reporting of Member Complaints Process 6.3 Notification Process to Providers
6.4 Provider Contracting
6.4a Agreement with Contracting and Subcontracting Entities 6.4b Termination of Provider or Contracting Entity
6.5 Continuity of Care 6.6 Credentialing Process
6.6a Network Participation Standards Overview 6.6b Network Practitioner Criteria
6.6c Facility/Organizational Participation Criteria 6.6d Credentialing Staff and Committee Structure 6.7 Payable Providers
6.7a Request for Exceptions
6.7b Medicare and Medicaid Sanctions/Exclusions 6.7c Mental Health Providers
6.8 Types of Review & Appeal Processes 6.8a Overview
6.8b Professional Review Action
6.8c Provider Grievance Resolution and Appeal Process 6.8d Disciplinary Action Procedure
6.9 Standards of Conduct 6.10 Access Standards
6.11 Telephone Nurse Advice Line
6.12 Medical Record Documentation Audit for Minnesota Plan Clinics
6.13 Practitioner Credentialing and Notification of Practitioner/Provider Changes
SECTION 7: MEDICAL MANAGEMENT SERVICES 7.1 Introduction to Medical Management Services
7.1a Medical Management Department 7.1b Overview of Utilization Management 7.2 Admission Notification
7.3 Elective Admissions Out of Network 7.4 Concurrent Hospital Review
7.5 Discharge Planning 7.6 Retrospective Review 7.7 Case Management
7.8 Utilization Review Criteria 7.9 Referrals and Authorizations
7.9a Overview
7.9b Referral Authorization Procedure 7.9c Prior Authorization
7.9d Prior Authorization Process
SECTION 8: QUALITY MANAGEMENT PROGRAM 8.1 Overview of Quality Management
8.1a Guiding Principles 8.1b Description 8.1c Purpose
8.1d Goals/Objectives 8.2 Conflict of Interest 8.3 Authority
8.4 Quality Measurement and Evaluation Methodology 8.4a Data Collection
8.4b Adverse Events 8.5 Practice Guidelines
8.5a Overview
8.5b Preventive Care Guidelines 8.5c Clinical Practice Guidelines 8.6 Disease Management
8.6a Diabetes Disease Management 8.6b Heart Failure Disease Management 8.6c Asthma Disease Management 8.7 HEDIS
8.7a HEDIS Effectiveness of Care Measures 8.7b HEDIS CAHPS Measures
8.8 On-site Provider Evaluation 8.9 Quality Improvement Work Plan 8.10 Annual Evaluation
SECTION 9: PROVIDER BILLING AND REPORTING 9.1 Billing/Claim Submission Requirements
9.1a Claim Submission Requirements 9.1b Billing Reduced Services Modifiers 9.1c Prompt Payment
9.1d Claims Filing Limit
9.1e Provider Claim Payment Inquiries 9.1f Claims Submission Address
9.1g Filing Adjustments/Amended Claims 9.1h Electronic Claim Submission
SECTION 1: INTRODUCTION 1.1 Mission Statement
1.2 Using the Provider Manual
1.3 Provider Responsibilities – Gundersen Health Plan’s Expectations of Providers
1.4 Gundersen Health Plan Responsibilities – Providers’ Expectations of Gundersen Health Plan 1.5 Gundersen Health Plan Service Area
1.1 MISSION STATEMENT
Mission
We distinguish ourselves through service excellence, and by providing value through affordable insurance solutions and access to high quality, cost-effective medical care.
Vision
We will be the Health Plan of choice in our service area, known for our nationally recognized quality and service, and our affordable insurance products.
1.2 USING THE PROVIDER MANUAL Purpose
This manual is designed specifically for Gundersen Health Plan providers. This manual provides specific information needed for the care and treatment of Gundersen Health Plan members. This manual defines policies, procedures, and a guidelines required by Gundersen Health Plan. It applies to the Select and Plus Networks. Please note that for GundersenOne members, the Select Network would apply.
Updates or Revisions
Gundersen Health Plan Provider Manual will be updated on a routine basis. A complete on line version which provides the most up to date information can be found within the Provider menu of our website at www.gundersenhealthplan.org.
1.3 PROVIDER RESPONSIBILITIES –GUNDERSEN HEALTH PLAN’S EXPECTATIONS OF PROVIDERS
Gundersen Health Plan expects contracted providers to: Act in the best interest of our members;
Communicate fully with members regarding their illness, as well as diagnostic, treatment options, medication treatments and therapeutic options available to them regardless of benefit coverage;
Allow members to participate in their health care decisions;
Provide continuity of care for members by ensuring that there is an appropriate confidential exchange of medical information between all providers involved;
Refer members for specialty care or second opinions within the Gundersen Health Plan provider network and obtain written approval from Medical Management when it is felt that care is necessary outside of the Gundersen Health Plan’s network;
Assist Gundersen Health Plan members in obtaining prior authorization, as necessary, to facilitate claim payment;
Participate in Gundersen Health Plan’s utilization management and quality improvement initiatives, including allowing Gundersen Health Plan reasonable access to member medical records;
Inform the Medical Director when Gundersen Health Plan procedures or actions are perceived as threatening the health or well-being of the member;
Understand that Gundersen Health Plan does not deny patient care, but simply makes payment decisions based on the member’s coverage through Gundersen Health Plan; Communicate with members and Gundersen Health Plan in a way that assumes that all
parties are acting in good faith with the goal being good care for the member;
Recognize that Gundersen Health Plan is obligated to develop policies and procedures on benefit administration and to administer these in a fair and consistent manner even though this occasionally results in denial of payment for individual members;
Understand that Gundersen Health Plan has many different benefit plans that members may choose from. A benefit may be payable for one member, but may not be payable for another, depending on the benefit plan that each member has chosen;
Understand that Gundersen Health Plan’s goal is to improve access and quality of health care; and;
Complete a successful credentialing program prior to contact with Gundersen Health Plan members.
Table of Contents
1.4GUNDERSEN HEALTH PLAN RESPONSIBILITIES –PROVIDERS’EXPECTATION S OF GUNDERSEN HEALTH PLAN
Participating Providers can expect Gundersen Health Plan to:
Assist the provider in meeting the expectations of Gundersen Health Plan participation; Pay claims fairly and efficiently;
Provide due process to the provider when complaints or grievances are lodged against him or her;
Support the provider in practice by identifying opportunities to improve care when information is available on a practice basis or an individual member basis;
Maintain an appeals process that can respond quickly and appropriately to members and providers;
Educate and encourage members to be seen for appropriate preventive services;
Inform providers of quality or other initiatives that may affect them or our members ; and Work in all of our operational areas to improve service to our members and providers.
1.5 GUNDERSEN HEALTH PLAN SERVICE AREA The Provider Network
Gundersen Health Plan has a comprehensive network that includes clinics, hospitals, skilled nursing facilities, home health, chiropractic and other health care professionals.
Gundersen Health Plan offers two different provider networks; Gundersen Health Plan and Gundersen Health Plan Plus.
Gundersen Health Plan ensures the integrity of the network through quality initiatives such as credentialing, utilization review and ongoing quality programs.
Providers are encouraged to use Gundersen Health Plan’s online directories at
www.gundersenhealthplan.org/providerdirectory to determine if a provider is part of Gundersen Health Plan or Gundersen Health Plan Plus network. The online directories are updated daily for the most current listings.
SECTION 2: STAFF AND SERVICES
2.1 Hours, Location, Mailing & Internet Addresses 2.2 Telephone Directory
2.3 Gundersen Health Plan Marketing
2.4 Culturally and Linguistically Appropriate Services (CLAS)
2.1 HOURS,LOCATION,MAILING &INTERNET ADDRESSES Hours of Operation
Gundersen Health Plan is open Monday through Friday, 8:00 a.m. - 5:00 p.m. A complete Gundersen Health Plan Telephone Directory is listed on the following pages for your reference regarding specific functions and the areas that are responsible for these functions.
Gundersen Health Plan Location
Gundersen Health Plan offices are located on the 2nd floor of the Support Services Building in Onalaska, 3190 Gundersen Drive, Onalaska, WI 54650
Gundersen Health Plan also staffs an information desk at the Resource Center, which is located on the first floor of the Gundersen Clinic in La Crosse. Customer Service Representatives will be available Monday through Friday, 8:00 a.m. - 5:00 p.m.
Mailing Address
Written inquiries to Gundersen Health Plan should be sent to: Gundersen Health Plan NCA2 -01
19001900 South Avenue La Crosse, WI 54601 Internet Address
Please visit Gundersen Health Plan’s website for additional information: www.gundersenhealthplan.org
2.2 TELEPHONE DIRECTORY
Gundersen Health Plan Services Telephone Numbers
Customer Service and Claims Verify member eligibility
Provide member schedule of benefits Provide general information or assistance Record member address or name changes Provide benefit information
Record member complaints Verify newborn coverage
Coordination of benefits questions Check for co-payments
Pre-existing conditions/investigations Determine Claim Status
Adjustment Procedure and Inquiry
Questions regarding Explanation of Payments Durable Medical Equipment
Assistance in identifying Gundersen Health Plan providers
(608) 775-8007 or
(800) 897-1923 Extension 58007
Configuration
Questions regarding Electronic Claim Submission
(608) 775-8053 or (800) 897-1923 Extension 58053
Provider Network Management
Network application and credentialing status
Provide administrative support to Plan requirements Contractual issues/fee schedule
Provide educational training and assistance Discuss primary care group administration
Initiate physician affiliation, disaffiliation, and transfer
(608) 775-8026/8034 or (800) 897-1923 Extension 58026 or 58034 Medical Management
Admission review/discharge planning Case Management
Home Health/IV therapy
Referrals for Out of Plan services Skilled Nursing Facilities
Procedures/services requiring prior authorization Hospice
(608) 775-8022 or
(800) 897-1923 Extension 58022
Quality Management Disease Management Clinical Practice Guidelines Health Promotion/Preventive Care HEDIS
Clinical Quality Reviews
(608) 775-8792 or
(800) 897-1923 Extension 58792
Compliance
Monitor compliance of Gundersen Health Plan
Provide information on state and federal laws affecting HMOs Monitor pending legislation affecting HMOs
Coordinate member grievance and appeal process Address privacy and confidentiality issues and concerns Privacy Officer/Compliance Officer
(608) 775-8774 or
(800) 897-1923 Extension 58774
Extension 58758
Nurse Advisor Program
Advice from a registered nurse at Gundersen is available 24 hours a day, 365 days a year
(608) 775-4454 or
(800) 858-1050
Chiropractic Information
Members can call ChiroCare to confirm whether their chiropractor is a participant in the Gundersen Health Plan network
(800) 537-3448
Marketing
Questions from prospective employer groups
(608) 775-8777 or
(866) 491-1335
Group Administration
Eligibility and effective dates of members Termination of coverage
Proof of creditable coverage
(608) 775-8007 or
(800) 897-1923 Extension 58007
2.3 GUNDERSEN HEALTH PLANMARKETING
Gundersen Health Plan has assembled a dedicated staff of marketing representatives who are specifically trained and licensed for marketing activities. Gundersen Health Plan encourages providers to address their marketing questions to the Director of Sales and Marketing at (608) 775-8088.
Marketing Restrictions
Due to the complexity of the regulations, Gundersen Health Plan does not allow providers to act in a manner where they might be viewed as Marketing Agents for Gundersen Health Plan. Reasons why Providers should not act as Marketing Agents are listed below:
1. Gundersen Health Plan retains all authority for the marketing and sales.
2. All materials that are shared with a member, including newspaper or other articles that reference Gundersen Health Plan, require prior approval by Office of the Commissioner of Insurance (OCI) for Wisconsin and the Department of Health for Minnesota.
3. If marketing sites were allowed:
Members may be confused whether the physician is acting in the role of a provider or as an agent of Gundersen Health Plan.
Provider’s knowledge of their member’s health status may increase the potential for both their discriminating in favor of beneficiaries with positive health status, as well as steering unhealthy patients to the higher benefit level offered by Gundersen Health Plan.
Providers may not be aware of membership plan benefits or costs, or other membership information. Gundersen Health Plan and/or the provider may bear responsibility if a benefit or cost is misrepresented.
4. Providers may not be the best source of membership information for their patients. 5. Marketing activities for Gundersen Health Plan are strictly regulated by the Office of the
Commissioner of Insurance for the State of Wisconsin and the Department of Health for the State of Minnesota. Discussion of certain topics, including presentation or discussion of premiums or benefits, may require state licensure as an insurance agent.
2.4 CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES (CLAS)
Gundersen Health Plan, Inc. does not discriminate based on race, religion or national origin or limit the opportunities of minorities to gain equal access to services. Gundersen Health Plan is committed to providing superior service without discrimination to all of our members including those who have special needs as described above and those who are at high risk of developing special needs.
Gundersen Health Plan’s working definition of special needs refers to any population of members that require special assistance or intervention in order to meet their customer service and/or health care needs. This includes but is not limited to culturally sensitive populations; visually, hearing, physically and mentally impaired populations; and members with chronic disease states such as diabetes, congestive heart failure (CHF), asthma, etc.
An increasing body of health service research indicates that the provision of culturally and linguistically appropriate services leads to improved health outcomes, increased patient or beneficiary satisfaction, and organizational efficiencies that result in decreased expenditures.
Gundersen Health Plan is committed to providing optimal services to all our members and to assisting physicians and other health care providers in delivering these services. An increasing number of people in our communities have limited English proficiency and come from various cultural backgrounds. In order to provide optimal care we need to be aware of the ever-changing diversity in our community and proactively identify strategies to meet these needs.
In an effort to reduce health care disparities, the Center for Medicare and Medicaid Services (CMS) chose to focus on Culturally Appropriate services. Gundersen Health Plan participates in quality improvement projects as required by CMS and recognizes the importance of proactively identifying strategies to meet the needs of these members.
Gundersen Health Plan Providers play a major role in the provision of culturally appropriate services through their increased awareness and sensitivity to the diverse needs of their patients and community. Culturally and linguistically appropriate services and strategies for Gundersen Health Plan Providers include but are not limited to:
Increased awareness of those patients/members with limited English proficiency Interpretive services through on-site interpreter or Language line service
For members who are deaf, hard of hearing, or speech impaired please call 711, or member may call through a Video Relay Service company of their choice.
Educational materials available in appropriate languages
Increased cultural awareness and sensitivity of staff through training programs
SECTION 3: MEMBER-RELATED INFORMATION
3.1 Introduction to Gundersen Health Plan Customer Service Representatives 3.2 Eligibility and Effective Dates
3.3 Termination of Coverage
3.4 Practitioner/Provider Responsibility for Verification of Eligibility 3.5 Member Identification Cards
3.6 Member Grievance Process 3.7 Member Complaint Process 3.8 Advance Directives
3.9 Member Rights and Responsibilities
3.10 Emergency Room/Urgent Care – Access Standards 3.11 Confidentiality
3.1 INTRODUCTION TO GUNDERSEN HEALTH PLAN CUSTOMER SERVICE REPRESENTATIVES Gundersen Health Plan Customer Service Department
Customer Service Representatives are available to assist members and providers with any questions or concerns. Customer Service Representatives maintain direct contact with Claim Specialists and Group Administration. They can provide status on claim processing, member eligibility, and plan benefits. If unable to answer your question, Customer Service
Representatives will direct you to the appropriate person(s).
Providers who encounter members who have questions regarding benefits, should instruct the member to call Gundersen Health Plan Customer Service Department with their questions. As a provider, you may not always be aware of your patient’s individual plan benefits or the costs involved. Gundersen Health Plan and/or you the provider may have to bear the financial responsibility if a benefit or cost is misrepresented. For this reason, providers should refrain from quoting member benefits. However, providers may call the Customer Service
Representative to verify member eligibility and can inquire about member benefits.
Customer Service Representatives can be reached Monday through Friday, 8:00 a.m. - 5:00 p.m. at (608) 775-8007 (external), ext. 58007 (internal), or (800) 897-1923
3.2 ELIGIBILITY &EFFECTIVE DATES
The eligibility and effective dates of a member are based upon the criteria established by each employer group. Employer groups apply their eligibility rules to determine the waiting period (if any) as it applies to eligible members, in accordance with their Employer Group Agreement. To verify or confirm eligibility for a particular member, please contact the Group Administration Department, at (800) 370-9718 ext. 58032 or 58067.
3.3 TERMINATION OF COVERAGE
Termination of a member is based upon the criteria established by each employer group. Each employer group applies their own termination rules to determine the termination date of members, in accordance with the Employer Group Agreement.
To verify or confirm the termination date for a particular member, please contact the Group Administration department at (800) 370-9718, ext. 58032 or 58067.
3.4 PRACTITIONER/PROVIDER RESPONSIBILITIES FOR VERIFICATION OF ELIGIBILITY The practitioner/provider shall request the member’s ID card before services are provided,
and verify that all demographic and insurance information is correct in order to assure correct registration, billing, and reporting processes.
The practitioner, provider or designee shall contact the Customer Service Representative at (800) 897-1923 or (608) 775-8007 any time verification of eligibility or verification of insurance is necessary.
The practitioner’s office shall contact the Customer Service Representative at (800) 897-1923 or (608) 775-8007 any time the practitioner or designee becomes aware of incorrect member information.
3.5 MEMBER IDENTIFICATION (ID)CARDS
Member ID cards are distributed by the Group Administration department directly to the enrolled contract holder. The ID card format and language vary depending on the plan type, i.e., HMO, POS, and Self-Funded.
3.6 MEMBER GRIEVANCE PROCESS
Customer Service Representatives are available to assist members and providers with most complaints or concerns. When resolution cannot be reached via phone call, the member has the right to file a grievance by documenting the complaint in writing. As the provider of care, you may grieve on behalf of the member.
Grievance Procedure
A “grievance” is a written complaint from a member, or from an individual on behalf of a member, expressing dissatisfaction with the provision of services, determination to reform or rescind a policy, determination of a diagnosis or level of service required for evidence-based treatment of autism spectrum disorders, or claims practices. All grievances and related questions should be directed to Gundersen Health Plan’s Member Advocate.
Member Advocate Contact Information: Gundersen Health Plan, Inc.
Attn: Member Advocate
1900 South Avenue, Mail Stop: NCA2-01 La Crosse, WI 54601
(608) 775-8052
A grievance from, or on behalf of, a member is acknowledged with five (5) business days of receipt and resolved within thirty (30) days of receipt.
Members who remain dissatisfied with a Gundersen Health Plan decision, will have additional voluntary level of appeal rights offered to them. Members will have the option to submit a complaint to the Office of the Commissioner of Insurance in the state of Wisconsin, the Iowa Insurance Division in the state of Iowa, the Department of Health in the state of Minnesota, American Arbitration Association, or an Independent Review Organization. Contact information for these organizations can be found on Gundersen Health Plan’s web site or by contacting the Member Advocate.
Members, or their designated representative, also have the option of requesting and expedited grievance if using the standard process could result in any of the following: (a) serious jeopardy to the life or health of the member or the ability of the member to regain maximum function; (b) in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance; or (c) it is determined to be an expedited grievance by a physician with knowledge of the member’s medical condition.
The Member Advocate will respond with written confirmation acknowledging the expedited grievance request on the same day the expedited grievance is received, both verbally and in writing. The grievance will be reviewed by a Gundersen Health Plan’s Medical Director, or his/her designee, for resolution within seventy-two (72) hours of Gundersen Health Plan’s receipt of the expeditedgrievance.
Medical Record Retrieval
Providers will work cooperatively with Gundersen Health Plan in submitting medical records when requested by the Member Advocate for review of standard and expedited grievance
requests. Due to the limited time frame for making decisions under an expedited grievance request, the Member Advocate may request medical records be sent within twenty-four (24) hours via fax.
For a more detailed description of Gundersen Health Plan’s grievance procedure, please call the Gundersen Health Plan’s Member Advocate at (608) 775-8052 or (800) 897-1923, ext. 58052.
3.7 MEMBER COMPLAINT PROCESS
All Gundersen Health Plan providers and staff share in the responsibility for assuring that members are satisfied with our services. If a member has a complaint relating to the administration, claims practices, or provision of services, the member should contact a
Gundersen Health Plan Customer Service Representative at (608) 775-8007 or (800) 897-1923. The Customer Service Representative shall assist the member in trying to resolve the complaint on an informal basis.
If the matter cannot be resolved informally, the member may file a grievance with the Gundersen Health Plan’s Member Advocate according to the procedures described in Section 3.6, Grievance Procedure.
3.8 ADVANCE DIRECTIVES Overview
As capable adults, patients have the right to accept or refuse medical treatment, including life-sustaining treatment. In addition, a member may appoint someone else to make health care decisions on their behalf should they become mentally or physically unable to do so. To comply with these rights, Gundersen Health Plan educates staff and providers concerning Advanced Directives. An Advance Directive is a document by which a person’s wishes and decisions for future health care can be placed in writing and communicated to their family and health care providers. They can also designate a Health Care Agent who will make health care decisions on their behalf when it is determined that they are no longer capable of making these decisions for themselves. Two types of Advance Directives are commonly used:
Living Will
Power of Attorney for Health Care
Living Will
A Living Will is a written statement by the member, of his/her choices regarding the type of life-sustaining care they would want if they had a life-threatening condition and were no longer able to communicate their wishes.
Power of Attorney for Health Care
The Power of Attorney for Health Care (POA-Health Care) form allows a member to appoint another person or persons to make health care decisions on their behalf should they become unable to make these decisions for themselves. The person (or persons) appointed is called their Health Care Agent. This form does not give the Health Care Agent any authority to make
financial or other business decisions on behalf of the member.
If a member has an Advance Directive, they are encouraged to provide copies to their health care providers, family, and their Health Care Agent, if they have designated one.
3.9 MEMBER RIGHTS AND RESPONSIBILITIES Members Have The Right:
To Choose:
Members have the right to choose a personal physician from among Gundersen Health Plan’s network of physicians.
To Receive Information About Their Health Plan Relating To: Covered and excluded health care benefits;
Available primary and specialty care providers; Preventive care information;
Their illness and treatment options;
The process to file a complaint, appeal or grievance; Policies and procedures relevant to their care;
To Privacy and Confidentiality
Members have the right to privacy and confidentiality of all communications and records about their care.
To Participate in Their Care
Members have the right to be active in decisions about their treatment. They have the right to a candid discussion of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. They have the right to be informed about the risks and benefits of treatment and to refuse care.
To Present a Complaint or Grievance/Appeal
Members have the right to voice concerns about Gundersen Health Plan or the care provided, and to receive a prompt and fair review of their complaints.
To Be Treated with Respect and Dignity
Members have the right to be treated with respect and dignity regardless of their race, age, gender, sexual orientation or creed.
Members Responsibilities:
To Know Their Benefits and Requirements: Understand their Gundersen Health Plan benefits;
Follow the required procedures; Present their ID card each time they receive services;
Know how to use the Gundersen Health Plan’s provider network; and Ask questions about things they don’t understand.
To Provide Accurate Information
Members have a responsibility to provide accurate and complete information about their health history and their eligibility/enrollment to Gundersen Health Plan and providers.
To Participate in Their Care
Members have a responsibility to participate in their care by; Asking questions to understand their health care problems;
Developing mutually agreed upon treatment goals, to the degree possible; Following the recommended, agreed upon treatment goals for their care; and Making healthy lifestyle choices to try to maintain their health and prevent illness.
To Keep Their Appointments
Members have a responsibility to keep their appointments or to give early notice if they must cancel.
To Show Consideration and Respect
Members have a responsibility to show consideration and respect to health care providers and staff.
3.10 EMERGENCY SERVICES/URGENT CARE -ACCESS STANDARDS Emergency Services
An emergency is defined as a services related to a medical condition involving acute symptoms that would lead a prudent layperson, who possess an average knowledge of health and medicine, to reasonably conclude that a lack of immediate medical attention would result in serious
jeopardy to the person’s health, impairment to bodily functions, or serious dysfunction to one or more organs.
Emergency services are covered regardless of whether or not services are received from a participating provider. In case of an emergency, the member should seek care from the nearest provider of health care equipped to handle their condition. If they are admitted to the hospital following emergency treatment, Gundersen Health Plan should be contacted within twenty-four (24) hours of the admission or as soon as reasonably possible. If the member requires follow-up care before being able to return to the service area, a prior authorization must be obtained.
Urgent Care
Urgent care is defined as care that needed sooner than a scheduled physician’s visit, but is not an emergency. Some examples of urgent care are sprains, minor cuts and burns, drug reactions, and non-severe bleeding.
Urgent care services are covered when received from a participating provider or a non-participating outside of Gundersen Health Plan’s service area.
3.11 CONFIDENTIALITY
Both providers and Gundersen Health Plan (staff, committee members and business associates) agree to safeguard all individually identifiable member information and to protect the
confidentiality and integrity of all healthcare information exchanged between providers and Gundersen Health Plan. Both the provider and Gundersen Health Plan agree to comply with all applicable requirements of both state and federal law regarding health information, including but not limited to, the HIPAA administrative simplification laws concerning privacy, security and electronic transactions.
Gundersen Health Plan Notice of Privacy Practices describes how Gundersen Health Plan uses and discloses member’s medical information; member’s rights (the right to inspect and copy, request amendment, accounting of disclosures, request confidential communications, and request restrictions to disclosures); how to file a complaint; and who to contact regarding privacy issues. The Notice of Privacy Practices is available on the Gundersen Health Plan website at
www.gundersenhealthplan.org or by contacting our Customer Service Department at (608) 775-8007. You may also contact the Gundersen Health Plan Privacy Specialist at (608) 775-8754 or the Privacy Officer at (608) 775-8758 with privacy related questions or concerns.
SECTION 4: BENEFIT INFORMATION 4.1 Benefit Information 4.2 Coordination of Benefits 4.3 Subrogation 4.4 Workers Compensation 4.1 BENEFIT INFORMATION
Gundersen Health Plan administers self-funded plans, HMO and Point-of-Service plans, all with variations in benefits. This section contains information on some of the benefits available for HMO and Point-of-Service plans. Note that members of our HMO plans must receive primary care from a participating provider, except for urgent and emergency situations. Please contact our Customer Service Department with questions concerning benefits available for each plan. Customer Services Representatives can be reached Monday through Friday, 8:00 a.m. - 5:00 p.m. at (608) 775-8007 (external), ext. 58007 (internal), or (800) 897-1923.
These are general guidelines that apply to fully insured HMO and POS plans. Benefits vary for self-funded groups. Please call Customer Service for full benefit verification. 4.2 COORDINATION OF BENEFITS
Definition
A coordination of benefits (COB) provision is an insurance contract provision intended to avoid claim payment delays and duplication of benefits when a person is covered by two or more insurance plans.
Coordination of Benefits Rules
Gundersen Health Plan determines the order of benefits using the “birthday rule”. This means that the subscriber with the earliest day of birth in the calendar year has primary coverage if coverage exists under more than one insurance plan. There are exceptions to the birthday rule, including but not limited to other coverage from a plan that does not follow the birthday rule or a court order. Other insurance coverage information should be provided on the claim when it is submitted. If Gundersen Health Plan is the primary insurance, the claim will be processed as if no other coverage exists. If Gundersen Health Plan has determined that primary coverage exists, claims will be denied for the Explanation of Payment (EOP) or the Explanation of Benefits (EOB) from the primary carrier. Gundersen Health Plan will reprocess claims upon receipt of the primary insurance payment information.
4.3SUBROGATION
Gundersen Health Plan maintains a right of subrogation when claims have been paid for which a third party is liable, i.e. accidents on private property, motor vehicle accidents, and non-work related injuries. Gundersen Health Plan will request information from members to determine if third party liability exists. If a third party payer, such as an auto carrier, agrees to pay first, Gundersen Health Plan will not pay until medical payments through that carrier are exhausted. When the determination of liability is unresolved, Gundersen Health Plan will allow payment of claims and pursue post-payment reimbursement from the other carrier. Customer Service Representatives are available to assist members and providers with any questions and can refer calls to our Subrogation Specialist if additional information is needed.
Customer Service Representatives can be reached Monday through Friday, 8:00 a.m. - 5:00 p.m. at (608) 775-8007, or (800) 897-1923.
4.4 WORKERS COMPENSATION
Gundersen Health Plan policies exclude coverage of treatment, services, or supplies for any illness or injury arising out of, or in the course of, any activity for pay, profit or gain. This exclusion applies regardless of whether benefits under Workers Compensation or Occupational Health laws have been claimed, paid, waived or compromised.
Work-related claims must be filed with the Workers Compensation carrier. Gundersen Health Plan does not coordinate benefit payments with Workers Compensation.
SECTION 5: PHARMACY
5.1 Introduction to Pharmacy Department Services 5.2 Prescription Drug Formulary
5.2a Non-Covered Drugs 5.2b Generic Dispensing Policy 5.2c Restrictions/Limitations 5.3 Utilization Management Process
5.3a Failure to obtain Drug Prior Authorization
5.1 INTRODUCTION TO PHARMACY MANAGEMENT SERVICES
Pharmacy Management oversees the operation and administration of the prescription drug benefit program for Gundersen Health Plan members. Our Pharmacy Department is staffed with a Pharmacy Director, Pharmacy Specialists and Pharmacy Benefit Coordinators. In working closely with our Pharmacy Benefit Manager (PBM), we develop policies and procedures that meet all federal and state regulatory requirements.
The department also monitors formulary compliance, coordinates prescription authorization activities, and monitors utilization of pharmacy services. In addition, Pharmacy Management analyzes new pharmaceuticals and oversees the drug formulary, reviews drug utilization information in order to promote rational, safe, and cost effective drug therapy for Gundersen Health Plan members. All of these processes are done in accordance with Center for Medicare and Medicaid Services (CMS) regulations, National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) standards.
It is the expectation of Gundersen Health Plan that all plan providers review, cooperate and participate with the Pharmacy Management requirements outlined below and assist members with understanding of any requirements and responsibilities.
Pharmacy Management inquiries should be directed to: Gundersen Health Plan
Pharmacy Department NCA2-01 1900 South Avenue
La Crosse, WI 54601 Fax: (608) 775-8790
Telephone: (608) 775-8007 or toll free at (800) 897-1923 ext. 58007
Please refer to Section 2.1 for Gundersen Health Plan business hours. In situations where a member’s life or health is in serious jeopardy and it is after regular business hours, a weekend, or holiday; you may contact the PBM directly at (800) 546-5677 for immediate assistance.
5.2 PRESCRIPTION DRUG FORMULARY
The formulary is a list of medications identified by the Gundersen Health Plan’s interdisciplinary Pharmacy and Therapeutics (P&T) Subcommittee. The subcommittee is composed of physicians, pharmacists, nurses, and other healthcare professionals. These members work in collaboration to establish and maintain the drug formulary and review drug utilization information in order to promote rational, evidence based, safe, and cost effective drug therapy for Gundersen Health Plan members.
The formulary applies to outpatient prescription medications dispensed by participating
pharmacies. Drugs requiring the assistance of a medical professional (office-based injectables) are not covered under the pharmacy benefits. Medically necessary office based injectables are covered under the major medical benefits and may be subject to prior authorization review for medical necessity.
Providers may request that the P&T Subcommittee review a new or existing medication. The provider will be required to complete a Request for DrugReview form. These forms can be
accessed on our Gundersen Health Plan website at
www.gundersenhealthplan.org/pharmacyforms. Once completed the form may then be
forwarded to the Gundersen Health Plan Pharmacy Management Department. The request may be reviewed and presented at the next quarterly P&T Subcommittee meeting. If it is determined the drug was reviewed at the P&T Subcommittee within the past year of the request, a new review will not be done until the following year.
New medications recently approved by the FDA will be excluded from coverage until reviewed and approved by our P&T Subcommittee. Unless excluded by the benefit or benefit design, only drugs with an FDA approved indication will be eligible for coverage.
Experimental or investigational drugs prescribed by a physician for the treatment of HIV infection or a medical condition arising from or related to HIV infection are covered if the drug is in, or has completed a Phase III clinical investigation. Such investigation must have been performed according to federal regulations. The drug must be prescribed and administered in accordance with the treatment protocol approved for it under federal regulations.
Most Formularies are administered with a Four Tier* cost share design: Tier 1-Generic medications
Tier 2-Preferred formulary brand medications. Tier 3-Non-preferred formulary brand
Tier 4-High Cost/Specialty Drugs
However, some plans offered by Gundersen Health Plan have a Three Tier* design: Tier 1-Generic medications
Tier 2-Preferred formulary brand medications. Tier 3-Non-preferred formulary brand
* A member’s benefit will determine coverage and may be independent of the formulary.
Gundersen Health Plan formularies can be located on the Gundersen Health Plan Website at www.gundersenhealthplan.org/formulary .
Gundersen Health Plan strongly encourages the use of generic drugs or preferred brand formulary alternatives. The P&T Subcommittee will monitor and contact practitioners who prescribe non-formulary drugs to request compliance with formulary alternatives.
When prescribing medications for a Gundersen Health Plan member, it is important to keep in mind that they are required to use an in-network pharmacy. A searchable provider directory is available on our website at www.gundersenhealthplan.org/providerdirectory. These directories are updated daily to include a current listing of practitioners and facilities, including network pharmacies, contracted with Gundersen Health Plan. The availability of providers is subject to change.
Gundersen Health Plan is unable to consider a Drug Prior Authorization request for drugs that are specific benefit exclusions. Some examples are listed below in the non-covered drugs section.
5.2a Non-Covered Drugs
Over-the-counter medications and their equivalents (unless the medication has been approved for coverage by the Pharmacy and Therapeutics Committee as part of an over-the-counter program);
Replacement drugs (lost, stolen, damaged or destroyed); Drugs used for the treatment of obesity;
Drugs used to enhance athletic performance;
Drugs requiring prior authorization that was not obtained; Drugs used for cosmetic purposes;
Emergency contraceptives (e.g. Preven and Plan B);
Medication quantities exceeding the limitations established by us;
Investigational and or experimental drugs with the exception of investigational drugs used for the treatment of HIV as required by Section 632.895(9) Wis. Stats;
Unit dose medication (individually packaged doses of a medication); Charges for medications administered during a nursing home stay;
Take home prescription drugs dispensed by a hospital or other outpatient facility;
Medications with no approved FDA indication; Drugs used to prevent a travel related illness;
Drugs that do not meet prior authorization criteria for medical necessity; Both oral and injectable drugs used to treat impotence or erectile dysfunction; Compounded medication when formulary alternatives are available;
Medications used to treat onychomycosis Early refill requests
Nutritional Products 5.2b Generic Dispensing Policy
Generic equivalents may be dispensed by the pharmacy if allowed by the provider or by law. All brand drugs that have a generic equivalent may be subject to an ancillary charge:
If you or the member chooses a brand name medication and there is a generic equivalent available, the member will be required to pay the difference in cost between the brand name medication and the generic equivalent in addition to the co-payment/coinsurance. If there is a medical reason that a member cannot use a generic equivalent, the
practitioner will need to indicate on the prescription that a brand name drug is medically necessary. The ancillary charge may then be overridden at the pharmacy level.
5.2c Restrictions/Limitations
Some covered drugs may have additional requirements or limits on coverage. These may include:
Prior Authorization – To promote the most appropriate utilization, selected high-risk or high-cost prescriptions or devices require prior authorization. The criteria necessary for a prior authorization is established by our P&T Committee. Upon enrollment and upon request, members receive a list of drugs which require prior authorization. These medications are also identified on the Formulary.
Step Therapy - Certain prescription drugs may be subject to step therapy, which
means a member must try and fail a drug(s) listed in the first-line category before
we will consider coverage of the second-line drug. Several drug classes require step therapy where generics or lower cost brand name drugs are available and equally effective. If there is medical documentation to indicate that the first line drug was unsuccessful, or that members are unable to attempt a trial of first line drugs, practitioners may submit a drug prior authorization along with medical documentation for review.
Quantity Limits - Some medications may have a quantity limit per prescription fill and/or per month supply. Medications with a quantity limit are identified on the formulary. One copayment and/or coinsurance will apply to each prescription fill.
Maintenance Medications - Some drugs, depending on the member’s benefits, can be dispensed in quantities greater than a 30 day supply. These drugs are called maintenance drugs. Maintenance drugs are medications taken on a regular basis for chronic, long-term conditions and this list is determined by Medispan in collaboration with the PBM. Examples of chronic conditions that may require maintenance medications are: high blood pressure, high cholesterol, and diabetes. Although maintenance drugs can be written and dispensed up to a 90 day supply, the member’s copayment will still apply for each 30 days (or 3
copayments/coinsurance amounts). 5.3UTILIZATION MANAGEMENT PROCESS
As described above, certain prescription drugs, as determined by the Gundersen ’s Health Plan’s P&T Subcommittee, require prior authorization, or may be subject to quantity limits or step therapy.
Utilization Management (UM) criteria will be established with input from our plan practitioners, pharmacy benefit manager, and consideration of current medical literature. Practitioners and providers can find the criteria for drugs requiring prior authorization, step therapy, as well as the maintenance list, and formularies with quantity limits noted, by accessing Gundersen Health Plan’s website at www.gundersenhealthplan.org/pharmacydept.
Prior authorization forms, which are located on our website at
www.gundersenhealthplan.org/pharmacyforms. will need to be completed and directed to Pharmacy Management at the address listed below:
Gundersen Health Plan
Pharmacy Department NCA2-01 1900 South Avenue
La Crosse, WI 54601 Fax: 608-775-8790
Telephone: (800) 897-1923 ext. 58077 or (608) 775-8077
Requests will be reviewed by the appropriate pharmacy staff. All denials will be reviewed by the Pharmacy Director or a Medical Director. Gundersen Health Plan does not allow financial incentives to staff or healthcare practitioners/providers at any time. All UM decisions are based only on the appropriateness of care and services and the existence of coverage. No practitioner, provider, or individual will be rewarded for issuing denials of coverage, service, or care. Within 15 days upon receipt of a request, the member will be notified by a phone call, or in writing, of the prior authorization determination. If a practitioner or provider fails to follow Gundersen Health Plan’s procedures for filing the prior authorization, they will be notified within five days upon receipt of the request.
The period of the initial decision may be extended up to 15 days if the plan determines it is necessary due to:
Matters beyond the control of the plan (including failure to submit medical
documentation and/or additional information requested by Gundersen Health Plan), and; The Pharmacy Department will notify the requesting practitioner prior to the expiration
of the initial 15 days, regarding the circumstances of the extension with the date the plan expects to render a decision.
To obtain coverage of a prescription requiring prior authorization in an urgent care situation, practitioners may contact our Pharmacy Management at (608) 775-8031 or toll free at (800) 897-1923 ext. 58031. The time frame for an urgent review and determination will not exceed 72 hours from receipt of the request. A Pharmacy Management representative will notify the submitting practitioner and the member of the decision by telephone, writing, or fax within 72 hours of receipt of the prescription prior authorization request.
Denials
Gundersen Health Plan provides the practitioner information to understand and decide whether to appeal a decision to deny coverage. The following information is included in all denial notices:
The specific reason or reason(s) for the denial, in easily understandable language
Reference to the specific plan provision, guideline, or protocol on which the denial is based.
Instruction for filing a grievance/appeal regarding the denial and independent external review (if applicable)
Also included in the letter will be notification that members and practitioners may obtain a copy of the criteria, clinical guidelines, or benefit provisions used for making the decision. Please contact us by phone at (800) 370-9718 ext. 58022, or (608) 775-8022, or send your request to us at the following address:
Gundersen Health Plan
Pharmacy Department NCA2-01 1900 South Avenue
La Crosse, WI 54601
Gundersen Health Plan is staffed with a full time Pharmacy Director who is able to discuss medical necessity decisions. In the event the Pharmacy Director is unavailable, our Gundersen Health Plan also staffs a Medical Director and Associate Medical Directors to address questions regarding determinations.
5.3a Failure to Obtain Prior Authorization
Failure to obtain prior authorization will result in denial of the claim as patient responsibility. Providers/practitioners are subject to plan guidelines and under certain circumstances, or contractual obligation, the services may be denied as provider/practitioner responsibility.
SECTION 6: PROVIDER RIGHTS AND RESPONSIBILITIES 6.1 Identification of Members
6.1a Prohibition of Interference - Advice to Members 6.2 Provider Reporting of Member Complaints Process 6.3 Notification Process to Providers
6.4 Provider Contracting
6.4a Agreement with Contracting and Subcontracting Entities 6.4b Termination of Provider or Contracting Entity
6.5 Continuity of Care 6.6 Credentialing Process
6.6a Network Participation Standards Overview 6.6b Network Practitioner Criteria
6.6c Facility/Organizational Participation Criteria 6.6d Credentialing Staff and Committee Structure 6.7 Payable Providers
6.7a Request for Exceptions
6.7b Medicare and Medicaid Sanctions/Exclusions 6.7c Mental Health Providers
6.8 Types of Review & Appeal Processes 6.8a Overview
6.8b Professional Review Action
6.8c Provider Grievance Resolution and Appeal Process 6.8d Disciplinary Action Procedure
6.9 Standards of Conduct 6.10 Access Standards
6.11 Telephone Nurse Advice Line
6.12 Medical Record Documentation Audit for Minnesota Plan Clinics
6.1 IDENTIFICATION OF MEMBERS
Gundersen Health Plan members should present an identification card every time a service is rendered. This will ensure correct registration of members and will reduce the possibility of confusion in the billing process. Possession of the card does not necessarily guarantee that coverage is available for the individual at the time of service. Please consult Customer Service to verify eligibility and coverage levels with each visit to verify benefits have not changed. 6.1a Prohibition of Interference - Advice to Members
Gundersen Health Plan advocates and upholds the patient/practitioner relationship and does not prohibit or otherwise restrict a health care professional, acting within their lawful scope of practice from providing advice to an individual who is a patient and enrolled in Gundersen Health Plan. Specifically, Gundersen Health Plan will not interfere with the communications between the provider and patient regarding:
The patient’s health status, medical care, or treatment options (including the provision of sufficient information to the individual to provide an opportunity to decide among all relevant treatment options, including no treatment as an option);
The risks, benefits, and consequences of treatment or non-treatment; or
The opportunity for an individual to refuse treatment and to express preferences about future treatment decisions.
6.2 PROVIDER REPORTING OF MEMBER COMPLAINTS PROCESS
In an effort to maintain patient satisfaction, regulatory and quality standards, Gundersen Health Plan participating providers are required to establish a formal mechanism for prompt response and resolution of member complaints consistent with the Gundersen Health Plan Provider Services Agreement and plan policy 11.218. Providers should have a person designated within their organization who will function as the primary contact for this process.
Provider Responsibilities:
Establish a primary contact person for complaint management. Document the process of complaint handling in a policy or procedure. Investigate and promptly respond to facilitate complaint resolution.
Maintain all documentation related to complaints for ten (10) years following resolution and make available upon request.
Plan Responsibilities:
Promptly notify appropriate provider administration of the complaint received. Monitor complaint for timely response and resolution.
Maintain records and reports as appropriate to monitor provider complaints.
Providers are not required to provide any information that is privileged and confidential under the attorney-client privilege, the Attorney Work Product Doctrine or Wisconsin’s Peer Review Statutes, nor shall they be required to provide any information, except in accordance with laws governing confidentiality of patient and health care records and information.
Providers should direct any member complaints related to Gundersen Health Plan service issues, benefits or claims status to the Department of Customer Service at (800) 897-1923 or (608) 775-8007.
6.3 NOTIFICATION PROCESS TO PROVIDERS
Gundersen Health Plan ensures notification to providers/practitioners regarding obligations to Gundersen Health Plan through the following mechanisms:
1. Notices regarding contract changes and clarification of obligations under the contract will be provided in the Provider Services Agreement. This includes:
Requests for changes in any fee or reimbursement schedule. Changes regarding contract provisions.
Changes in State, Federal or other regulatory agency requirements in which the Provider will be required to comply.
Terminations of contractual relationships.
2. Notification to Providers regarding changes in policies and procedures including but not limited to:
Prior authorization requirements. Referral guidelines.
Billing Requirements/Terms for Payments. Participation standards (Provider Manual).
Quality improvement initiatives and performance criteria. Data reporting requirements.
Grievance and appeals responsibilities and rights (Member and Provider) Drug formulary requirements.
3. Gundersen Health Plan will provide sixty (60) days written notice regarding changes in #2 of the above requirements. All notices must be received by provider sixty (60) days prior to effective date. This will be accomplished through:
certified mail hand delivery direct mailing fax web-site postings electronic mail internet availability provider manual updates Hot Topics
Gundersen Health Plan Commercial Provider Manual
This manual is used to supply specific information needed for the care and treatment of Gundersen Health Plan members. This guide defines policies, procedures, and guidelines required by the State and Federal regulations, external accreditation agencies, as well as by Gundersen Health Plan.
The Gundersen Health Plan Provider Manual is an informational dynamic tool, changing and evolving with Gundersen Health Plan. All providers will be notified of any updates or revisions as noted in 6.3 (3).
Hot Topics
A provider bulletin, entitled “Hot Topics” is distributed to Gundersen Health Plan
providers and practitioners. “Hot Topics” is a supplement to the Gundersen Health Plan
Provider Manual and will offer further clarification of current issues and regulations. 6.4 PROVIDER CONTRACTING
6.4a Agreement with Contracting and Subcontracting Entities
When the Provider or contracted entity provides services under the provider contract through subcontracts with other individuals or entities, the Provider shall require those individuals or entities to comply with all applicable laws, regulations, and requirements of the Gundersen Health Plan’s Provider Services Agreement.
6.4b Termination of Provider or Contracting Entity
Consistent with all applicable regulatory requirements, Gundersen Health Plan reserves the right to terminate any provider or contracted entity for failure to be compliant with any of the
following:
1. Gundersen Health Plan participation standards;
2. Persistent non-compliance to Gundersen Health Plan policies and/or procedures;
3. Breach of the Gundersen Provider Service Agreement without remedy of such breach after thirty (30) day notification;
4. Upon receipt of written notice that provider no longer can meet the obligations required under their agreement, not limited to suspension, revocation of expiration of any license or certificate which is required to perform required obligations under this contract;
5. Upon notification of bankruptcy or insolvency;
6. Notification of any sanction, remedial action or revocation of Medicare or Medicaid participation, or that of any applicable State or Federal agency;
7. In the event that, in the judgment of Gundersen Health Plan, continuation of the agreement would jeopardize the health and welfare of members;
8. With or without cause, accompanied by appropriate written notice as designated within the Gundersen Provider Services Agreement; or
9. In the event provider services are no longer needed in a geographical location. In the event of termination, Gundersen Health Plan will:
1. Notify the provider or contracting entity of termination, including effective date and if applicable:
Reasons for termination; Right to appeal decision; or
Obligations of the provider in the termination process.
2. Notify Gundersen Health Plan members and coordinate transfer of member care to other Gundersen Health Plan practitioners/providers.
3. Notify as applicable, any State, Federal or regulatory agencies.
Termination of providers will be consistent with Gundersen Health Plan policies and procedures and any applicable State or Federal laws.
6.5 CONTINUITY OF CARE
In the event a contractual agreement is terminated for reasons other than provider’s/practitioner’s misconduct, the provider/practitioner shall be entitled to receive payment for services furnished to members, as required under Wisconsin Stat. 609.24, for the duration of the continuation period (defined in Wisconsin Stat. 609.24), and as specified below.
Members may continue to seek care from the inactive provider/practitioner, consistent with any State, Federal, and Gundersen Health Plan requirements. Gundersen Health Plan recognizes that inactive providers/practitioners are not obligated to continue services except as required by any State or Federal law. Providers/practitioners agreeing to continue care must agree to meet the continuous care standards utilized by Gundersen Health Plan.
During the continuation period, the provider/practitioner agrees to accept payment rates set forth in any contractual agreement and abide by the terms of the contractual agreement, including, but not limited to, the Hold Harmless Clause and Gundersen Health Plan’s utilization review and quality assurance procedures. In accordance with Wisconsin Stat. 609.24, Gundersen Health Plan’s obligation to provide compensation for services furnished to a member shall only apply if Gundersen Health Plan represented to the member that the provider/practitioner was, or would be, a participating provider/practitioner, participating hospital or participating agency in marketing materials that were provided or available to the member at the most recent open enrollment or renewal period.
The period in which care may be continued:
In the case of a practitioner specializing in Family Practice, General Practice, General Medicine or Pediatrics, a period that shall not exceed the end of the current plan year In the case of a practitioner (who is not a primary care physician), whose member is undergoing a course of treatment, a period that shall not exceed:
Except as provided below, the remainder of the course of treatment, or ninety (90) days after practitioner’s participation terminates, whichever is shorter, or
If the course of treatment is maternity care and the member is in the second or third trimester of pregnancy at the time participation terminates, until the completion of postpartum care for the woman and infant.
6.6 CREDENTIALING PROCESS
6.6a Network Participation Standards Overview
The purpose of the Gundersen Health Plan Credentialing Program is to ensure that the Gundersen Health Plan network is comprised of appropriately qualified practitioners and
facilities (providers). The Gundersen Health Plan Credentialing Program is designed to comply with the standards of the National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS), State and Federal agencies, and Gundersen Health Plan’s policies. Before a practitioner can render services to a Gundersen Health Plan member, he or she must meet Gundersen Health Plan’s credentialing standards.
The credentialing process includes the systematic collection, verification and evaluation of information about a practitioner’s education, experience, qualifications, licensure and quality of care. Unless there are clear and convincing reasons to depart from these guidelines, Gundersen Health Plan Credentialing committees and staff will adhere to these guidelines.
Gundersen Health Plan practitioners must receive credentialing approval by Gundersen Health Plan for inclusion in the Provider Directory. Gundersen Health Plan retains the discretion to list practitioners consistent with Plan policy.
Practitioners must be recredentialed in order to qualify for continued Gundersen Health Plan network participation. This process occurs in increments of up to every three years. The recredentialing process includes, but is not limited to, a review of performance data such as utilization review, quality information, and member satisfaction.
Information acquired through the credentialing/recredentialing process is considered
confidential. Gundersen Health Plan is responsible for ensuring that all credentialing and peer review information remains confidential unless otherwise provided by law. The release of any practitioner information obtained during the credentialing/recredentialing process is prohibited without written, signed, and dated consent provided by the practitioner.
Practitioners have a right to review the documentation received by Gundersen Health Plan as a part of the credentialing process with the exception of letters of reference, and peer review protected information. Practitioners also have the right to correct any erroneous information that varies substantially from information they have provided on the credentialing application and,
upon request, to be informed of the status of their credentialing or recredentialing application. Gundersen Health Plan will notify practitioners of their credentialing status within 60 days of the decision.
Gundersen Health Plan reserves the discretionary authority to deny network participation to applicants except as otherwise dictated by law. In selecting practitioners, Gundersen Health Plan does not discriminate in terms of participation, reimbursement, or indemnification, against any health care professional that is acting within the scope of his or her license or certification under State law, solely on the basis of the license or certification. Further, Gundersen Health Plan does not discriminate against race, ethnic/national identity, gender, age, sexual orientation, types of procedures performed, types of patients seen, professionals who serve high-risk populations, or those who specialize in the treatment of costly conditions. Providers and practitioners applying for participation in the Gundersen Health Plan network shall be responsible for maintaining the participation requirements that are outlined in this Provider Manual and their Health Plan provider contracts. If the practitioner does not maintain these requirements, Gundersen Health Plan maintains the authority to deny, suspend or discontinue their participation in the Gundersen Health Plan network except as otherwise required by law.
Break in Service (including military and extended medical leave): If Gundersen Health Plan is unable to recredential a practitioner within the required regulatory timeframes because the practitioner is on active military assignment, but the contract between the organization and the practitioner remains in place, Gundersen Health Plan will recredential the practitioner upon his/her return. At a minimum, the organization must verify that a practitioner who returns from military assignment has a valid license to practice before he/she resumes seeing patients.
Successful recredentialing must occur within 60 days of when the practitioner resumes practice. If a practitioner terminates/breaks a contract with Gundersen Health Plan not related to quality issues, but later wants to return, the practitioner must be initially credentialed again if the break in service is greater than 30 days.
Locum tenens: If a practitioner will be providing services for a period of 60 days or more, he/she will be considered a locum tenens practitioner and must thereby meet specific Gundersen Health Plan requirements.
A Gundersen Health Plan application must be completed, verified, and approved by the Gundersen Health Plan’s Credentialing Subcommittee prior to rendering payable services to Gundersen Health Plan members.
Expedited Credentialing: At the discretion of Gundersen Health Plan, a practitioner may be considered for an expedited credentialing process whereby the practitioner will be
