MHIS attempts to maintain current and accurate information. The information is subject to changes that occur each day by insurers and employers. When changes are received by MHIS they are included in the next publication of the MHIS Managed-Care Directory.

The information is intended to help identify who provides coverage and who needs to be contacted to verify eligibility and authorize care. It is the providers’ responsibility to verify that the patient is eligible and obtain appropriate authorization for treatment. It is also the providers’ responsibility to confirm the addresses for claims submission and or other insurer and network requirements.

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Note: Logos, and Names of Managed Care Organizations presented in the "Managed-Care Directory" are the Service Marks, Trademarks of the Respective organizations.

Introduction......................................................................... 1-1

Directory Organization..... ................................................. 1-1

Networks and Payors........................................................ 1-2

Plan Type Chart..................................................................1-4

ID Cards............................................................................. 1-6

How To Assign A Payor To A Network............................ 1-8

Managed Care Organizations...................................... 2-1

Payor Registry ............................................................... 3-1

Network Registry ...........................................................4-1

Employer Registry ........................................................ 5-1

Appendice

Federal and Pers Health Plans......................................... A1

Common Abbreviations................................................... B1

Insurer & Employer Name Rules .................................... B2

Addition & Change Form................................................. C1

Introduction

Each health maintenance organization (HMO) and each preferred provider organization (PPO or EPO) require that care be coordinated with the managed-care plan. The most difficult aspect of administering managed-care patients is knowing who, what, when, where, and why a particular form, call, or process must be completed for a specific managed-care plan.

Managed Healthcare Information Services (MHIS) has created the Managed-Care Directory to provide accurate, concise, and up-to-date reference for most managed-care plans.

Directory Organization

The MHIS Managed-Care Directory organizes information so that it is easy to find contact information on a managed care payor and the managed care network.

How To Use The Managed-Care Directory, Section 1, explains how the book is organized and used.

Section 2, Managed Care Organizations (MCO), provides a listing of the managed-care networks including physician medical groups (PMG) listed in the MHIS Managed-Care Directory.

The Insurer Registry, Section 3, provides a comprehensive alphabetical list of over 20,000 insurers, payors, health maintenance organizations, individual practice associations, PPO networks, EPO networks and other such managed-care entities. Following the name of the payor, the name of the managed-care network is provided. The agents for these plans are identified, and key addresses and phone numbers are given.

The Network Registry, Section 4, contains the same type of information as the Insurer Registry. If several payors are part of the managed-care network, each payor’s name and relevant information is presented alphabetically within the network listing.

The Employer Registry, Section 5, is a consolidated listing of employers offering one or more managed-care options to employees. The names of employers are obtained from the managed-care networks or payors’ communications to providers. Currently the Employer Registry contains about 35,000 employers.

Networks and Payors

There are several thousand managed-care payors and hundreds of managed-care networks. To receive correct payments and adhere to the utilization management programs, it is important to assign the patient to the correct managed-care contract. To assign a patient to a managed-care contract, it has become necessary to identify both the network and the payor.

Networks

The managed-care network is created by an organization through its contracts with several hospitals and/or physicians and other providers. The managed-care organization's name is on the providers' contract. This name is generally associated as the network's name.

A network can be a HMO, PPO, EPO, or other managed-care plan. A network may be established by a single insurer. However, some managed-care organizations create networks which they then make available to many different insurers and third party administrators.

A managed-care network can be a local, regional, or national organization. HMOs tend to be local; however, recently some have expanded to be regional or statewide. Some national insurers have created national PPO, or EPO networks.

A few national insurers market Point of Service (POS) plans, which allow enrollees the option to select from the insurer's PPO, EPO, or local HMO options, at the time of service.

Payors

Payors are insurers or other organizations, using the network's provider contracts. The payors pay the provider for health benefits of a covered patient. In some cases the payor is the network.

The single payor networks tend to be large national insurers, a large self-funded employer, or a HMO.

Many managed-care networks include several insurers, self funded employers, and self funded unions. Because many PPO and EPO networks include multiple payors, it becomes necessary to always determine if there is a specific payor to be identified in administering the patient, as well as a network name.

Medical Groups

Some HMOs have delegated payment and utilization management to the individual practice associations or physician medical groups. For these HMOs, it is critical that you identify the correct IPA or PMG as the payor, in addition to identifying the HMO network.

Multiple Relationships

Payor has established multiple affiliations with managed care contracting networks. If the network name is not known use the claims office address and/or UR Agent name to identify the managed care contracting affiliation.

When network affiliation change

1. Payors with subsidiaries that they include in their provider contracts;
2. Insurers with subsidiaries who exclude some or all their subsidiaries from some or all of their managed-care provider contracts;
3. Subsidiaries or specific offices of a payor that contracts with a specific managed-care network for a specific employer;
4. Insurers with their own managed-care network, who utilize another managed-care network for a specific employer;
5. Payors who contract with several different managed-care networks, but each network applies to specific employer groups;
6. Payors who contract with several networks and include all employer groups in all the networks;
7. Large insurers that set up a single managed-care network for the EPO, PPO, and HMO options; and
8. Large insurers that set up independent managed-care networks, with unique and distinct provider panels, for each EPO, PPO or HMO option.

These are a few examples of the multiple relationships that exist in managed-care today. More examples are created each year.

The claims offices, utilization management programs, and eligibility verification offices used by a payor generally change with each network association.

Network and Payor Names

An additional factor to consider when assigning a payor to a network is the existence of similar names for many managed care organizations. Payors, unions, and employers that are incorporated or organized in different states or counties may have the same name, but are not related organizations. Examples of name similarities include:

EPO

Exclusive Provider Organization

HMO

Group Model & Staff Model

HMO

Network Model & IPA Model

PPO

Preferred Provider Organization

POS

Point of Service

HMO

Medicare Risk HMO / Medicaid Risk HMO

Payor Type: EPO

EPOs take many forms. EPOs are more restrictive than PPOs. They are similar to HMOs, because members can not self refer. Some EPOs are formed by either an HMO or a PPO. They may be created to allow the organization to market a POS or triple option program.

Payor Type: HMO

The staff model HMO employs the necessary medical staff, and other providers.

The group model contracts with a single medical group for all the HMOs' patients.

Payor Type: HMO

The HMO contracts with several physician medical groups(PMGs) and/or IPA(s) for the provision of care to its enrollees.

HMOs often delegate utilization management to the medical group or IPA. The referral of patients is generally limited to the physicians & providers who contract with the medical group or IPA.

Payor Type: PPO

PPO's take many forms. A PPO may be created by large national payor exclusively for its own insurance company, or a PPO may be created by a managed care organization for several different payors (insurers). Some PPOs are created exclusively for a single large employer group.

Payor Type: POS

This point of service option allows members to elect HMO type or PPO type benefits at the time of service.

Several HMOs contract with Medicare and/or Medicaid. Individuals who select the HMO are fully enrolled in the HMO. The eligibility, utilization management, and provider payments are determined by the HMO.

Members are assigned to a PCP who coordinates all aspects of treatment.

Medicare Risk HMOs or the Medicaid Capitation HMOs

Medicare patient may still have a Medicare Card, but the HMOs rules and procedures apply if the patient has elected to enroll as an HMO risk member.

Some HMOs have a cost contract with Medicare rather than a risk contract. The HMO will authorize care. Payments for hospital care may be paid by Medicare if the HMO has a cost contract. HMOs with a cost contract may cover services in addition to standard Medicare benefits.

Medicare Supplements

Many PPOs, HMOs and Indemnity Insurers offer Medicare Supplemental plans.

PCPs are not required by PPOs and indemnity payors. HMOs generally assign a PCP.

Medicare procedures apply for all authorizations, admissions, and outpatient services. HMOs and/or PPOs may require use of preferred providers for maximum supplemental benefits.

Supplemental Plans pay the copayments and deductibles.

Medicare A & B benefits are paid by the carriers and intermediaries.

Primary Care Physician: EPO

Members are generally assigned to a PCP who coordinates all aspects of treatment.

Primary Care Physician: HMO

Primary care physicians coordinate and manage each member.

Primary Care Physician: HMO

A PCP is responsible for coordinating referrals to specialists.

Primary Care Physician: PPO

Patients may select any physician for treatment. No physician is assigned as a PCP for coordinating the patients' treatment.

Primary Care Physician: POS

Members are assigned to a PCP, but can self refer. Patients receive a lesser benefit if they use non-contracting providers.

Pre-certification is required. The PCP name and Member ID # may be required.

This type HMO generally has a closed panel of physicians. The HMO Medical Director controls the authorization of all inpatient care. Always obtain an authorization to hospitalize the patient.

Authorization of inpatient care is needed. Elective care generally requires prior authorization. The HMO authorizes care, or may delegate authorization authority to the patients' IPA or Medical Group.

Authorization of inpatient care is required. Elective care generally requires prior authorization.

Pre-certification is required. The PCP name and Member ID # may be required.

Outpatient Pre-certification Program for most EPOs.

Some have an ambulatory procedures list.

The staff model HMO employs the physicians and limits outpatient referrals to a limited panel of contracting providers. Always obtain a referral and authorization for treatment from the HMO.

Authorization policies for outpatient care vary among HMOs, Medical Groups, and IPAs. Some allow PCPs to approve some outpatient procedures. Other Plans centralize authorization with the IPA, Medical Group or the HMO.

Some PPOs have a single utilization management program, others have a different UR organization for each payor. Authorization policies for outpatient care vary among PPOs, Some plans have lists of outpatient procedures that require authorization.

Outpatient pre-certification programs required for most groups.

Some have an ambulatory procedures list.

Emergency admissions must be certified. The PCP or on call physician should be contacted for advice or to request an authorization. Begin emergency treatment as necessary.

Emergency treatment will be covered at contracting and non-contracting hospitals. Contact the HMO as soon as possible. The HMO may deny payment if the care was not a life threatening condition nor required immediate treatment.

Emergency treatment will be covered at contracting and non-contracting hospitals. Contact the HMO as soon as possible. The HMO, (the IPA or Medical Group) may deny payment if the care was not for a life threatening condition nor required immediate treatment.

Emergency treatment will generally be covered at contracting and/or non-contracting hospitals. Contact the PPO as soon as possible.

Emergency admissions must be certified. PCP or on call physician should be contacted for advice or to request an authorization. Begin emergency treatment as necessary.

PCP must refer members to participating providers

HMOs limit referrals of patients to contracting providers. They do not allow self referrals by patients.

HMOs limit referrals of patients to contracting providers. They do not allow self referrals by patients. PCP obtains per-certification for referrals to specialists, high dollar tests, treatments, ancillary services, non par providers, retroactive referrals.

Some HMOs allow female members an annual ob/gyn exam from a participating provider without a referral.

Patients are generally free to choose between preferred providers or other providers. The benefit level and copayments are often reduced if out of plan providers are used for care. Patients may self refer.

Member may choose providers in or out of the network.

PCP calls for pre-certification for a member to receive maximum benefits.

ID Cards

There are no uniform standards for the information provided on ID cards issued by managed-care networks and payors; therefore, you need to look carefully at each card to find the information.

Payors issue the ID Cards

Payors (not the network) generally issue PPO and EPO identification cards. HMOs generally issue their own ID cards. Ideally, the ID cards should indicate the name of the managed-care network and state the name of the payor organization that covers the patient.

Some networks require that the payor print the network name on the card; other networks suggest a sticker be placed on the card; and other networks have no uniform standards or requirements for their payors’ ID cards.

Identifying the contracting network is complicated because:

(1) HMOs, EPOs, and POS plans typically assign a member to a Primary Care Physician. Even if the card does not indicate the type of payor your can generally classify a payor type as an HMO, EPO or POS if the card has a the name of a physician medical group, IPA, and the name of the PCP.

(3) Single payor PPO Networks issue their own ID Cards. The PPO Network Logo and/or name will be printed on the card. PPOs generally allow members to self refer to any covered provider; therefore, no reference to a physician name is printed on the card.

(2) PPO Networks with multiple payors generally have ID cards that are issued by each payor. Therefore, the card generally has the Payor Name and uses the Payor's ID Card. Most PPO Networks request that the PPO Network Logo and/or name be printed on the card. Some PPOs use stickers that are attached to the card. Some payors do not place the PPO Network Name or logo on their cards.

(4) The back side of the ID Card, generally, have information on benefits, whom to call for authorization, and where to mail claims. There are no patterns to the back of the cards which can be used to differentiate between the types of managed care payors and networks.

Assign A Payor to A Network

It is critical to identify the correct payor network affiliation. The correct payor agent must authorize patient care. Calling offices associated with the wrong payor-network affiliation can result in payment denials and or cash flow problems.

Thousands of HMOs, PPOs, EPOs, POS plans, payors, networks, single payor networks, multiple payor networks, and medical groups exist. Payors and medical groups affiliate with several different managed care organizations.

Assigning the patient to the right payor and network contract can be accomplished if you efectively use information from the patient, a provider, employer, and/or the patient's ID card.

The ID card contains the information needed to assign a patient to a network contract. The card also indicates who verifies coverage and whom to contact for authorization of services.

When the patient does not have the card, or information on the card is out of date, illegible, or incomplete, the MHIS Managed-Care Directory can help you identify whom to contact.

To correctly administer a managed-care patient, you need to know:

(1) the insurer (payor) name;

(2) the employer and/or union name;

(3) the network name; and

(4) the UR agent name.

Look for:

If you know two or three of the above names, it is easy to identify and contact the correct managed-care network and payor.

Network Name Known

If the names of the network or the network logo and the payor are on the ID card, it is easy to look up the network/payor in the MHIS Managed-Care Directory. You can find the information in either the Insurer Registry or Network Registry Sections.

Refer to either section and find whom to call to confirm and verify eligibility and benefits, and obtain authorization for a service.

Phone numbers and addresses that are not available on the card are printed in the Managed-Care Directrory.

Using the process of matching known information, you can usually identify the network.

Sometimes a few possibilities will still exist after you have cross matched the information. Remember you must always call and confirm the patient’s eligibility and obtain an authorization.

If you don’t know the name of the managed-care network, use the Insurer Registry to look up the payor. If the payor belongs to more than one managed-care network, use the information on the ID card to select a managed-care network from those listed in the insurer registry section.

(1) Match the name of the UR agent, claims payor, or third party administrator, and addresses and phone numbers with those in the insurer/network listings in the directory.

(2) Match the name of the payor. Some payors use different subsidiary names for different network relationships so look for an exact name match.

(3) Match the plan type, e.g. HMO, PPO, EPO, with a listing from the directory. If the card specifies the name of a PCP ( primary care physician) it is probably an HMO or EPO. If an IPA (individual practice association) administers the authorization it is probably an HMO.

(4) Find the employer name in the Employer Registry and match the MHIS network payor code in the Insurer Registry. MHIS lists the employer name for about 10,000 employers.

(5) Match the logos on the card to the network and payor logos in the Insurer Registry.

While confirming coverage with the payor, be sure to discuss the name of the managed-care network so that you can correctly assign the patient’s care to the correct managed-care network contract.

Not a Managed-Care Patient

Some patients are covered by indemnity plans which are not part of a managed-care plan or network. The ID cards will not reference any network. Unfortunately, because so many cards for patients covered by a managed-care network fail to indicate the name of the network, it is hard to know which patients are covered by managed-care and which patients are not covered by a managed-care plan.

The MHIS Managed-Care Directory has information on selected indemnity plans offered to a few employer groups. While confirming coverage with the payor, be sure to discuss if the patient is part of a managed-care network so that you can assign the patient’s care to a managed-care network contract if it is relevant.