Hillsborough County Health Care Plan PROVIDER GUIDE

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Hillsborough County Health Care PlanPROVIDER GUIDEHCFLGov.net

Table of ContentsPage(s)Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4How Hillsborough County Health Care Plan Operates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Eligibility Requirements for Hillsborough County Health Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Hillsborough County Health Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Appointment Availability/Access Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6The Role of the Primary Care Provider (PCP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Specialty Referrals and Authorizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Network Transfers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Covered Health Care Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Healthy Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Claims Submission & Timely Filing Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Claims Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Provider Reimbursements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Payments for Unfunded Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Financial Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Coordination of Benefits/Third Party Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Third Party Recovery (Medicaid/Medicare). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Medicare Fee Schedules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Provider Website & Customer Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15Attachments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

IntroductionHillsborough County would like to take this opportunity to welcome you to the ProviderNetwork for the Hillsborough County Health Care Plan (HCHCP). We would also like to thankyou for your participation and support of the HCHCP managed care program, administered byHillsborough County Health Care Services (HCS).Hillsborough County has provided medical care to its low-income citizens for many years.In the past, funding was based on ad valorem (property tax) monies. As the cost of medicalcare increased, Hillsborough County sought avenues to continue to provide care with the leastmonetary impact on its citizens. A Florida Statute was passed which permitted counties to enactan ordinance to levy a sales tax to help fund health care for indigent citizens of HillsboroughCounty. Hillsborough County enacted such an ordinance in 1991.Qualified individuals are those persons “certified by the authorizing county as meeting thedefinition of the medically poor, defined as persons having insufficient income, resources, andassets to provide the needed medical care without using resources required to meet basic needsfor shelter, food, clothing, and personal expenses; or not being eligible for any other state orfederal program, or having medical needs that are not covered by any such program; or havinginsufficient third-party insurance coverage. In all cases, the authorizing county is intended toserve as the payer of last resort.”HCS has the option to secure medical services from various facilities throughout HillsboroughCounty following the HCHCP’s philosophy of providing the best possible and most costeffective inpatient care, outpatient treatment, emergency services and prescribed medications.Hillsborough County is the payer of last resort whenever payment is requested.When HCHCP administrative protocols and operational procedures change, this ProviderGuide will be updated. Updates will include contract and operational changes to the ProviderGuide and will include instructions for incorporating them into the Provider Guide. Allguidelines for services must be followed in order of date issued for services to be eligible forreimbursement. The effective date of any change will be stated in the updated document. Wewill endeavor to provide thirty (30) days’ notice prior to the effective date of the implementationof any major or significant change.4

How HCHCP OperatesHillsborough County contracts with four Medical ServiceOrganizations (MSOs) who manage four provider networksestablished in the county as well as one Behavioral HealthProvider group with co-located primary care services.Each network includes primary care providers and clinicssometimes referred to as “Core Services”. Specialistsare contracted by the MSOs under a “Specialty Care”arrangement, and hospital-based services are contractedwith most hospitals in Hillsborough County. HillsboroughCounty also contracts with other ancillary service providers,sometimes referred to as “Overlay” providers. Membersauthorized by HCS to receive services are assigned toa specific medical network and primary care provider(PCP) who manages and monitors the member’s care.Services are rendered based on criteria established forthe HCHCP and depicted in each of the MSO and Overlayindividual contracts, as well as the HCHCP Provider Guide.Participating providers must be Medicaid and Medicarecertified providers.Medical ManagementEligibility RequirementsHillsborough County has contracted with a medicalmanagement vendor to provide medical management andutilization review, which includes prior authorization ofcertain outpatient services, inpatient hospital admissions,admissions to a skilled nursing facility and inpatientrehabilitation. The medical management vendor alsoprovides case management services and retrospectivehospital chart reviews. The medical management vendoralso provides all authorizations for referrals to specialists,home health care services, supplies, and durable medicalequipment. Providers can visit the HCHCP’s medicalmanagement vendor’s website at: https://hchcp.kepro.comfor a complete listing of those services that require priorauthorization.Eligibility for HCHCP services is basedon the following: Residency in Hillsborough County Assets within HSS guidelines Income at 175% or lower of Federal Poverty Guidelinesat the time of enrollment or re-enrollmentOnce determined eligible for the HCHCP, the member isenrolled in the appropriate plan.Health Care Plans Plan A members are covered for all necessarymedical services covered by HCHCP. The member’sPCP must coordinate all services for these planmembers and certain services require referrals andprior authorization from the medical managementvendor.Appointment Availability/AccessStandardsHCHCP has certain expectations regarding appointmentavailability for members within contracted networks.Appointment availability for primary care providervisits should follow the access standards/ availabilityguidelines below: Plan J members are covered for all Plan A serviceswith the exception of inpatient facility charges.Plan J members are enrolled in the MedicaidMedically Needy program. Urgent but non-emergent - within 24 hours Non-urgent but in need of attention - within one week Routine and preventive - within 30 calendar days Plan D members require specific authorization fromHCHCP for each service authorized. Plan D membersare covered for only limited and specific services.5

Case Management S creening and management of chronic conditionssuch as hypertension, diabetes, etc. Nutrition counseling Preventive diagnostics, e.g. TB screening Retinal eye exams for diabeticsThe medical management vendor’s case managementnurses and, in some instances, HCHCP staff nurses, willassist in the management of acute and chronic medicalconditions, including catastrophic illnesses, injuries andthe planning and management of anticipated medicalneeds. They will coordinate with primary care providers,specialists, and other health care providers.The medical management vendor’s case managementprogram uses nationally recognized and acceptedutilization management criteria, guidelines and protocols.The PCP is responsible for coordinating themember’s medical care and will: P rovide preventive care and routine checkupsto help keep the member well P rovide appropriate treatment when themember is ill O rder necessary laboratory, x-ray and otherroutine diagnostic tests O rder necessary DME, supplies, home healthcare and oxygen services A rrange for the member to see a participatingspecialist when necessaryIn all cases, the medical management vendor’s clinicalstaff and HCHCP staff nurses are available to help providerscoordinate and arrange the delivery of covered servicesunder the HCHCP policies and procedures.The Role of thePrimary Care Provider (PCP)HCHCP is based on the concept of managed care.Care is managed by the PCP, who authorizes referrals tonetwork specialists, and arranges for diagnostic tests andother necessary medicalservices.HCHCP is committedto ensuring that qualitymedical care will beavailable to all of ourmembers. HCHCP’sgoals also includeensuring that all care ismedically appropriateand provided in the mostcost effective manner.The primary caremodel provides a rangeof preventive health careservices. They includeregularly scheduledhealth care services that are age-appropriate and assessthe general health status of the member. These preventivehealth care services include: Immunizations Preventive well care Pap smears Mammograms Vision services (excluding eye exams and eyeglasses) Hearing Services – Audiology (excluding hearing aids) Family planning and counseling can be done atthe PCP level or referred to the Hillsborough CountyDepartment of HealthSpecialty Referralsand Prior AuthorizationsIn order for a PCP to receive an authorization forreferral of a HCHCP member to a network specialist, thePCP must request an authorization from the medicalmanagement vendor electronically. The electronic referralis a web-based, HIPAA compliant, Direct Data Entry (DDE)application that enables providers to request referrals orother services and to submit necessary clinical informationsupporting the request.The authorization issued by the medical managementvendor will specify which procedures are authorized,or the type of service, and/or the number of visits thatthe specialist may see the member.Specialists should not see any member without a priorauthorization from the medical management vendor.Failure to obtain a prior authorization from the medicalmanagement vendor will result in the denial of payment.Retroactive authorizations are not provided.6

Prior authorization by the medical managementvendor is required for selected elective inpatienthospital admissions to determine medical necessity,certain outpatient procedures, all skilled nursing facilityadmissions, all inpatient rehabilitation admissions, routinestretcher transports, and home health care.Prior authorization is not required for emergencyadmissions or for procedures listed as outpatient whenperformed in an inpatient setting.Services requiring prior authorization may beperiodically updated based on utilization reviews.For a complete list of current procedures and servicesrequiring prior authorization, providers can visit theHCHCP medical management vendor’s website atHCHCP.KEPRO.com.member under the direction of a participating provider.These services include, but are not limited to, room andboard, professional services, medical supplies, diagnosticand therapeutic services, use of hospital facilities, drugs,nursing care, and all equipment necessary to provide theappropriate member care and treatment.Network TransfersChanging PCP assignment is allowed if a memberrelocates within Hillsborough County, or for otherjustifiable reasons. If the member wishes to changenetworks, the change is at the discretion of HCS.The contracted medical management vendor for HCHCPrequires prior authorization for select inpatient surgicalprocedures. For a complete list of all services requiringpre-certification, refer to HCHCP.KEPRO.com.It is the member’s responsibility to request and signa release of medical information to have medical recordsforwarded to the new PCP.Skilled Nursing/Inpatient RehabilitationSkilled Nursing and inpatient rehabilitation servicesare covered but require prior authorization through theHCHCP’s medical management vendor and are limited toa maximum of (45) days per episode of care.Covered ServicesThe services listed below are generally availablethrough HCHCP, but each individual’s designated healthcare “plan” (A, J, or D) will determine whether a particularservice is available. Please see Attachment (1) for a list ofnon-covered services.Laboratory ServicesInpatient laboratory services are covered and providedthrough all network hospitals. Charges are included in thehospital bill. Network contracted outpatient laboratoryservices require only a prescription from a participatingprovider. Providers must use a network contractedoutpatient laboratory service to be reimbursed.Inpatient Hospital ServicesInpatient hospital services include all medicallynecessary services provided by participating networkhospitals for the care and treatment of an inpatientOutpatient SurgeryHCHCP covers outpatient surgical procedures performedin a participating provider’s office, ambulatory surgerycenter (ASC) or hospital outpatient setting, under thedirection of the participating physician.These services include, but are not limited to,professional services, medical supplies, diagnostic andtherapeutic services, use of facilities, drugs, nursing care,and all supplies and equipment necessary to provideappropriate care and treatment.A surgery/procedure requires a referral from the PCPto the providing specialist and a prior authorization from7

PCP. The specialty physician will report findings andrecommendations back to the member’s PCP.There must be a written referral from the primary careprovider for outpatient specialist services to be covered.Second opinions within the network are reimbursableif requested by the member and a referral has beenobtained from the PCP in advance.Telehealth/TelemedicineProviders may utilize Telehealth/Telemedicine whenmedically appropriate and is in accordance with CMSguidelines.the medical management vendor prior to performingoutpatient surgical services. For a complete listing ofservices requiring prior authorization, providers can visitthe HCHCP’s medical management vendor’s website atHCHCP.KEPRO.com.Chiropractic ServicesChiropractic services are covered under HCHCP, butare limited to three visits annually. A referral from the PCPis required.Emergency Room ServicesOutpatient Diagnostic ServicesHCHCP covers emergency room services in aparticipating hospital’s emergency room when requiredto prevent imminent loss of life, irreparable damage, orserious impairment of bodily function, and covers thoseservices that are medically necessary to avoid severe painand discomfort at participating emergency rooms only.Outpatient diagnostic services are covered whenmedically necessary and appropriate, as determined bythe medical management vendor. Diagnostic proceduresordered by the member’s PCP or specialty physician/provider, and performed in a participating hospital’slaboratory or radiology department are covered. Someoutpatient diagnostic services require prior authorizationfrom the medical management vendor prior to servicesbeing rendered.Primary and Specialty Care ServicesPrimary Care ServicesPrimary care services are those health care servicesthat are provided, coordinated, and managed by aprovider designated as a HCHCP PCP.Radiology ServicesRadiology services are a covered service. When theservice is provided at a network hospital, charges areincluded in the hospital inpatient bill or billed separatelyfor outpatient radiology services. If the service isprovided at a separate network stand-alone facility, aprovider must bill through the network medical serviceorganization (MSO). Some radiology services require aprior authorization from the medical management vendorbefore services are rendered.Primary care services include periodic medicalscreening visits, one physical exam every twelvemonths, family planning, routine immunizations, routinelaboratory and radiology testing, vision screening, hearingscreening, oral assessment, and health education, as wellas referral for further diagnosis, treatment and therapy asindicated by the screening process.HCHCP does allow PCP’s to provide physical examsand complete forms necessary for members seekingemployment and/or to obtain licenses/certificates neededfor employment.It is the responsibility of the PCP to perform necessaryand basic diagnostic testing for all HCHCP members priorto referring any member to a specialty physician.Specialty Care Physician/Provider ServicesSpecialty care physician/provider services areprovided by a participating specialty physician or otherauthorized network specialty provider, who has beenasked to provide a specific service by the member’s8

Ambulance ServicesAny member requiring long term services for a chronicillness should be referred to Community Care for theElderly (CCE) or Community Care for Disabled Adults.Ambulance transportation services are covered foran incapacitated HCHCP member when transported toa participating hospital. Non-emergent transports requireprior authorization from the medical management vendor.The member may self-refer for emergency services.The member may not self-refer for non-emergenttransportation. Members are routinely expected toprovide their own private transportation, use publictransportation, or the Hillsborough County SunshineLine, which may be able to provide:HCS does not provide custodial care. Discharge planningis available for HCHCP members at all participatinghospitals. The participating hospital will notify the homehealth agency discharge planner for HCHCP membersrequiring home health services.Home Oxygen ServicesOxygen services are a covered benefit by HCHCPfollowing Medicare standards. Transportation from home to a hospital day surgery. Transportation to a specialty clinic and back home.IV TherapyIV therapy is a covered service in both inpatient andoutpatient settings and is also available through the homehealth contracted vendor.More information about Sunshine Line can be foundat HCFLGov.net/SunshineLine.Hearing Services – AudiologyDurable Medical Equipment/DisposableMedical Supplies, Prostheticsand OrthoticsHearing services include necessary hearingexaminations, diagnosis, and treatment. Hearing aidsand hearing aid repair are not covered by HCHCP.Durable medical equipment (DME) and disposablemedical supplies (DMS), including orthotics and prostheticsare covered by HCHCP but must be supported by aprescription and documented medical necessity. For acomplete listing of services requiring prior authorization,providers can visit the HCHCP medical managementvendor’s website at HCHCP.KEPRO.com.Dental ServicesDental services with no copays will include preventivecare (cleanings, x-rays, etc.), full service dental care suchas fillings, caps, and even dentures. Dental services shallnot exceed 2500 per member per year. Orthodontiaservices are not covered.Oral surgical procedures and services require a referralfrom a general dentist and prior authorization from themedical management vendor.Home Health Care ServicesHome health care services are provided for short term,skilled intermittent care in the acute recovery phase of anillness or injury and must follow Medicare guidelines.Routine Vision CarePrior authorization is required.Routine vision care services include one eye exam andglasses every other year. The limited benefit for services is: Annual vision exam 100F rames 150S ingle vision lensses 50B ifocal lenses 75 Trifocal lenses 100 C ontact lenses 175Eye prosthetics are also covered.Mental Health ServicesMental health services are not generally covered;however, initial evaluation and diagnosis by a psychiatristand subsequent medication management by a psychiatristare covered services. Members must be referred by theirPCP in order to be eligible for these limited mental health9

services. HCHCP does not pay for outpatient counseling,residential, or long-term mental health therapy.members are required to participate and assist withprocessing the application for medications that qualify forthe PAP Program.Psychotherapy is available from behavioral healthspecialists through Network primary care clinics. Clientsare eligible for 24 visits per calendar year. No authorizationis necessary for visits 1-12; a prior authorization by thePCP is needed for visits 13-24. Drug or alcohol diagnosisare excluded when used as the primary diagnosis.FormularyHCHCP utilizes a closed formulary. An effective formularysystem permits the selection of drugs that offer thebest balance of clinical effectiveness, safety, cost, andresource utilization. The formulary system is an importantcomponent of the overall HCHCP program because it canreduce spiraling drug costs and ensure the highest qualitylevel in prescription drug utilization.Pain ManagementAcute pain management is defined as 60 days or lessin duration for non-surgical events and, for-post surgicalevents, 90 days or less in duration. Pain Managementand all related procedures require a PCP Referral andprior authorization.Emergency CareThe Emergency Medical Treatment and ActiveLabor Act (EMTALA) definition of emergency care is:A medical condition manifesting itself by acute symptomsof sufficient severity (including severe pain, psychiatricdisturbances and/or symptoms of substance abuse) suchthat the absence of immediate medical attention couldreasonably be expected to result in: C overage is limited to acute injury, dental,and pre- and post-surgical events. Coverage is provided for trigger point and Synvisc injections for clients who have failed a conservativepain management treatment plan. Coverage is provided for no greater than two setsof trigger point injections per 12-month period formyofascial pain syndrome. P lacing the health of the individual in serious jeopardyS erious impairment of bodily functionsS erious dysfunction of any bodily organ or partI nadequate time to effect a safe transfer to anotherhospital A threat to the health or safety of the individualcaused by the transferThe EMTALA is mainly directed towards hospitals thataccept Medicare and advertise emergency room treatmentand are designed to protect individuals whovisit the emergency room and do not have the means to payfor their own care. Such hospitals are statutorily required toprovide appropriate screening examinations to determinewhether emergency medical conditions exist, regardless ofmember ability to pay. Where emergency conditions areidentified, EMTALA further requires the hospital to stabilizethe member. Emergency care services are covered atparticipating HCS hospitals only.Chronic pain management is defined as greater than60 days in duration, with the exception of post-surgicalevents, which may be no greater than 90 days induration.Chronic pain management is not covered, exceptin cases with certain hematologic/oncologic diagnosis/treatment.Prescription Drug ServicesPrescription drug services are for medically necessaryand appropriate drugs prescribed by the member’s PCPor specialist in accordance with HCHCP’s Formulary.All prescriptions must be filled through HCHCPcontracted pharmacies.All prescriptions will be filled with GENERIC equivalentsunless a generic does not exist.Pharmaceutical Patient Assistance Program(PAP)/Mail Order Drug ProgramHCHCP requires members to participate in the PatientAssistance Program (PAP) for certain brandname medications prescribed by HCHCP participatingproviders. HCHCP contracts with a PAP vendor to facilitateand provide these services for HCHCP members. All PAPdrugs are mailed to the members’ home address and areusually provided as a three-month supply. Providers and10

Healthy Living ProgramThe Healthy Living Program provides guidanceand resources for a healthy lifestyle through local, onsite services. Healthy Living offers an exercise room,educational activities, group exercise sessions, andhealth screenings at Healthy Living Centers throughoutHillsborough County. Free classes on topics such as fitness,nutrition, weight loss, hypertension, smoking cessationand other Public Health Services are also available throughthe Healthy Living Program. Services are available toHCHCP members, Hillsborough County residents and BOCCcounty employees.Healthy Living Fitness Center LocationsThe Hillsborough County Department of Healthprovides services once the member tests positive for thedisease.Lee Davis Community Resource CenterHealthy Living Fitness Center3402 N 22nd St. Tampa, FL 33605The PCP will continue to provide other Health Careservices not related to the STD.Plant City Community Resource CenterHealthy Living Fitness Center307 N. Michigan Ave. Plant City, FL 33566Family PlanningSouthShore Community Resource CenterHealthy Living Fitness Center201 14th Avenue SE Ruskin, FL 33570HIVFamily planning services are available throughNetwork providers.HIV services are available at the Hillsborough CountyDepartment of Health. Once a member tests positiveor the status has previously been confirmed, the PCPshould refer the member to the Specialty Care Centerat the Hillsborough County Department of Health forappropriate evaluation.Public Health ServicesThe following programs and services are all availableto HCHCP members through the Hillsborough CountyDepartment of Health, under the State of Florida:Tuberculosis TreatmentProfessional Services Claims Submission& Timely Filing RequirementsTuberculosis services are available at the HillsboroughCounty Department of Health. A referral may begenerated if the provider suspects the member mayhave contracted the disease or if the particular serviceis not available at their medical site. Members shouldbe referred to the Hillsborough County Department ofHealth located at1105 E. Kennedy Blvd., Tampa. Members may also selfrefer for this service.Claims must be submitted and received by the thirdparty administrator from the network ManagementService Organization (MSO) within 12 months from thedate of service. Payments for claims received after 12months from the date of service will be denied.Once a claim has been processed, Hillsborough Countywill release payment to the network MSO’s. Appeals andadjustments for claims submitted and received within12 months from the date of service are limited to a periodof three months from the date of denial/processing.Providers contracted with their network MSO must submitclaims to their contracted network. (Note: If contractedwith more than one network, submit the claim based onthe member’s assigned network for office visits and placeof service network affiliation for hospital services.)The Hillsborough County Department of Healthprovides all related services once the member testspositive for the disease.The PCP will continue to provide other health careservices not related to tuberculosis.Sexually Transmitted DiseasesSexually transmitted disease (STD) services areavailable at the Hillsborough County Department ofHealth. A referral is generated if the provider suspectsthe member may have contracted an STD or if theparticular service is not available at their facility.Members may also self-refer for this service.Please note that claims submitted to the MSO mustalso be appealed to the MSO. The MSO will forwardappeals to the third party administrator or HCS ifappropriate.11

L ack of eligibility (member or provider) N on-contracted providers F ee schedule issues N on-covered services T imely filing (MSO supporting documentation isrequired) R equire a medical director’s review. (copy ofmember’s medical record or relevant medicalinformation must accompany appeal) C laims denied for all or some inpatient services A ppeals that have been denied by the TPA – but mustinclude substantive additional information/evidencethat would support reversing the appeal decisionmade by the TPAHospital Facility andOverlay Service C

Health Care Plans Plan A members are covered for all necessary medical services covered by HCHCP. The member's PCP must coordinate all services for these plan members and certain services require referrals and prior authorization from the medical management vendor. Plan J members are covered for all Plan A services

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