Health Insurance Portability & Accountability Act (HIPAA) Overview

The U.S. Congress passed into law the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with the goals of providing consumers with greater access to health care insurance, protecting the privacy of health care data, and promoting more standardization and efficiency in the health care industry. NetCare has been and continues to work to ensure compliance with the HIPAA law since its inception.

HIPAA regulations address the following key issues:

• Portability - Since 1996, HIPAA has protected health insurance coverage for workers and their families when they change of lose their jobs. If you need more information or need proof of coverage under a NetCare benefit plan, call our Customer Service Department at (671) 472-3610.
• Transaction Standards - Many providers and health care companies exchange information electronically (via computer). All covered entities, as defined by HIPAA, are required to use standard format, content and codes when submitting electronic transactions after October 16, 2003.
• Privacy Standards - HIPAA created new rights for individuals that provide more control over the use and disclosure of, and access to their own confidential information. The compliance deadline for all covered entities was April 14, 2003.
• Security Standards - All covered entities must take steps to assure the confidentiality, integrity, and availability of protected health information (PHI). Security requirements for Privacy were completed by the April compliance deadline. All covered entities must implement policies and procedures, both administrative and technical, to keep PHI secure and confidential, when it is PHI that is electronically transmitted, stored or manipulated by April 2005.
• Unique Identifier - Another goal of HIPAA is to assign one identifying number to each provider, employer, health plan and individual. The National Employer ID will be used in transactions beginning October 2003. The National Provider Identifier has been finalized and implemented May 28, 2007 with another extension on May 28, 2008. The National Health Plan Identifier has not been finalized.

i. Verify member eligibility with NetCare:

Eligibility Verification via our Customer Service Team.

As a participating provider, you may also contact NetCare’s customer service department for verification of eligibility by calling (671) 472-3610/14 Monday thru Friday from 8:00 am to 5:00pm.

If you have appointments scheduled for the weekend or weekday evenings (after 5:00 pm), then you may contact our customer service department during the weekday for eligibility verification prior to the scheduled appointment on the weekend or weekday evenings.

NetCare Portal Eligibility verification

We encourage you to register for on our website at www.netcarelifeandhealth.com and log into the Provider Portal to verify member eligibility, including benefit coverage, co-payments, limitations and exclusions. This service is available to you 24 hours a day.

ii. Please contact our Provider Relations team via email at providerrelations@netcarelifeandhealth.com

Purpose of Utilization Review

NetCare’s Utilization Review Program is committed to providing health care services to our members that is medically excellent, ethically driven and delivered in a patient-centered environment that recognizes the positive relationship between the health education, a culture of wellness, and emphasis on prevention and the cost effective delivery of care.

The purpose is to ensure consistent delivery of the highest quality health care and to optimize positive member outcomes. This is accomplished through the establishment of a fully integrated provide network and the coordination of all clinical and administrative services.

Goals

1. Consistently apply Utilization Review standards, guidelines, policy and procedure in the evaluation of medical care and services on a concurrent, retrospective and prospective basis.
2. Provide access to quality healthcare services delivered in the most appropriate and cost effective setting.
3. Facilitate and ensure continuity of care for members within and outside the service area.

Provider Responsibilities

Although, members are not required to select a primary care physician under the PPO Plan, they may choose any of NetCare’s participating providers as their primary care provider whether you are a primary care physician or a specialist care physician.

As a participating provider, you are responsible for the following activities:

1. Provide appropriate and cost-effective care consistent with NetCare’s Utilization Review plan, its protocols, standards and guidelines.
2. Submit complete and timely claims to NetCare for processing. NetCare shall have access at reasonable times and upon reasonable demand to a participating provider’s books, records and consultation information pertaining to a NetCare member for the purpose of processing and auditing claims.
3. Providers will refer patients within NetCare’s contracted provider network to the fullest extent and most reasonable extent possible within and outside the service area.
4. NetCare providers may also be requested to assist in the evaluation of medical appropriateness of care provided to their patients or of care provided by other participating providers, either on an individual basis or as part of the Utilization Review Committee.

Utilization Review Committee Structure

The Utilization Review Committee is composed of NetCare’s Medical Director who chairs the committee as well as the claims manager, Utilization Review Manager, Utilization Review Specialist, and Plan Administrator.

The Utilization Review Committee meets on a monthly basis and is responsible for the following:

1. Reviewing and discussing administrative information presented to the members
2. Reviewing utilization management statistics and data
3. Receiving, reviewing, evaluating and making recommendations regarding utilization review and quality improvement activities.
4. Reviewing proposed member treatment plans requiring input beyond the expertise of the Director of Medical Management Services and Medical Management Specialist.
5. Coordinating educational opportunities for participating providers and medical management staff regarding utilization review policies and procedure processes.

Utilization Reports

The following reports are reviewed in the Utilization Review Committee meetings:

1. Total Hospital bed days per 1000
2. Average length of stay (LOS) per patient
3. Average number of patients per day
4. Total number if hospital admissions per month (by specialty)
5. Total number of referrals off-island by specialty
6. Total number of pre-certification approved, deferred, denied and modified as well as pre-certification type (e.g. Home Health care, Diagnostic Procedure, Surgical Procedures)
7. Pre-certification and claims appeals
8. Emergency Room Utilization
9. Pharmacy Utilization
10. Number of Approved and Authorized Airfare Benefit
11. Review if cases for Disease Management and Case Management

Utilization Review Activities

NetCare’s Utilization Review Activities consist of pre-certification review; concurrent review, continued-stay review, discharge planning, retrospective review, prospective review, and case management.

• Concurrent Review
  

  For concurrent review of services, NetCare makes decisions for inpatient services at the time of onsite visit. The concept involves determining whether treatment and continued inpatient care during a patient’s hospitalization are necessary and appropriate. Monitoring of daily hospital admissions as well as performing concurrent review is handled by NetCare’s Medical Management Specialist who is a Guam licensed Registered Nurse (RN). The medical management specialist reviews a patient’s chart immediately following admission and at suitable subsequent intervals for the following:

  1. To assign an initial length of stay, if not already done, and assess the medical need for any extensions
  2. To assess the treatment program and efficacy of the care being given
  3. To abstract data for retrospective quality assessment in comparison with medical care criteria.

  The medical management specialist can authorize care that falls within pre-determined, explicit quality and length of stay guidelines. These guidelines are based on common practice and experience. NetCare utilizes and subscribes to the Milliman USA and Trilogy Medical Management Manual.
  
  Within 24 hours of each admission, the medical management specialist initiates a thorough review for a patient. Using diagnosis-specific criteria or general quality guidelines, the process begins with an initial chart review to determine the need for admission. If the chart does not clearly indicate the needed information, the medical management specialist will request clarification from the attending physician.
  
  Next, the appropriateness of the level of care is determined. Potential levels of care include intensive, acute, extended or rehabilitative, supportive, ambulatory, coordinated home health, and hospice care.
  
  The medical management specialist also assigns a diagnosis-specific length of stay range during the initial review. The length of stay range may be defined within a minimum that represents the median length of stay determined necessary to ensure quality care and a maximum that represents a limit based on the Milliman USA Inpatient Hospitalization Guidelines. NetCare must be advised of the need for an extended hospital stay with justification of the medical necessity (as evidenced by the inpatient medical information and progress report) for the extended hospitalization beyond the approved or allowed maximum.
  
  The date representing the minimum length of stay is noted in the patient’s chart. On that date the patient’s length of stay is reviewed again, and the medical management specialist, after looking at the patient’s chart, may assign a new review date.

• Continued-Stay Review
  Continued-stay review is an off-site medical review conducted during the member’s hospitalization. It is primarily based on telephone conversations between the medical management specialist and the attending physician, hospital utilization review staff or discharge planning staff. Telephone contacts are made at designated intervals consistent with the patient’s conditions until discharge occurs.
  
  Using established medical criteria and length of stay norms, NetCare’s medical management specialist determines the medical necessity and appropriateness of both treatment plan and length of inpatient stay. This is conducted in coordination and consultation of the patient’s physician.
• Discharge Planning
  NetCare’s medical management specialist will work jointly and in coordination with a patient’s physician to begin any discharge planning as early as possible.
  
  For patients who have not fully recovered but who do not require the acute care of a hospital, NetCare can make arrangements for continuing care in a less costly setting, such as skilled nursing facility or to a home health care agency as an alternative to a hospital set-up.
  
  NetCare is committed to ensuring that our patients receive the proper care in the most appropriate setting after a hospital stay.
• Retrospective Review
  The retrospective review process determines the appropriateness of the care that has been provided and the extent to which health care costs should be reimbursed. This process allows NetCare to establish utilization profiles for use in monitoring trend factors, including diagnoses, the fees charged for medical services, and where they were provided.
  
  In retrospective review of outpatient utilization, NetCare establishes the appropriate treatments for a given diagnosis in terms of tests required, and office visits permitted. When claims are received, they are reviewed against these treatment guidelines. Any treatment that does not fall within the guidelines must be justified by the provider or it may be denied for payment.
• Prospective Review
  NetCare’s medical management department performs prospective review for skilled nursing care, surgery and certain outpatient services. Major emphasis and focus is on managing the use of in -hospital services.
• Case Management
  Case Management is a planned approach to providing services or treatment to a member with a serious medical or chronic problem. It is aimed at effectively managing costs and promoting more effective interventions to meet patient’s needs.
  
  NetCare strongly emphasizes and makes benefits available for appropriate and cost-effective health care services including alternatives to hospitalization such as home health care services.
  
  NetCare’s case management program is designed to identify catastrophic illness or injury cases as early as possible. NetCare will identify individual claims with amounts of $5,000 or aggregate claims above $10,000 for one covered member. As a participating provider, you can alert our medical management department about a potential case management patient.

This explains the process and requirements for pre-certifications pertaining to outpatient services, procedures and hospitalization. Pre-certification is the process in which NetCare’s medical management department compares a member’s need for a non-emergency service to established criteria.

The purpose of this review are two-fold:

1. To determine the medical necessity of the service
2. To determine the appropriate setting for the service

Services Requiring Precertification Approval for ALL NetCare Plans EXCEPT HMO (Continental HMO/ Advantage HMO) (Effective June 1, 2009)
Precertification if required whenever a member is scheduled for any of the following procedures:

1. CT Scan /CTA
   Including but not limited to:
   1. Head
   2. Neck
   3. Chest
   4. Abdomen
   5. Pelvis
   6. Upper Extremity /Shoulder
   7. Lower Extremity/ Knee
2. MRI /MRA
   Including but not limited to:
   1. Head/Neck
   2. Chest
   3. Abdomen
   4. Pelvis
   5. Upper Extremity/Shoulder
   6. Lower Extremity/ Knee
3. PET Scan
4. Nuclear Cardiology and Medicine Studies
   Including but not limited to:
   1. Thyroid
   2. MIBI Scan/ Thallium/ Myocardial Perfusion Test
5. Interventional Radiology
   Including but not limited to:
   1. Angiogram/Angioplasty
   2. Embolization / Embolectomy
   3. Stent Procedures
   4. Foreign Body Extraction
   5. Hysterosalpingography, radiological supervision and interpretation
6. Elective Procedure (Major In-patient procedure)
   1. Cardiac Surgery (inluding but not limited to CABG, Septal Defect Repair, Aneurysm Repair
   2. Orthopedic Surgery (inluding but not limited to Laminectomy and Joint Replacement)
   3. Neurosurgery (inluding but not limited to Craniotomy)
   4. Gynecologic Surgery (inluding but not limited to TAHBSO)
   5. Urology Surgery (inluding but not limited to TURBT)
   6. Organ Transplant (inluding but not limited to Kidney Transplant and Heart Transplantation)
7. Cosmetic Surgery
   Including but not limited to:
   1. Abdominoplasty
   2. Augmentation Mammoplasty
   3. Blepharoplasty/ Brow Lift
   4. Chemical Peels
   5. Dermabrassion
   6. Excision of redundant skin
   7. Keloid removal
   8. Lipectomy/Liposuction/Panniculectomy
   9. Mastopexy
   10. Mastectomy for Gynecomastia
   11. Otoplasty
   12. Reduction Mammoplasty
   13. Removal/Reinsertion of Breast Implants
   14. Removal of Skin Tags any area
   15. Rhinoplasty
   16. Scar Revision
   17. Varicose Vein Surgery
   18. Wart Destruction
8. Operative and Diagnostic Endoscopies
9. Cancer Treatment (Chemotherapy and Radiotherapy)

Note: Pre-Certification request is valid for thirty (30) days from the approval date.
NOTE: Off-island pre-certification includes services and procedures mentioned above in addition to inpatient hospitalization.

HMO Plan Members (Continental HMO and Advantage HMO)

In addition to the above listed services, HMO plan members must obtain Prior Authorization/ Precertification for ALL services outside their PCP.

Members must obtain NetCare approved PCP referral before seeking Specialty Care Services or any services outside of their PCP, except for the services listed below:

Services that do not require PCP Referral, Prior Authorization or Precertification (for HMO Plan Members):

1. Mental Health Services (Specialty Co-payment applies)
2. Chiropractic Services
3. Labs, regular x-rays
4. Female members may self-refer to Obstetrical/Gynecologists for services during pregnancy
5. Services which are not covered benefits even if Primary Care Physician sent in a written referral
6. Routing Eye Care
7. Urgent/emergency Care provided on-island or while member is out of the NetCare service area.

The above listing of procedures provides only examples. Please be sure to contact NetCare’s Medical Management Department for information and clarification on other procedures requiring pre- authorization approval.

Required Documentation for Pre-certification

When submitting a pre-certification authorization request, please include the following:

1. Member or Patient Name (include Member I.D. Number)
2. Date of Birth
3. A completed and legible pre-certification form provided by NetCare
4. Name of referring physician
5. Name of physician performing the requested service
6. ICD-9/CPT codes pertinent to the requested service
7. Clinical Documentation to support the requested service
8. Contact name, phone number, fax number and location if provider has more than one location.

Procedures for submitting a Pre-certification Request

1. Patient and Physician determine the need for a procedure, test or service and submit a pre-certification encounter approval to NetCare.
2. Physician notifies its nurse coordinator to obtain a pre-certification authorization for the procedure or test with NetCare.
3. Nurse Coordinator pulls a member’s medical record or chart and copy of insurance card.
4. Nurse Coordinator determines if member has another third party insurance coverage.
5. Nurse Coordinator completes the NetCare Pre-certification Form and attaches any required documentations and submits the Pre-certification request to NetCare via Facsimile at (671) 472-3615 or (671) 472-6375.
6. NetCare’s Medical Management Department receives the pre-certification request and verifies benefits and eligibility as well as review the procedures or testing requested from the physician for medical necessity and established criteria.
7. NetCare’s Medical Management Department will respond within twenty four (24) hours from receipt indicating an approval with an authorization number, a denial of the request stating the reason for the denial or a modification stating NetCare’s recommendation and comments or a denial of the request.
8. If pre-certification request is approved by NetCare, then the physician’s nurse coordinator is responsible for sending the approved pre-certification form with the insurance coverage information to the respective billing department or business manager.
9. The physician’s nurse coordinator is also responsible for ensuring a scheduled appointment for the member using the authorization number provided by NetCare.

Appeal Process for Pre-Certification Denials
The following process or procedures are established for an appeal of any denial decisions:

1. The member or physician has the right to appeal a negative decision or denial or limited payment of benefits.
2. The appeal must be made in writing, giving all pertinent information and reasons for the reversal of decision.
3. The written appeal can be mailed to NetCare’s administrative offices at 424 West O’Brien Drive, Julale Center, Hagatna, Guam 96910 or by facsimile at (671) 472-3615 or 472-6375 or via e-mail at ljoaquin@netcarelifeandhealth.com.
4. A physician reviewer will review the appeal and recommend a written course of action or opinion to NetCare’s Medical Management Department and Plan Medical Director.
5. The decision of the Plan’s Medical Director will be made in writing to the member and physician and will be FINAL.
6. The written decision by the Plan’s Medical Director will state the affirmation, modification or reversal of the decision made.

Time-frame for making an appeal

• Members and physicians intending or wishing to appeal a negative decision must do so within thirty (30) days of learning of the decision.
• NetCare will review the case and appeal request within ten (10) working days following receipt for appeal and provide a written decision.

NetCare requires the completion of a Participating Provider Application for every practitioner wishing to become a NetCare Participating Provider. NetCare complies with accreditation guidelines for practitioners participating in network.

The Participating Provider Application be completed with the documentation:

1. Board Certifications or eligibility
2. Professional liability Insurance information
3. Medicare Assignment
4. Billing and Primary Address
5. Hospital Affiliations
6. Office or clinical hours
7. Educational Background & Residency Information
8. Malpractice Information
9. Fee Schedule
10. Professional Liability Insurance Policy
11. Guam License
12. Drug Enforcement Agency Registration
13. Guam Controlled Substance Registration
14. Completed Confidential Questionnaire

NetCare verifies all practitioner credentials including educational background, residencies, hospital affiliations and malpractice information. Credential review and approval is required prior to contracting.

NetCare also re-credentials all participating practitioners at every three years. The re-credentialing process includes primary source verification of:

1. Drug Enforcement Administration (DEA) registration number if the scope of practice would warrant the physician to have a DEA.
2. Professional Liability – minimum amount required per occurrence and per aggregate
3. Admitting privileges at Guam Memorial Hospital, Guam Regional Medical City
4. Clear report from the National Practitioners Data Bank
5. Board Certification or Board Eligible, if not Board Certified or Board Eligible, the physician must demonstrate appropriate training for specialty listed.
6. Proof of medical license
7. Sufficient information concerning any malpractice actions pending or resolved in the last five years.
8. Completed confidential questionnaire

Download our “Provider Application” today. Please contact our Provider Relations team via email at providerrelations@netcarelifeandhealth.com.