Provider Standards and Procedures

Welcome to the Provider Standards and Procedures Section. This section provides a framework for providers to collaborate with Premier Health Group leadership, with each other and with patients.

To achieve this goal, Premier Health Group partners with Premier Health Plan to provide certain administrative services for providers and patients as outlined in this manual. 

Provider Rights, Responsibilities, and Roles

Provider Rights

Providers have a right to:

  • Be treated by their patients and other healthcare workers with dignity and respect
  • Receive accurate and complete information and medical histories for patients’ care
  • Have their patients act in a way that supports the care given to other patients and that helps keep the doctor’s office, hospital or other offices running smoothly
  • Expect other network providers to act as partners in patients’ treatment plans
  • Expect patients to follow their directions, such as taking the right amount of medication at the right times
  • Help patients make decisions about their treatment, including the right to recommend new or experimental treatments
  • Make a complaint or file an appeal against Premier Health Plan and/or a patient
  • Receive copayments, coinsurance and deductibles as appropriate
  • File an appeal with Premier Health Plan on behalf of a patient, with the patient’s consent (for Medicare plans, providers should also refer to Member’s Appeal Rights for more detail)
  • Have access to information about Premier Health Group’s Quality Improvement Programs, including goals, processes and outcomes that relate to patient care and services. This includes information on safety issues.
  • Contact Premier Health Group Provider Services with any questions, comments or problems, including suggestions for changes in the Quality Improvement Program’s goals, processes and outcomes related to member care and services.

Provider Responsibilities

Providers have a responsibility to

  • Treat patients with fairness, dignity and respect
  • Not discriminate against patients on the basis of race, color, sex, national origin, gender identity, sexual orientation, disability, age, religion, mental or physical disability or limited English proficiency
  • Maintain the confidentiality of patients’ personal health information, including medical records and histories, and adhere to state and federal laws and regulations regarding confidentiality
  • Give patients a notice that clearly explains their privacy rights and responsibilities as it relates to the provider’s practice/office/facility
  • Provide patients with an accounting of the use and disclosure of their personal health information in accordance with HIPAA
  • Allow patients to request restriction on the use and disclosure of their personal health information
  • Provide patients, upon request, access to inspect and receive a copy of their personal health information, including medical records
  • Provide clear and complete information to patients, in a language they can understand, about their health condition and treatment, regardless of cost or benefit coverage, and allow the patient to participate in the decision-making process
  • Communicate freely with patients about treatment options and medication choices regardless of benefit coverage
  • Tell a patient if the proposed medical care or treatment is part of a research experiment and give the patient the right to refuse experimental treatment
  • Allow a patient who refuses or requests to stop treatment the right to do so, as long as the patient understands that, by refusing or stopping treatment, the condition may worsen or be fatal
  • Respect patients’ advance directives and include these documents in the patients’ medical record
  • Allow patients to appoint a parent, guardian, family member or other representative if they can’t fully participate in their treatment decisions
  • Allow patients to obtain a second opinion, and answer patients’ questions about how to access healthcare services appropriately
  • Collaborate with other healthcare professionals who are involved in the care of patients
  • Obtain and report to Premier Health Plan information regarding other insurance coverage
  • Follow all state and federal laws and regulations related to patient care and patient rights
  • Participate in data collection initiatives, such as HEDIS and other contractual or regulatory programs
  • Review clinical practice guidelines distributed by Premier Health Plan
  • Comply with Premier Health Plan Medical Management program as outlined in this manual
  • Notify Premier Health Plan in writing if the provider is leaving or closing a practice
  • Contact Premier Health Plan to verify member eligibility or coverage for services, if appropriate
  • Disclose overpayments or improper payments to Premier Health Plan
  • Invite patient participation, to the extent possible, in understanding any medical or behavioral health problems that the patient may have and to develop mutually agreed upon treatment goals, to the extent possible
  • Provide patients, or their designees, upon request, with information regarding office location, hours of operation, accessibility and languages, including the ability to communicate with sign language.
  • Provide patients, upon request, with information regarding the provider’s professional qualifications, such as specialty, education, residency and board certification status.

For Premier Health Advantage (HMO) and Premier Health Advantage VIP (HMO SNP):

  • Provide care to the member within a reasonable period after request for care

Provider Role in Compliance

Premier Health Plan must comply with various laws, regulations and accreditation standards to operate as a licensed health insurer. To meet these requirements, as well as combat cost trends in the healthcare industry such as fraud, abuse and wasteful spending, Premier Health Plan established its distinct Compliance program.

Premier Health Plan’s Compliance program serves to assist contracted providers, staff members, management and our board of directors with promoting proper business practices. Proper business practices include identifying and preventing improper or unethical conduct.

Reporting Compliance Concerns and/or Issues

Premier Health Plan has established a helpline for contracted providers, staff members and other entities to call to report compliance concerns and/or issues without fear of retribution or retaliation. The helpline number is (855) 222-1046(855) 222-1046 and it is available 24 hours a day, seven days a week. Callers may remain anonymous. Compliance concerns include, but may not be limited to, issues related to the Health Insurance Portability and Accountability Act (HIPAA), the Gramm-Leach-Bliley Act and the Americans with Disabilities Act (ADA).

Responsibilities of provider with regard to compliance:

  • All contracted providers are expected to conduct themselves according to Premier Health Plan’s Code of Conduct & Ethics.
  • All contracted providers have a duty to immediately report any compliance concerns and/or issues.
  • All contracted providers should be alert to possible violations of the law, regulations and/or accreditation standards, as well as to any other type of unethical behavior. Premier Health Plan prohibits retaliation against contracted providers who raise, in good faith, a compliance concern and/or issue, or any other question about inappropriate or illegal behavior.
  • Premier Health Plan prohibits retaliation against contracted providers who participate in an investigation or provide information relating to an alleged violation.

The success of Premier Health Plan’s Compliance program relies in part upon the actions taken by contracted providers. It is critical for contracted providers to be aware of the goals and objectives of the Premier Health Plan Compliance program, as well as of their responsibilities as providers.

For any questions regarding Premier Health Plan Compliance program and/or a contracted provider’s responsibilities, please call Provider Relations at (937) 499-7441(937) 499-7441.

CMS Provider Fraud Waste and Abuse and General Compliance Training Requirements 

CMS requires sponsors to provide general compliance and FWA training to all First-Tier, Downstream and Related Entities (FDRs) that are contracted with the sponsor to provide benefits or services. Providers who participate in the plan are considered first-tier entities, as they have a contractual relationship with Premier Health Group to deliver healthcare services to Medicare patients. 

All providers delivering services to Medicare patients must complete the required training upon initial contract and at least annually thereafter. As of January 1, 2016, all required training is located on the Medicare Learning Network (MLN)Off Site Icon.

Please note, providers enrolled in the Medicare program or accredited as a durable medical equipment prosthetics, orthotics and supplies (DMEPOS) provider must meet the FWA training and education requirements. Therefore, all providers are required to submit an attestation to prove this. General compliance training is still required for deemed individuals. 

Please be sure to submit the MLN certificate of completion and send it to Premier Health Group via fax at (937) 641-7377(937) 641-7377. The form must be submitted within 90 days of contracting with Premier Health Group and annually thereafter. 

Please note, if a provider does not complete this CMS requirement, he/she will be out of compliance, which may result in the termination of the agreement and/or contract. 

Provider Role in HIPAA Privacy & Gramm-Leach- Bliley Act Regulations

All Premier Health Plan policies and procedures include information to make sure Premier Health Plan complies with the Health Insurance Portability and Accountability Act (HIPAA) regulations and the Gramm-Leach-Bliley Act.

Hospitals and providers subject to HIPAA are trained to understand their responsibilities under these privacy regulations – as is the staff at Premier Health Plan.

Premier Health Plan has incorporated measures in all its departments to make sure potential, current and former members’ personal health information, individually identifiable health information and personally identifiable financial information are maintained in a confidential manner, whether that information is in oral, written or electronic format. Premier Health Plan employees may use and disclose this information only for those purposes permitted by federal legislation (for treatment, payment and healthcare operations), by the member’s written request, or if required to disclose such information by law, regulation or court order.

A form authorizing the release of personal health information is available on the Premier Health Plan website. This form complies with the core elements and statements required by HIPAA privacy rules. This form must be completed, signed and returned to Premier Health Plan before the plan will release information.

Premier Health Employee Plan members receive the Premier Health Plan Privacy Statement and Notice of Privacy Practices. Members also receive a copy of the privacy information annually. These documents clearly explain the members’ rights concerning the privacy of their individual information, including the processes that have been established to provide them with access to their Protected Health Information (PHI) and procedures to request to amend, restrict use and receive an accounting of disclosures. The documents further inform members of Premier Health Plan’s precautions to conceal individual health information from employers.

Premier Health Plan Notice of Privacy Practices is separate and distinct from the Notice of Privacy Practices providers are required to give to their patients under HIPAA. View the Premier Health Plan Privacy Statement and Notice of Privacy Practices. 

Provider Role in ADA Compliance

Providers’ offices are considered places of public accommodation and, therefore, must be accessible to individuals with disabilities. Providers’ offices are required to adhere to the Americans with Disabilities Act (ADA) guidelines, Section 504 of the Rehabilitation Act of 1973 and other applicable laws. Providers may contact Provider Services at (855) 514-3678(855) 514-3678 to obtain copies of these documents and other related resources.

Premier Health Plan requires that network providers’ offices or facilities comply with the authorities above. The office or facility must be wheelchair-accessible or have provisions to accommodate people in wheelchairs. Patient restrooms should be equipped with grab bars. Handicapped parking must be available near the provider’s office and be clearly marked. If needed, a Premier Health Plan representative will determine compliance during the on-site office/facility review.

Provider Role in Surveys and Assessments

Premier Health Plan conducts a series of surveys and assessments of members and providers in a continuous effort to improve performance. All providers are urged to participate when asked.

Reporting Fraud and Abuse

Premier Health Plan has established a hotline to report suspected fraud and abuse committed by any entity providing services to members.

The hotline number is (855) 222-1046(855) 222-1046, and it is available 24 hours a day, seven days a week. Voicemail is available at all times. Callers may remain anonymous and may leave a voicemail if they prefer.

Some common examples of fraud and abuse are

  • Billing for services and/or medical equipment that were never provided to the member 
  • Billing more than once for the same service
  • Dispensing generic drugs and billing for brand-name drugs 
  • Falsifying records
  • Performing and/or billing for inappropriate or unnecessary services

If reporting fraud and abuse by mail, please mark the outside of the envelope ― Confidential or Personal ― and send to:

Premier Health Plan
Compliance Department
110 N. Main Street
Suite 950
Dayton, OH 45402

Reporting Fraud and Abuse to the Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services has established a hotline to report suspected fraud and abuse committed by any person or entity providing services to Medicare beneficiaries. The hotline number is (800) HHS-TIPS(800) 447-8477 (800) 447-8477), and it is available Monday – Friday from 8:30 am - 3:30 pm. Callers may remain anonymous and may call after hours and leave a voicemail if they prefer.

Provider Standards and Requirements

Office Hours

Primary care physicians (PCPs) must have a minimum of 20 office hours per week and/or meet access demands.

Verifying Provider Practice Information

The network management staff will verify important demographic information about a practice each time a staff member makes a service call. This verification is needed to ensure accuracy in various areas that concern providers, including claims payments and provider directories.

Providers should notify Premier Health Plan of any provider additions, practice changes, corrections, or a change in status regarding their ability to accept new patients as soon as possible but no later than 15 days from the effective date of the change. Notification must be typewritten and submitted on business letterhead and must include the following information:

  • Physician name
  • Office address
  • Billing address (if different than the office address)
  • Phone number and fax number
  • Office hours
  • Effective date 
  • W-9 tax form

For provider changes, please fill out the “New Provider/Change of Address/Deletion Form” available online at Premierhealthplan.org.

Voluntarily Leaving the Network 

Unless your contract offers different terms, providers must give Premier Health Plan at least 180 days written notice before voluntarily leaving the network. For a termination to be considered valid, providers are required to send termination notices by certified mail (return receipt requested) or overnight courier. In addition, providers must supply copies of medical records to the patients’ new providers and facilitate the patients’ transfer of care at no charge to Premier Health Plan or the patient.

Providers must continue to render covered services to patients who are existing patients at the time of termination per the terms outlined in their Provider Participation Agreement.

Upon request from a patient undergoing active treatment related to a chronic or acute medical condition, Premier Health Plan will reimburse the provider for providing covered services for up to 90 days from the termination date. In addition, Premier Health Plan will reimburse providers for providing covered services to patients who are in the second or third trimester of pregnancy extending through the completion of postpartum care relating to the delivery. Exceptions may include

  • Patients requiring only routine monitoring
  • Providers unwilling to continue to treat the patient or accept Premier Health Plan payment

Premier Health Plan will notify members in writing of a provider’s termination, as applicable. If the terminating provider is a primary care physician (PCP), Premier Health Plan will request that the member elect a new PCP. 

Coverage for Providers on Vacation or Leave

While on vacation or leave of less than 30 days, a network provider must arrange for coverage by another provider. If a provider goes on an extended leave for 30 calendar days or longer, the provider must notify Provider Relations at (937) 499-7441.

Locum Tenens Billing Arrangements

Substitute providers are often necessary to cover professional practices when the regular providers are absent for reasons such as illness, pregnancy, vacation or continuing education. The regular provider should bill and receive payment for the substitute provider’s services as though these services were performed by the regular provider.

The regular provider may submit the claim and receive payment in the following circumstances:

  • The substitute provider does not render services to patients over a continuous period of longer than 60 days
  • The regular provider identifies the services as substitute provider services by entering a Q6 modifier (services furnished by a locum tenens provider) after the procedure code

24-Hour On-Call Coverage

PCPs and OB-GYNs are required to provide 24-hour on-call coverage and be available seven days a week. If a provider delegates this responsibility, the covering provider must participate in Premier Health Plan’s network and be available 24 hours a day, seven days a week.

Provider Scope of Services

Providers may bill Premier Health Plan for all services performed for assigned patients. The services should be within the scope of standard practices appropriate to the provider’s license, education and board certification.

Provider Effective Date

The effective date for provider participation is the date that Premier Health Plan Credentialing Committee approves the application.

For Specialists: In-Office Procedures

Specialists should perform procedures only within the scope of their license, education, board certification, experience and training. Premier Health Plan will periodically evaluate the appropriateness and medical necessity of in-office procedures.

Guidelines Regarding Advance Directives

An advance directive (sometimes referred to as a living will) is a written statement that an individual composes in advance of serious illness regarding medical decisions affecting him or her. In the event that an individual is unable to communicate his or her medical decisions, an advance directive informs the provider of the patient’s intent.  In order to be effective, the advance directive must meet all the requirements of state and federal law.

A Health Care Power of Attorney

A health care power of attorney (sometimes referred to as a durable power of attorney) is a signed, witnessed, written statement by an individual granting another person a power of attorney to make medical decisions if the individual is unable to do so. A health care power of attorney can include instructions about any treatment the individual desires to undergo or avoid.  In order to be effective, the health care power of attorney must meet all the requirements of state and federal law.

What Is the Legislative Basis for Informing Individuals about Advance Directives?

The requirements for informing individuals about advance directives are outlined in the Omnibus Budget Reconciliation Act of 1990, which went into effect on December 1, 1991. Providers subject to the Act must not discriminate against an individual based on whether the individual has an advanced directive. 

If a patient decides to execute an advance directive, living will or a healthcare power of attorney, the patient is encouraged to notify his or her PCP of its existence, provide a copy of the document to be included in personal medical records and discuss this decision with the PCP.

Guidelines for Medical Record Documentation

Premier Health Plan requires participating network physicians to maintain medical records in a manner that is accurate and timely, well-organized, readily accessible by authorized personnel and confidential. Per Premier Health Plan policy, all medical records must be retained for 10 years.

Consistent and complete documentation in the medical record is an essential component of quality patient care. Medical records should be maintained and organized in a manner that assists with communication among providers to facilitate coordination and continuity of patient care.

Premier Health Plan has adopted certain standards for medical record documentation, which are designed to promote efficient and effective treatment. Premier Health Plan periodically reviews medical records to ensure that they comply with the guidelines.

Medical Record Confidentiality and Security

A provider must store medical records in a secure location that can be locked and protected when not being used but still permits easy retrieval of information by authorized personnel only. A provider must also periodically train medical office staff and consistently communicate the importance of medical record confidentiality.

Basic Information:

  • Place the patient’s name or ID number on each page of the medical record.
  • Include marital status and address, the name of employer and home and work telephone numbers.
  • Include the author’s identification in all entries in the medical record. The author’s identification may be a handwritten signature, a unique electronic identifier or his or her initials.
  • Date all entries.
  • Ensure that the record is legible to someone other than the writer.

Medical History:

  • Indicate significant illnesses and medical conditions on the problem list. If the patient has no known medical illnesses or conditions, the medical record should include a flow sheet for health maintenance.
  • List all medications and prominently note medication allergies and adverse reactions in the record. If the patient has no known allergies or history of adverse reactions, providers should appropriately note this in the record.
  • Document in an easily identifiable manner past medical history (for members seen three or more times), which may include serious accidents, operations and illnesses. For children and adolescents (18 years old and younger), past medical history should relate to prenatal care, birth, operations and childhood illnesses.
  • For patients 14 years old and older, note the use of cigarettes, alcohol and substances. (For patients seen three or more times, query substance abuse history).
  • Maintain an updated immunization record for patients aged 17 and under.
  • Include a record of preventive screenings and services in accordance with the Premier Health Group Preventive Health Guidelines.
  • Include, when applicable, summaries of emergency care, hospital admissions, surgical procedures and reports on any excised tissue.

Treatment:

  • Document clinical evaluation and findings for each visit. Identify appropriate subjective and objective information in the history and physical exam that is pertinent to the member’s complaints.
  • Document progress notes, treatment plans and any changes in a treatment plan, including drugs prescribed.
  • Document prescriptions telephoned to a pharmacist.
  • Document ancillary services and diagnostic tests that are ordered and diagnostic and therapeutic services for which a patient was referred.
  • Address unresolved problems from previous office visits in subsequent visits.

Follow-up:

  • Include on encounter forms or notes a notation regarding follow-up care, calls or visits.
  • Providers should note the specific time of the recommended return visit in weeks, months or as needed.
  • Keep documentation of follow-up for any missed appointments or no-shows. Physicians should document initial consultation, lab, imaging and other reports to signify review.
  • A review by and signature of another professional, such as a nurse practitioner or physician assistant, does not meet this requirement.
  • Consultation, abnormal lab and imaging study results must have an explicit notation of follow-up plans in the record.

Accessibility Standards

Premier Health Plan follows accessibility requirements set forth by applicable regulatory and accrediting agencies.

Emergency Services

In case of a medical urgency, a patient should attempt to call his or her PCP, if possible, explain the symptoms, and provide any other information necessary to help determine appropriate action.

The member should go to the nearest emergency facility for the following situations:

  • If directed by the PCP
  • If the patient cannot reach the PCP or the covering provider
  • If the patient believes he or she has an life-threatening medical condition

Patients with an emergency medical condition should understand they have the right to summon emergency help by calling 911 or any other emergency telephone number, as well as a licensed ambulance service, without getting prior approval.

Premier Health Plan will cover care for an emergency medical condition with symptoms of such severity that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of woman or her unborn child) in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

Urgent Care

Urgent care is defined as any illness, injury or severe condition that, under reasonable standards of medical practice, would be diagnosed and treated within a 24-hour period and, if left untreated, could rapidly become an emergency medical condition.

When in the primary service area, patients should contact their PCPs if they have an urgent medical need. Premier Health Plan encourages providers to make same day appointments available for their patients who call with unscheduled urgent healthcare needs. This improves the quality and continuity of patient care.

If patients are unable to contact their PCPs, and they believe they need care immediately, they should seek immediate medical attention. After such treatment, patients should contact their PCPs within a reasonable amount of time. A reasonable amount of time is typically considered 24 hours, unless there are extenuating circumstances.

Out-of-Area Care

Out-of-area care should not be confused with out-of-network care. Out-of-area care is care rendered to patients traveling outside Premier Health Plan’s primary service area. Out-of-network care is care sought by members at a facility or provider not within the network appropriate to the patient’s benefit plan.

All patients are always covered for emergency and urgent care services.

Routine Care

Patients must seek routine and preventive care from providers within their network.

Injury or Illness

A patient who needs care while traveling outside the service area should contact his or her PCP, if applicable, within 24 hours or as soon as reasonably possible, to inform the PCP of the nature of the illness or injury. The PCP must call Medical Management at (855) 869-7140(855) 869-7140 to obtain authorization for services rendered by a non-participating provider.

If Medical Management authorizes the care, the level of benefits will be determined at that time.

Patients who receive a bill or have paid for services provided outside the area should submit those bills to Premier Health Plan. If patients have questions, they may call Member Services.

Referrals and Coordination of Care

Provider Role in Coordinating Care

Premier Health Plan relies on each provider to ensure the appropriate use of resources by delivering quality care in the proper setting at the right time. Premier Health Plan’s approach to accountability is based on the belief that providers know what is best for patients. We rely on our providers to

  • Provide the appropriate level of care
  • Maintain high quality
  • Use healthcare resources efficiently

Providers are encouraged to coordinate a patient’s care with other specialists, therapists, hospitals, laboratories and facilities in the network appropriate to the patient’s benefit plan. Network providers are responsible for determining the type of care the patient needs and the appropriate provider or facility to administer that care.

The Role of the Referring Provider

It is recommended that providers communicate with specialists, therapists and other providers regarding patients’ care. In turn, those providers should reciprocate by informing the referring provider of their findings and proposed treatment. This sharing of information can be accomplished by telephone, fax, letter or prescription. Providers are also encouraged to supply Premier Health Plan with critical information needed to authorize certain types of care and process claims.

Providers should follow these steps when referring a patient to a specialist:

  • Direct specialty care to providers, therapists, laboratories and/or hospitals appropriate to the patient’s benefit plan: The only time a provider should send a patient to specialists, therapists, labs and hospitals outside the patient’s benefit plan is when extenuating circumstances require the use of an out- of-network specialist or facility or because the only available specialist or facility is not part of the patient’s benefit plan. The provider must have prior authorization from Medical Management at (855) 869-7140(855) 869-7140 to refer a patient to an out-of-network specialist or facility.
  • Correspond with the specialist/behavioral health provider: The provider may call or send a letter, fax or prescription to the specialist. The referring provider should communicate clinical information directly to the specialist without involving the patient.
  • Give the facility, specialist or behavioral health provider the following referral information:
    • Patient’s name
    • Reason for the referral
    • All relevant medical information (e.g., medical records, test results)
    • Referring provider’s name and Unique Provider Identification Number (UPIN) or National Provider Identifier (NPI)

Please refer to the provider directory, which can be found online. For a copy, please call Provider Relations at (937) 499-7441(937) 499-7441.

The Role of the Specialist for all Premier Health Group Patients

  • Verify the care was coordinated: When a patient sees a specialist, the specialist’s office needs to determine whether a provider coordinated the care or the patient directly accessed the specialist for care.
    • If a provider coordinated the care, collect any paperwork or check office records for communication from the referring doctor.
    • If the patient self-directed care to a specialist, contact the PCP, if applicable, to obtain medical records and check to see if any diagnostic testing already has been completed to avoid duplicate testing.
    • If the patient does not have a PCP, obtain a medical history and try to determine whether any prior diagnostic testing has been performed.
     
  • Determine the copayment: If the visit is self-directed by a patient whose benefit plan does not require the selection of a PCP, care is covered at a higher benefit level if the patient uses a network provider and at a lower benefit level if the patient uses an out-of-network provider.
  • Communicate findings: The specialist must communicate findings and treatment plans to the referring provider within 30 days from the date of the visit. The referring provider and specialist should jointly determine how care is to proceed.

Specialists who need to send their patients to out-of-network specialists and facilities must get prior authorization from Medical Management at (855) 869-7140(855) 869-7140. The requesting provider must give the reason for the out-of-network referral. If written information is required, it may be sent to:

Premier Health Plan
950 N. Meridian St.
Suite 600 
Indianapolis, IN 46204

Hospital Guidelines

Observation Status

Observation status applies when inpatient hospital admission is being considered for a patient but is not certain. Observation status should be used: 

  • When the patient’s condition is expected to be evaluated and/or treated within 24 hours (48 hours for Medicare Advantage members)
  • Follow-up care is provided on an outpatient basis
  • When the patient’s condition or diagnosis is not sufficiently clear to allow the patient to leave the hospital

In Network Hospitals

Inpatient Admissions:

Network providers may admit a patient to any network hospital appropriate to the patient’s benefit plan. If the admitting provider is a specialist, the specialist must communicate the admission to the patient’s PCP, if applicable, to ensure continuity and quality of care.

Emergency Admission:

Upon admitting a patient from the emergency department, the hospital should collect the following information:

  • The practice name of the patient’s PCP, if applicable
  • The name of the patient’s referring provider if referred for emergency care
  • The name of the admitting provider if different from the referring provider or PCP

The hospital or facility must notify Medical Management at (855) 869-7140(855) 869-7140 within 48 hours or on the next business day following the emergency admission. Notifications can also be faxed to Medical Management at (855) 431-8762.

Out-of-Network Hospitals

Emergencies:

When a patient is admitted to an out-of-network hospital for an emergency medical condition, the patient’s provider should contact Medical Management at (855) 869-7140(855) 869-7140 and ask to speak to a medical review nurse. The nurse may coordinate a transfer to a hospital appropriate to the patient’s benefit plan when the patient is medically stable.

Non-Emergencies:

Patients should not be admitted to out-of-network hospitals unless prior authorization is obtained for medically necessary services not available in the network. Call Medical Management at (855) 869-7140(855) 869-7140 for prior authorization. The request may also be submitted via fax to (855) 431-8762 or submitted electronically through Identifi Practice. For access to this web-based secure electronic submission process, please email PHGProviderRelations@premierhealth.com

Inpatient Admission ─ Notification Guidelines 

Inpatient Admission Notification Requirements 

Notify Premier Health Plan within 48 hours of hospital admission and discharges, or the next business day for weekend or holiday admissions and discharges. 

Admissions to skilled nursing facility, acute rehab, or long-term acute care hospital levels of care require prior authorization. 

Admission Notification is not required for the following: 

  • Routine labor and delivery admissions for the following federally mandated guidelines: Normal vaginal delivery w/post-partum length of stay (LOS) of 48 hours or less; Cesarean section delivery w/post-partum length of stay (LOS) of 96 hours or less 
  • 23 hour outpatient surgery (exception for: Out of Network or Cosmetic procedures and E&I)  
  • Observation status admission for up to 23 hours

Information Needed to Report Hospital Admissions 

The following data elements are necessary for accurate, efficient and timely processing of inpatient admission notification.

  • Member name & ID number 
  • Member date of birth (DOB), address and phone number 
  • Admission date, if discharged provide discharge date and disposition 
  • Facility name & Provider NPI and TAX ID number 
  • Admitting physician (first & last name) 
  • Admitting diagnosis and/or ICD-10 code 
  • Admission source (emergency, elective, etc.) and admission type (medical, surgical, etc.) 
  • Contact name & phone/fax number (for additional information if needed) 
  • Clinical Information

Submission of Hospital Admission Notifications 

  1. Fax of a Daily Facility Admission / Discharge Report to (703) 842-8555
  2. Fax of a completed Inpatient Certification Request form to (855) 431-8762
  3. Call (855) 869-7140(855) 869-7140 to report hospital admissions and/or request prior authorization.

The Inpatient Certification Request form is located on Premier Health Plan website - Certification Request for Authorization of Services.

If the above information is not received timely this may result in a delay of decision making and subsequent determination. As these cases will be sent to the Medical Director for review and determination. More information on the determination process can be found in the Provider Disputes section of this manual.  

Inpatient Consultation and Referral Process

If the admitting provider determines that a patient requires a consultation with a specialist, the admitting provider can refer the patient to a network specialist appropriate to the patient’s benefit plan. The referral should follow the hospital’s locally approved procedures (e.g., consultation form, physician order form).

The admitting provider and specialist jointly should determine how care should proceed. 

Coordination of care occurs through active communication among the PCP, the admitting provider, and the specialist.

Pre-Admission Diagnostic Testing

All pre-admission diagnostic testing conducted before a patient’s medically necessary surgery or admission to the hospital is covered when performed at a hospital appropriate to the patient’s benefit plan. Some procedures may require prior authorization. 

Pre-admission diagnostic testing includes

  • Laboratory diagnostic tests
  • Radiological diagnostic tests
  • Other diagnostic tests, including electrocardiogram, pulmonary function and neurological

If testing is completed within 72 hours of the patient’s admission, it is included with the admission. Otherwise, the testing can be billed separately. 

Transfers

Transfers between in-network facilities:

If a patient is admitted to a network hospital and needs to be transferred to another hospital, please contact Medical Management at (855) 869-7140(855) 869-7140.

Transfers to out-of-network facilities:

remier Health Plan requires prior authorization for transfer to an out-of-network facility. The transferring provider must contact Medical Management at (855) 869-7140(855) 869-7140 and speak to a medical review nurse. Without prior approval, coverage will be denied.

Discharges

Medical Management works with the hospital’s Utilization Management department to coordinate discharge planning.

A discharge planner is available to assist in coordinating follow-up care, ancillary services and other appropriate services. Contact Medical Management at (855) 869-7140(855) 869-7140 to speak to a discharge planner.

Hospital Delivery Notification

The hospital in which a Premier Health Plan newborn is delivered should call Medical Management to inform them of the delivery.

Provider Disputes

If a provider disagrees with a decision by Premier Health Plan to deny coverage of care or services, the provider may be able to dispute the decision or bring an appeal on behalf of the affected member. Punitive action will not be taken against a provider who requests an expedited resolution or supports a member’s appeal.

Requests for appeals must include the reason for the appeal and a copy of the medical record or other supporting documentation. The request for appeal should clearly state why and on what basis the provider wishes to appeal. To answer any additional questions about the right to appeal or how to file an appeal, providers may call Provider Services at (855) 514-3678(855) 514-3678. For Medicare plans, providers should also contact Provider Services and refer to Member’s Appeal Rights for more detail.

Resubmitting a corrected claim due to minor error or omission is not an appeal. Corrections or resubmissions of claims due to minor errors or omissions should be sent to the customary claims address.

Administrative Appeal

Administrative appeals involve claims that have been denied for reasons other than those related to medical necessity. Therefore, administrative denials are not reconsidered based on medical necessity. An example of an administrative appeal is if prior authorization was required but not obtained.

The following procedure outlines the administrative appeal process:

  • Provider sends a written appeal to Premier Health Plan at the following address within 120 days of the denial stating the reason the claim was denied (from the Explanation of Payment) and any supporting documentation as to why the provider believes the decision should be reversed. For Medicare plans, providers should contact Provider Services at (855) 514-3678(855) 514-3678, and also refer to Member’s Appeal Rights for more detail.
  • Premier Provider Appeals
    P.O. Box 2718
    Pittsburgh, PA 15230-2718

  • Premier Health Plan will review the administrative appeal.
  • Premier Health Plan will inform the provider of its decision within 60 business days (or sooner as may be required for Medicare plans). All decisions are final. If the administrative denial is reversed, the claim is adjusted within 30 business days of the date of the decision.

Medical Necessity Appeal

Providers have the right to appeal Premier Health Plan’s decision to deny benefit coverage for healthcare services on the patient’s behalf. Medical Necessity appeals must be submitted within 180 days of the denial. Unless a patient is enrolled in the Premier Health Employee Plan, or other self-insured plans, pursuant to Ohio Revised Code Section 1751.82(B), medical necessity appeals may only be brought with the patient’s consent and should be submitted in accordance with the member’s appeal rights documentation and Member Handbook or Certificate of Coverage. The appeal request should include the reason for the appeal, a clear statement of why and on what basis the provider wishes to appeal, as well as a copy of the medical record or other supporting documentation. A physician who was not involved with the initial determination and who has experience in the same or similar specialty as the condition at issue will review the appeal. 

Reconsiderations

Prior to filing an appeal, although not required, a provider may request a reconsideration. Reconsiderations can be requested related to prospective determinations or concurrent review determinations where an admission, availability of care, continued stay or other healthcare service has been reviewed and does not meet the requirements for benefit payment and coverage is, therefore, denied, reduced or terminated. Providers must request a reconsideration within two business days of receipt of this denial. Premier Health Plan will conduct the reconsideration within three business days of receipt. Based on the patient’s condition, the provider can request an expedited reconsideration. If the provider/patient is not satisfied with the outcome of the reconsideration, the patient or the provider on behalf of the member can request an appeal within 180 days of the date of initial denial.

Providers should consult with the patient to confirm the appeal process that applies to their Premier Health Plan benefits. Some benefit plans provide for one level of appeal; other benefit plans provide for two levels of appeal. All benefit plans allow patients to request an external review after exhausting Premier Health Plan’s internal appeal process. 

Premier Health Plan ensures review of patient appeals by individuals, including a physician reviewer, who were not involved in the initial denial (or previous levels of appeal, if applicable) and who are not subordinate to an individual who was involved in the initial denial (or previous levels of appeal, if applicable). 

Expedited Appeal

With documented patient consent, a provider with knowledge of the patient’s conditions can request an expedited review if he/she believes the patient’s life, health or ability to regain maximum function is in jeopardy because of the time required for the usual review process. A decision is rendered as quickly as is warranted by the patient’s condition but no later than 72 hours after the review is received. Under Medicare guidelines, the 72-hour period begins when the request is received by the appropriate office or department designated by the Medicare health plan regardless of whether the provider is under contract to the Medicare health plan. An expedited review can be requested by calling Medical Management at (855) 869-7140(855) 869-7140. Clinical documentation is required.

Provider Credentialing

The provider credentialing process involves several steps: application, primary source verification, on-site evaluation, notification and a Credentials Committee review.

Application

Please contact Provider Relations at (937) 499-7441(937) 499-7441 for any questions related to credentialing. Premier Health Plan utilizes the CAQH application. If you are in the credentialing process and have not already done so, please attest to your CAQH application.

Primary Source Verification

The Credentialing department contacts each primary source to verify the following credentials:

  • Board certification
  • Malpractice insurance coverage and history of liability claims
  • Medicare and Medicaid sanctions
  • Residency or medical school only if not board-certified (highest level of education or training must be verified)
  • Sanctions, restrictions or suspensions of a state license
  • Status of staff privileges at a network Health Plan hospitals
  • Valid DEA or CDS certification
  • Valid, unrestricted license to practice in states in which the practice resides
  • Work history—this does not require primary source verification, although gaps of 6 months must be reviewed with the practitioner and gaps of 1 year need to be clarified in writing by the practitioner for inclusion in the credentialing file.
  • Medical liability insurance per plan requirements 
  • Eligibility for participation in Medicare (did not opt-out)

On-Site Evaluation

If deemed necessary, a network representative will contact PCPs, OB-GYNs, and high-volume specialists to arrange an on-site evaluation of practice sites and medical record documentation.

The following standards will be assessed:

  • Adequacy of waiting room and exam room space
  • Availability of appointments
  • Emergency care and CPR certification
  • Hazardous waste elimination
  • Medical equipment management
  • Medical record documentation
  • Medication administration
  • Physical accessibility, availability and appearance of practice sites
  • Radiology, cardiology and laboratory services (if applicable)

Notification

Once all information is complete, including primary source verification and office site review (if applicable), the Credentialing department reviews and compares all information on the application to the primary source data. If any discrepancies are noted, the provider is notified in writing and has two weeks to forward the correct information in writing to the Credentialing department supervisor.

In addition, a provider has the right to review the information submitted in support of his or her application. If the provider discovers erroneous information on the application, the provider has the opportunity to correct this information before the Credentials Committee reviews it. The provider must initial and date the corrected information.

Upon request, a provider also has the right to request information regarding the status of his/her credentialing/recredentialing application.

Credentials Committee Review

Completed credentialing files are then presented to the Credentials Committee for review and deliberation. A welcome letter and packet are sent to practitioners once they are approved as providers in the provider network.

Providers will be notified in writing if they are denied credentialing status for some reason. In the event that a practitioner wishes to appeal a credentialing denial decision, the request must be submitted via a letter addressed to the chairperson of the Credentials Committee.

Recredentialing Process

All providers must be recredentialed within two to three years of the date of their last credentialing cycle. The recredentialing process is the same basic process as that for credentialing, except that providers also are evaluated on their professional performance, judgment and clinical competence. Criteria used for this evaluation may include, but not be limited to, the following:

  • Compliance with policies and procedures
  • Sanctioning related to utilization management, administrative issues or quality of care
  • Patient complaints
  • Patient satisfaction survey
  • Participation in quality improvement activities
  • Quality-of-care concerns 

Applications for reappointment are forwarded to the providers about 6 months before the practitioner’s recredentialing date to enable the credentialing process to be completed within the required period.

Dual Credentialing and Recredentialing as a PCP and Specialist

Premier Health Group will consider, as an exception, requests from providers to participate as both a PCP and specialist when the provider:

  • Meets credentialing standards for each specialty requested
  • Provides documentation demonstrating adequate professional training, expertise, capacity and capabilities to undertake such responsibilities for providing both primary care and specialty services
  • Agrees to be listed as a PCP in all patient literature and accept membership
  • Provides evidence of continuing medical education credits (CMEs) per three-year period in the additional area in which he or she wants to be credentialed
  • Agrees not to bill consultation charges for patients enrolled in the PCP practice regardless of the nature of the visit

Credentialing and Recredentialing Issues

Premier Health Group requires that PCPs and specialists be board certified in their respective specialties by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). During the credentialing and/or recredentialing period, board certification will be verified. Depending on the availability of qualified, board-certified physicians, the following exceptions may apply:

  • Providers who meet all other qualifications but began practicing a specific scope of medical practice before the availability of board certification in their particular specialty. Such practitioners must have active admitting privileges at a Premier Health Group-affiliated hospital and maintain CME requirements as specified by the Ohio State Medical Board.
  • Providers who are within five years of completing an approved residency or fellowship in the specialty in which they practice.
  • Providers who are members of a group practice in which 50 percent of the group physicians are board certified in the requesting practitioner’s specialty.
  • Providers who are practicing in federally designated underserved areas and meet all other credentialing standards, including
    • Practicing in a requested specialty for more than five years
    • Active admitting privileges at a network facility in the appropriate department
    • CME requirements as specified by the Ohio State Medical Board  

Malpractice Insurance

Providers must submit a copy of their current malpractice insurance face sheet with the amount of coverage and policy effective dates at the time of credentialing or recredentialing.

Credentialing Denials and Appeals

Premier Health Group will send a letter to a provider who has been denied credentialing. A practitioner may appeal a credentialing decision in the following manner:

  1. Providers should send requests for appeals to the following address:
  2. Premier Health Plan
    Compliance Department
    110 N. Main Street
    Suite 950
    Dayton, OH 45402

  3. The Credentials Committee sends the provider written notice of the hearing.
  4. The hearing date, time and place, as well as the composition of the appeals committee, will be sent to the provider at least 30 calendar days before the scheduled hearing date. The notice will include a request for the provider’s consent to disclose the specifics of his or her application and all credentialing documentation to be discussed at the hearing.

    The provider has the right to be present and is allowed to offer evidence or information to explain or refute the cause for denial. Legal counsel also can represent the provider, as long as Premier Health Group is informed of such representation at least seven days before the hearing.

  5. The Appeals Committee conducts the hearing and sends a recommendation to the Quality Improvement Committee (QIC).
  6. The Appeals Committee, consisting of three voting providers selected by the Credentials Committee chairperson, will deliberate without the provider present. Its decision will be by majority vote and will be forwarded to Premier Health Group’s Quality Improvement Committee (QIC) as a recommendation.

  7. The QIC makes a decision and notifies provider.
  8. The QIC’s decision is final. Written notice of the QIC’s decision will be sent to the provider in an expeditious and appropriate manner and will include a written statement giving the basis of the decision.

Provider Sanctioning

Premier Health Group follows a three-phase process for addressing the actions of providers who fail to adhere to certain requirements set forth below.

Actions that Could Lead to Sanctioning

Actions that could lead to sanctioning fall into three main categories: administrative noncompliance, unacceptable resource utilization and quality of care concerns.

Administrative Noncompliance

Administrative noncompliance is consistent or significant behavior that is detrimental to the success or functioning of Premier Health Group.

Examples include:

  • Conduct that is unprofessional or erodes the confidence of patients
  • Direct or balance-billing for services

Unacceptable Resource Utilization

Unacceptable resource utilization is a utilization pattern that deviates from acceptable medical standards and may adversely affect a patient’s quality of care.

Quality of Care

A quality of care issue may arise from an episode that adversely affects the functional status of a patient or a pattern of medical practice that deviates from acceptable medical standards. For quality of care concerns, the QIC has selected a severity scale. This scale ranks cases that may involve a practice pattern deviating significantly from the norm. The sanctioning process and focused monitoring of the provider remain in effect for no less than one year from the date the provider is notified by a Premier Health Group representative. The provider is notified when the process and follow-up activities are satisfied and the sanctioning is no longer in effect. In instances of recurring similar noncompliance activities, Premier Health Group reserves the right to expedite the sanctioning process.

Provider Termination

The QIC, as part of the sanctioning process, may recommend the termination of a provider contract. The provider will be notified in writing and offered the opportunity to appear at a hearing, if appropriate. The termination process involves the following steps:

  1. Medical director notifies provider about termination.
  2. The provider will be given notice stating that a professional review action was recommended and the reasons for the proposed action. The provider has the right to request a hearing within 30 calendar days.

  3. Provider may request a hearing.
  4. If a hearing is requested, the provider will be given notice stating the place, time and date of the hearing—to occur no later than 60 calendar days after the date of the notice—and the names of witnesses, if any, expected to testify on behalf of Premier Health Group.

  5. QIC appoints an Appeals Committee.
  6. The QIC will appoint an Appeals Committee on an ad hoc basis. The QIC will not select as members of the Appeals Committee anyone in direct economic competition with the provider who is the subject of the hearing or anyone who has previously voted on the action.

  7. Appeals Committee conducts the hearing and makes recommendations.
  8. After the QIC recommends termination of participation status or another sanction, the Appeals Committee will hear the appeal from a provider if the QIC—in its sole discretion—offered the provider the opportunity to appeal. The Appeals Committee will conduct the hearing and recommend to the QIC that it accept, reject or modify its original recommendation. The right to the hearing may be forfeited if the provider fails, without good cause, to appear. The QIC’s decision is final, and the provider will have no right to further appeal.

At the hearing, the provider has the right to:

  • Receive representation by an attorney or other person of the provider’s choice
  • Have a record made of the proceedings, copies of which may be obtained by the provider upon payment of any reasonable charges associated with the preparation of the records
  • Call, examine and cross-examine witnesses
  • Present evidence determined to be relevant by the hearing officer regardless of its admissibility in a court of law
  • Submit a written statement at the close of the hearing

Upon completion of the hearing, the provider has the right to receive the written recommendation of the Appeals Committee from Premier Health Group in an expeditious and appropriate manner, including a written statement giving the basis of the decision.