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TABLE OF CONTENTS
QUICK REFERENCE GUIDE .........................................................................................................................................................4
MEMBER INFORMATION ............................................................................................................................................................6
Member Eligibility .................................................................................................................................................................6
Eligibility Verification............................................................................................................................................................6
Member Hold Harmless..........................................................................................................................................................8
Member Confidentiality .........................................................................................................................................................8
Member Rights and Responsibilities ......................................................................................................................................9
Advance Medical Directives...................................................................................................................................................13
Benefits and Services..............................................................................................................................................................13
PROVIDER INFORMATION ..........................................................................................................................................................13
Role of the Primary Care Physician (PCP).............................................................................................................................13
Role of the Specialist Physician .............................................................................................................................................14
Communication between Providers........................................................................................................................................14
Provider Marketing Guidelines...............................................................................................................................................14
PROVIDER CREDENTIALING AND PARTICIPATION ...........................................................................................................15
PROVIDER & ALLIED HEALTH PRACTITIONERS CREDENTIALING CRITERIA ........................................................15
Required Information .............................................................................................................................................................15
Credentials Criteria.................................................................................................................................................................16
Additional Requirements........................................................................................................................................................19
Initial Credentialing Office Site Reviews...............................................................................................................................19
Provider Re-Credentialing......................................................................................................................................................20
Practitioner’s Rights ...............................................................................................................................................................20
PROVIDERS DESIGNATED AS PRIMARY CARE PHYSICIANS............................................................................................21
CHANGES IN ADMINISTRATIVE, MEDICAL AND/OR REIMBURSEMENT POLICIES..................................................21
NOTIFICATION REQUIREMENTS FOR PROVIDERS.............................................................................................................21
CLOSING PATIENT PANELS.........................................................................................................................................................22
PROVIDER ACCESS AND AVAILABILITY STANDARDS.......................................................................................................22
CLAIMS SUBMISSION ...................................................................................................................................................................23
Professional Claims................................................................................................................................................................23
Institutional Claims.................................................................................................................................................................24
Participating Provider Claim Reconsideration Process ..........................................................................................................25
Claim
Adjustment Reason Codes...........................................................................................................................................26
NATIONAL PROVIDER IDENTIFIER (NPI)................................................................................................................................31
HIERARCHICAL CONDITION CATEGORIES (HCC) ..............................................................................................................33
SAMPLE EXPLANATION OF BENEFITS (EOB) STATEMENT AND PAYMENT CHECK................................................34
