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Memorial Hermann Health Solutions, Inc.
PPO Provider Manual
Table of Contents
Chapter 1
Introduction
 Network Services
 How to Reach Us
 MHHSI Provider Website
Chapter 2
PPO Quick Reference Guide
Chapter 3
Eligibility
Chapter 4
General Administrative Requirements
 Access Standards
 After-Hours Care
 Arrange Substitute Coverage
 Continuity of Customer Care
 Medical Record Standards
 Provide Official Notification
 Non-discrimination
Chapter 5
Medical Management
 Purpose
 Medical Necessity Criteria
 Medical Management Process
 Appeal of Clinical Non-authorization
 Medical Review of Claims
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Chapter 6
Billing/Claims Coding and Submission
 Purpose
 Medical Necessity Criteria
 Medical Management Process
 Appeal of Clinical Non-authorization
 Medical Review of Claims
Chapter 7
Reimbursement Guidelines, Coding and Bundling
 Authorization and Payment Determination
 Explanation of Benefits (EOB)

Member Liability
Chapter 8
Customer Service
Chapter 9
Credentialing and Recredentialing
 Purpose
 Confidentiality
 Credentialing Process
 Recredentialing Process
 Termination of Network Participation Status
 Appeal Process
Chapter 10
Pharmacy
Chapter 11
HIPAA
Chapter 12
Provider Rights and Responsibilities
Chapter13
Glossary
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Chapter 1 Introduction
MHHSI is a subsidiary of Memorial Hermann Healthcare System. We provide traditional and ASO products and
services.
MHHSI is committed to working with its independently contracted physicians, other healthcare professionals and
members to provide a high level of satisfaction in delivering quality health benefits. The MHHSI PPO Operations
Manual is an integral part of this commitment.
This manual is a summary of some of MHHSI’s more significant policies and procedures. MHHSI reserves the right
to modify, amend or implement new policies or procedures without notice. In those instances where information in
this manual differs from that in the provider Agreement, the manual takes precedence over the Agreement.
Network Services:
Network Services has three distinct functions: contracting, credentialing and provider relations. Our staff supports
the network through the contracting, credentialing and re-contracting processes and provides ongoing education and
support to healthcare professionals and their office staffs.
In order to provide the most current, detailed information possible, the most up-to-date version of the Provider
Manual is located on MHHSI website at www.mhhealthplan.org. The Provider Manual is reviewed and updated at
least once annually or more often if the need arise.
As a provider of MHHSI, you have agreed to follow and adhere to “Rules & Regulations,” which include, but is not
limited to, all quality improvement, utilization management, credentialing, peer review and other policies and
procedures established and revised by MHHSI from time to time and the MHHSI Provider Manual, as amended
from time to time. Further, the policies and procedures set forth herein may be altered, amended, or discontinued by
MHHSI at any time upon notice to the provider.
How to Reach Us:
Provider Responsibility for Notification of Change:
Please submit notifications of change of practice name or affiliation, Tax Identification Number (TIN), National
Provider Indicator (NPI), address, phone number or other demographic data on the provider’s office letterhead
stationery to MHHSI Network Services as soon as possible. Notifications may be faxed to the appropriate number
below.
Fax - (713) 704-0621
MHHSI Provider website:
mhhealthplan.org
Visit the MHHSI provider website to obtain additional information on:
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medical policies
member eligibility
claim status
formulary
HIPAA
advanced notification of fee schedule updates
advanced notification of contracted provisions
provider manuals – self-insured and fully insured
internet provider finder
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Chapter 2 Quick Reference Guide
Customer Service/Eligibility:
We can be reached online at Mhhealthplan.org or call (713) 338-4683 or if you are outside the Houston area, 1-888594-0671. Utilize our website or call Customer Service for assistance with questions regarding:
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Benefits
Claims
Copayments
Eligibility
Claim Submissions:
Refer to the member’s ID card for claims payment addresses.
EDI Claim Submissions:
Refer to the member’s ID card for electronic claims payor information.
MHHSI encourages Electronic Data Interchange (EDI) claims submission, which can promote faster claim
turnaround and improve efficiency. You can discuss EDI submission with your billing service. For additional
information about electronic claims submission, please contact your Provider Relations (PR) representative at (713)
338-4801 or e-mail at [email protected].
Medical Management
Memorial Herman Health Solutions, Inc. – Self Insured
Phone: (713) 338-6588
Toll Free: (888) 738-8778
Fax: (713) 338-6494
Hours: 8 a.m. to 5 p.m. CT
Memorial Hermann Health Insurance Company – Fully Insured
Phone: (713) 338-5594
Toll Free: (888) 252-7680
Fax: (713) 338-6494
Hours: 6 a.m. to 6 p.m. CT
Weekend and Holiday Coverage: 9 a.m. to 12 p.m. Call are routed to on-call nurse.
Mailing Address:
7737 Southwest Freeway, Suite C-97
Houston, TX 77074
Network Services:
[email protected] or (713) 338-4801
Precertification:
The member’s Plan Booklet provides detailed information about the necessity to provide advance notification of
hospital admissions and certain outpatient surgical and diagnostic procedures. To obtain benefit precertification on
the member’s behalf, please contact the Customer Service number located on the ID card.
It is important to note that benefit precertification is not a guarantee of payment. Benefits will be determined in
accordance with the terms of the applicable certificate of coverage in effect at the time services are rendered.
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Chapter 2 Quick Reference Guide
Pharmacy:
MHHSI maintains a formulary of preferred drugs as well as procedures on the provider section of the MHHSI
website. Physicians should obtain benefit certifications for non-formulary drugs by phone (866-475-0056). Members
also have a mail order prescription drug benefit for maintenance drugs.
Mail Order Prescription Program:
Caremark
PO Box 659541
San Antonio, Texas 78265-9541
Web Site Address:
Visit the MHHSI website at www.mhhealthplan.org to obtain information regarding medical policies, formulary,
HIPAA, updates of network activities, changes in fee schedules and contracting provisions and many other resource
materials.
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Chapter 3 Eligibility
Confirming Eligibility
There are two ways to verify a member’s eligibility: via the MHHSI website or by calling Customer Service at the
number on the member’s ID card
MHHSI Website
You can utilize the MHHSI website as an electronic way of determining member eligibility and claims status. It is
easy to use and can be accessed 24 hours a day. In order to check eligibility and claims status, you must have a user
ID to access that portion of the website. If you currently do not have a user ID and are interested in utilizing this
service, please contact Provider Relations at [email protected] or (713) 338-4801.
Customer Service
Customer Service can provide information such as coverage limitations and/or exclusions as well as whether the
member’s policy includes supplemental benefits or riders. Confirmation of eligibility does not guarantee payment. If
the member’s ID card is not available, contact a MHHSI representative at (713) 338-6535 or 1-888-642-5040 during
business hours.
Identification Cards
All members are issued an ID card. The member should present his/her ID card when seeking medical services.
Please check the member’s health care ID card at each visit and keep a copy of both sides of the card for your
records.
ID cards provide the following information:
1. Member name
2. Member ID number
3. Group number
4. Office visit copayment
5. Customer Service telephone number(s)
6. Claims mailing address
7. Pre-certification telephone number
MHHSI customers receive health care ID cards containing information needed for you to submit claims. Each card
will display essentially the same information (such as claims address, copayment information, telephone numbers
such as those for Customer Service and Pre-certification) and is viewable on MHHSI website.
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Chapter 3 Eligibility
Sample Health Care ID card:
Memorial Hermann Insured Select
Subscriber: Subscriber Name
ID #: 999999999
Group: S99XXXXXX-XX-XXX
In-Network Member Cost:
DED
Individual $2500, Family $5000
OV
$35 Copay (OV, Rad, Lab), $0 (Well), Deductible (Other)
ER
$60 ($0 with Admit) then Deductible
IP
Deductible (with Auth)
Dependent Name
Dependent Name
Dependent Name
Dependent Name
Dependent Name
Dependent Name
Network:
Select
I-Plan: MHU
Gen $15, Brand Form $30, Nonform $45
BIN: 004336, PCN: ADV, Grp: RX3269
(866) 475-0056 www.caremark.com
Call (713) 338-4683 or (888) 594-0671 for Benefits, Claims Status, or Auth Requirements.
Visit www.mhhealthplan.org to search for health care providers in the Memorial Hermann Network
or the wrap networks below for residents outside the Memorial Hermann Network service area.
(800) 678-7427
www.multiplan.com
(888) 342-7427
www.multiplan.com
Healthy Directions
MultiPlan is a complementary network available within the PHCS Healthy Directions network area.
Memorial Hermann Health Insurance Company
Claims Dept.
7737 Southwest Freeway, Suite C-97
Houston, TX 77074-1807
To send claims electronically:
Availity EDI Payer ID: MHHNP
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Chapter 4 General Administrative Requirements
Providers and its representatives shall comply with the MHHSI, Inc. Administrative Guidelines. Some or all
Administrative Guidelines may be communicated in the form of a provider reference manual, MHHSI, Inc. website
and/or in other written materials distributed by MHHSI, Inc. All changes to Administrative Guidelines will be
conveyed to providers in advance notice.
Access standards
MHHSI, Inc. establishes standards for appointment access and after-hours care to make sure timely access to care
for our members/injured employees. Performance against these standards is measured at least annually.
MHHSI, Inc. standards are shown in the tables below:
Health Plan
Type of Service
Preventative Care
Regular/Routine Care Appointment
Urgent Care Appointment
Emergency Care
After-Hours Care
Standard
Within 4 weeks
Within 14 days
Same day
Immediate
24 hours/7days a week for primary physicians
Employer Solutions
Type of Service
Priority scheduling for all WorkLink
patients
Standard
Within 24 hours of initial patient request/call
The guidelines listed above are general MHHSI, Inc. guidelines; state regulations may require more stringent
standards. Contact your Network Management representative for questions.
After-hours Care
We ask that you and your practice have a mechanism in place for after-hours access to make sure every
member/injured employee calling your office after-hours is provided emergency instructions, whether a line is
answered live or by a recording. Callers with an emergency are expected to be told to:
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Hang up and dial 911, or its local equivalent, or
Go to the nearest emergency room.
In non-emergent circumstances, we would prefer that you advise callers who are unable to wait until the next
business day to:
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Go to an in-network urgent care center,
Stay on the line to be connected to the physician on call,
Leave a name and number with your answering service (if applicable) for a physician or qualified health
care professional to call back within specified time frames, or
Call an alternative phone or pager number to contact you or the physician on call.
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Chapter 4 General Administrative Requirements
Arrange Substitute Coverage
If you are unable to provide care and are arranging for a substitute, we ask that you arrange for care from other
physicians and health care professionals who participate with MHHSI, Inc. so that services may be covered under
the member/injured employee’s in-network benefit. We encourage you to go to MHHSI benefits.org to find the most
current directory of our network physicians and health care professionals.
Continuity of Customer Care Following Termination of Your Participation
If your network participation agreement terminates for any reason, you are required to assist in the transition of our
member/injured employee care to another physician or health care professional who participates in the MHHSI, Inc.
network.
This may include providing services for a reasonable time at our contracted rate during the continuation period, as
further described in your agreement with us. Our staff is available to help you and our member/injured employee
with the transition. At least 30 calendar days prior to the effective date of your departure from the network, we will
send notification to affected member/injured employee. If applicable state law requires earlier notification, we will
follow the state law.
Access to Records
We may request copies of medical records from you in connection with our utilization management/care
management, quality assurance and improvement processes, claims payment and other administrative obligations,
including reviewing your compliance with the terms and provisions of your agreement with us, and with appropriate
billing practice. If we request medical records, you will provide copies of those records free of charge unless your
participation agreement provides otherwise.
In addition, you must provide access to any medical, financial or administrative records related to the services you
provide to our members/injured employees/injured employees within 14 calendar days of our request or sooner for
cases involving alleged fraud and abuse, a members/injured employees/injured employee grievance/appeal, or a
regulatory or accreditation agency requirement, unless your participation agreement states otherwise.
These records must be maintained and protected for confidentiality for 6 years or longer if required by applicable
statutes or regulations. You must provide access to medical records, even after termination of an agreement, for the
period in which the agreement was in place.
Medical Record Standards
A comprehensive, detailed medical record is vital to promoting high quality medical care and improving patient
safety. You agree that information concerning Covered Person(s) shall be kept confidential and shall not be
disclosed to any person except as authorized by applicable state and federal laws or regulations. This confidentiality
provision shall remain in effect notwithstanding any subsequent termination or expiration of an Agreement.
Provide Official Notice
You must send notice to us at the address noted in your agreement with us and delivered via the method required,
within 10 calendar days of your knowledge of the occurrence of any of the following:
 Material changes to, cancellation or termination of, liability insurance;
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Chapter 4 General Administrative Requirement
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Bankruptcy or insolvency;
Any indictment, arrest or conviction for a felony or any criminal charge related to your practice or
profession;
Any suspension, exclusion, debarment or other sanction from a state or federally funded health care
program;
Loss, suspension, restriction, condition, limitation, or qualification of your license to practice;
For physicians, any loss, suspension, restriction, condition, limitation or qualification of staff privileges at
any licensed hospital, nursing home, or other facility; or
Relocation or closing of your practice, and, if applicable, transfer of Customer records to another
physician/facility
Proactive Notification of Changes
We ask that you notify us of changes to the following demographic information 30 calendar days prior to the
effective date of the change: TIN changes, address changes, additions or departures of health care providers from
your practice, and new service locations. Notification must include the effective date of the change, W-9 form, etc.,
and submitted on our Provider Change Form located under Forms on our website
(Healthplan.memorialhermann.org) and faxed to Provider Relations (713) 338-4102.
Non-discrimination
You must not discriminate against any patient, with regard to quality of service or accessibility of services, on the
basis that the patient is a member/injured employee of MHHSI, Inc. or its affiliates, or on the basis of race, ethnicity,
national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims
experience, medical history, evidence of insurability, disability, genetic information, or source of payment. You
must maintain policies and procedures to demonstrate you do not discriminate in delivery of service and accept for
treatment any member/injured employees in need of the services you provide.
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Chapter 5 Medical Management
MHHSI’s Medical Management Department works with independently contracted network physicians to promote
delivery of health care services that are medically necessary meet professionally recognized quality standards and
are provided in the most appropriate setting. Member benefit plans describe specific that are not eligible for
benefits. Benefit agreements may limit or exclude a service that is medically necessary. Nevertheless, all decisions
regarding care or treatment remain with the member and physician, whether the service is a covered
expense.
MHHSI’s medical management benefit decision-making is based upon the terms set forth in the member’s
certificate of coverage. MHHSI does not reward any staff for issuing non-certifications and does not offer incentives
to encourage inappropriate underutilization.
Case Managers on the Medical Management staff are available to discuss care and benefit options for catastrophic
cases as well as care that may require multidisciplinary or community services. These options can maximize benefits
for both members and physicians.
Medical Necessity Criteria:
Medically necessary services as defined in most benefit plans are those that are:
 Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition;
 Provided for the diagnosis or direct care and treatment of the medical condition;
 Within the standards of good medical practice of the organized medical community;
 Not primarily for the convenience of the member, the member’s physician or any other medical
professional; and
 Provided in the most appropriate setting.
Medical Management Process:
The medical management staff, comprised of Physicians and Nurses, determines benefits according to the criteria
for medical necessity set forth in the member’s certificate of coverage. These benefit determinations may be made
prospectively, concurrently or retrospectively. The review criteria consider local, regional and national
professionally acceptable standards for quality medical care in accordance with state or federal law or regulation. In
general, MHHSI uses standard guidelines for both inpatient and outpatient services based in part on well-established
medical practice protocols such as Milliman Care Guidelines for inpatient and surgical care. Following the benefit
review determination, the treating provider will receive a letter advising that the service was certified or not certified
for benefits. Members will also receive a letter if the service is not certified.
Medical Management Requirements for Pre-Certification:
MHHSI encourages providers to initiate this benefit precertification, since clinical information is required. Providers
should call the Customer Service phone number on the member’s ID card with questions concerning a member’s
plan requirements. Member’s plan requirements for benefit precertification may vary significantly among plans and
lack of precertification may result in a reduction of benefit coverage for the member. Be sure to call the Customer
Service telephone number on the member’s card to verify the need for benefit precertification.
Precertification of benefits should be initiated as soon as possible, but not less than three working days prior to a
scheduled inpatient hospitalization or outpatient service. If Medical Management determines that additional clinical
information is required to make the determination, Medical Management, will respond within two (2) business days
of receipt of request for non-urgent certifications and within one (1) hour of receipt of request for urgent care (if care
is not certified for benefits), as per Texas state law. Exceptions to this timeframe are subject to regulatory and state
requirements.
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Chapter 5 Medical Management
PRE-CERTIFICATION REQUEST FORM COMPLETION GUIDELINES
This section assists MHHSI in determining the urgency of the provider’s request for Authorization. Instructions are
as follows:
1.
Expedited Requests: Any medical problem with a sudden onset of symptoms requiring intervention and preauthorization of services within a twenty-four (24) hour period. Such requests are handled as a priority and will
be processed immediately with a return authorization to your office within a twenty-four (24) hour period,
unless additional information is needed. Expedited Requests require clinical to be submitted within one (1) hour
of the request.

For inpatient admissions that are life-threatening situations, there is no need for preauthorization. Notify MHHSI retrospectively after the patient has been stabilized and admitted
within two (2) business days.
In no instance will a retroactive denial be issued for an emergency admission in the following circumstances:
a. Prior authorization was rendered by MHHSI for an ER admission based on severity of
symptoms or illness
b. The patient met InterQual/Milliman criteria at the time of ER admission notification

c.
Should the findings from initial concurrent review indicate that the patient no longer meets
criteria for continued stay, then a denial determination may be made per approval by either
the Medical Director or PA, but only for continued stay days which begin at the point of the
notification or at the time of the initial concurrent review.
d.
ER Admissions shall be retroactively authorized at the time of notification; providers are to
notify MHHSI of an ER admission within one (1) business day of the admission.
After the initial review of clinical information, the Medical Director may determine that the patient did
not meet medical necessity criteria for continued stay beyond a certain date, and a denial from that date
forward may be issued.
2.
Urgent Requests: Requests will be processed as soon as feasible but no later than seventy-two (72) hours from
the date of the request provided MHHSI has all of the information to render an authorization decision.
3.
Non-urgent Requests: Are routine and will be processed within three (3) business days from the date of the
request, provided MHHSI has all the information to render a decision.
Requestor Information on Urgent, Non-urgent and Concurrent Reviews:
Please complete the MHHSI Pre-certification form with supporting clinical documentation for the requested service:
Section A –Please identify the type of Request.
Section B
1.
Date of Request: Insert the date this request for authorization is completed.
2.
Person Completing Request: Enter the name of the person completing the requested information.
3.
Type of Request: Check the appropriate box of who is requesting authorization of services.
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Chapter 5 Medical Management
4.
Provider Tax Identification Number: Enter the providers billing tax identification number.
5.
National Provider Identifier: Enter the provider’s NPI number.
6.
Phone Number/Fax Number: Enter provider’s call back telephone number and fax number.
Section C - Patient Information
1.
Patient Name: Enter the full name, including any middle initials of the patient.
2.
Date of Birth: Enter the date of birth of the patient.
3.
Age: Enter the age of the patient.
4.
Sex: Enter the sex of the patient.
Section D - Insurance Information
Each physician’s office should have a system in place for identifying each patient’s primary and secondary health
insurance coverage. MHHSI also recommends that providers have a system in place at the time of patient check in
to verify if there have been any changes in health insurance coverage since the last time the patient was seen.
MHHSI requires that this section be completed if the patient has other insurance coverage, such as a secondary or
supplemental health insurance policy, is covered under Medicare/Medicaid and/or if the requested service is related
to a Worker’s Compensation (WC) claim or a Third Party Liability Claim. Instructions are as follows:
1.
Insurance Company: Enter the name of the patient’s health plan in the designated section.
2.
Subscriber Name: The subscriber is the person holding the health insurance policy. The subscriber name is
needed for services requested for dependents of a subscriber, (i.e., child or spouse). If the subscriber is also the
patient please note such by either re-entering the member’s name or note “same as above” in this section.
3.
Policy and Group #: Enter the name of the member’s group number and ID number as provided on the
member’s health insurance card. It is recommended that the provider’s office make a copy of the health
insurance card (front and back) and keep it in the patient’s billing file.
4.
Coordination of Benefits: Check the “yes” box if the patient has other insurance and list the name of the
subscriber, insurance company name, policy number and phone number. Otherwise, check the “no” box.
5.
Coverage under Medicare/Medicaid: If the patient is also covered under Medicare and/or Medicaid, circle the
applicable coverage, and check the “yes” box. Provide the patient’s social security (SS) number. Otherwise,
check the “no” box.
6.
Worker’s Compensation (WC) /Personal Injury (PI): Please note by checking the appropriate box, if the
requested services are related to a work related injury that may fall under WC or an injury related to a third
party liability or PI claim. MHHSI’s pre-authorization department will need this information for coordination
of claims or claims subrogation with the appropriate insurance carrier or Third Party Administrator (TPA).
However, MHHSI is not responsible for authorizing services for WC or PI related injuries.
7.
Benefits Verified: Please indicate if the patient’s benefits have been verified electronically or with our
Customer Service Department at 713-338-6535 and record the name of the person that provided the patient’s
benefit information.
Section E - Requested Services
If the request for authorization is for “Healthcare Services”, the following sections are to be completed as applicable.
Please refer to the Pre-Certification List for the list of services that require authorization.
1.
Date Requested: Please complete the date you are submitting your request to MHHSI.
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Chapter 5 Medical Management
2.
CPT/ICD-9 Codes: Completion of diagnosis and procedure codes is optional; however, a description of the
diagnosis and procedure codes is needed to complete the precertification request. MHHSI reserves the right to
request those codes if the level, extent or type of services requested is not clear.
3.
Surgery/Medical Procedure: If the patient is to have a surgery or other medical procedure, please note the name
of the procedure. Please denote if the surgery/medical procedure will be Inpatient (I/P) or outpatient (O/P) by
checking the appropriate box. Then proceed to Section F and note the name of the facility where the
surgery/medical procedure will be performed. The hospital’s abbreviations may be used for surgeries/medical
procedures to be scheduled at Memorial Hermann Hospital System facilities.
4.
Imaging/Invasive Diagnostic Procedures: For procedures requiring authorization, please note the procedure(s)
being performed, including the CPT or HPCS codes.
NOTE: If multiple procedures are requested for the same date of service to support a diagnostic impression,
MHHSI’s Medical Director may recommend one primary procedure based on Interqual/Milliman Criteria or
other nationally recognized clinical protocols, unless the treating physician can substantiate the clinical rationale
for requesting multiple procedures. (i.e. requests for upper GI series and endoscopy on the same date of
service). Such requests will be handled on a case-by-case basis with any special medical needs or
considerations of the patient taken into account.
5.
Durable Medical Equipment (DME)/Prosthetics/Supplies: Authorization for DME/prosthetics is to be initiated
by the requesting physician in order to determine if the patient meets DME/prosthetic criteria and specific
health plan benefit limitation requirements.
MHHSI reserves the right to authorize either rental or purchase, depending upon the type of DME and the
length of time the DME may be needed. Coverage for prosthetics is dependent upon health plan benefit
coverage limitations. MHHSI will provide the name of contracted vendors to be utilized.
6.
Injectable Drugs: Some injectable Medications may require authorization from MHHSI. Please contact MHHSI
for questions regarding pre-certification of any other drugs.
7.
Outpatient Rehabilitation: Please check type of O/P rehabilitation (PT, OT, ST) service requested; MHHSI
reserves the right to initially authorize an “evaluation only” to determine whether the patient meets criteria for
rehabilitation services based on health plan benefit requirements and/or to determine the rehabilitation potential
of the patient. Some plans have yearly limitations for these services.
8.
Home Health/Infusion Therapy Services: Pre-authorization is to be obtained by the requesting physician.
MHHSI reserves the right to initially authorize an “evaluation only” to determine whether the patient meets
criteria for home health/infusion therapy services based on health plan benefit requirements.
9.
Other: If there are any other requested services that require authorization, but are not specifically delineated in
this section, please enter the service in this area.
Section F - Location of Services
In this section, note the name and location where the Requested Services will be rendered: Outpatient Surgery
Facility, Inpatient Facility, Physician Office, or Other.
MHHSI will make authorization considerations based on whether the requested facility is a contracted provider for
the services to be provided, and/or if the facility has the capabilities to appropriately meet the needs of the patient.
Section G - Patient Clinical Information
All requests for authorization require clinical information about the patient. This information is needed to
appropriately render a determination of medical necessity; instructions are as follows:
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Chapter 5 Medical Management
1.
Primary Diagnosis: Please note the patient’s primary diagnosis. The primary diagnosis may be that which is
related to the need for the requested service.
2.
Additional Diagnosis: Please note any of the patient’s secondary diagnoses.
3.
Supporting Clinical Information must be faxed to support the medical necessity of the requested service.
Please fax a completed Pre-Certification Request Form to:
MHHSI Medical Management Department
(713) 338-6588
Please direct all benefits and eligibility questions to:
[email protected] or MHHSI Customer Service Department
(713) 338-6535
Denial Rationale: MHHSI’s Medical Director will issue an initial pre-authorization denial with the rationale for a
denial to the provider via a written “Denial Notification Letter”. The provider may appeal a denial by notifying
MHHSI’s Customer Service Department either by phone or in writing. Please let MHHSI know if an expedited
appeal is needed, such as in the case of an urgent or life threatening condition.
Assigned Authorization Number: MHHSI will assign an authorization number for internal tracking and to
facilitate billing. Please note this authorization number is not a guarantee of coverage. Final claim determination
will be made in writing following receipt and review of the claim and verification of benefits and eligibility. Please
reference the authorization number for the claim.
The following information is required when requesting benefit certification:
 Patient name and ID number
 Patient’s age and sex
 Diagnosis (ICD-9 or ICD-10 code)
 Reason for admission, service or procedure
 Scheduled date of admission/service/procedure
 Planned procedure or surgery (CPT code)
 Date of planned procedure, surgery or admission
 Hospital or facility name, if inpatient
 Name and telephone number of treating or admitting physician
If an emergency room visit results in a hospital admission, the physician or member should call the Customer
Service phone number on the member’s ID card within one (1) business day.
Providers may not bill the member for services that are not certified for benefits because they are determined to be
not medically necessary or inappropriate according to the terms in the member’s benefit plan, unless the member has
provided written agreement of financial responsibility in advance of receiving such services.
Providers must contact Medical Management if the patient stay requires additional days beyond those certified in
response to the initial call for benefit precertification.
Prospective Review:
Inpatient Care:
Precertification of benefits is required for any elective (non-urgent, non-emergent) admission to a hospital or
facility, including those for the following:
 Medical and surgical services except for normal vaginal and C-section deliveries
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

Skilled nursing services (including Skilled Nursing Facility)
Psychiatric and substance abuse services (behavioral/mental health)
Note: If there is an unplanned admission for early or threatened labor, premature birth or other high risk situation or
complication, the provider must call Customer Service at the phone number on the member’s ID card to determine if
certification is required.
Outpatient/Ambulatory Care:
Many outpatient services performed in hospital, ambulatory surgical and physician office settings require benefit
precertification. A complete list of these services may vary by member benefit plan, but may include:
 Surgical procedures (such as breast surgery, surgery of head/face/nose/mouth/throat/external ears and
eyelids, gastric bypass, abdominoplasty/panniculectomy, lipectomy/liposuction, injection of collagen, vein
stripping/injection of sclerosing agents, cochlear implants, etc).
 Diagnostic procedures (such as MRIs, CT scans, PET scans, nuclear cardiac scans, etc.)
 Home health care
Call Customer Service to determine if a service or procedure requires benefit precertification .
Concurrent Review:
Concurrent review is the process that determines coverage during the inpatient stay (including, but not limited to,
Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTACH) and inpatient rehab). This is also
necessary when the patient stay will exceed the previously approved benefits for length of stay. Providers should
contact Medical Management to obtain additional certification of days.
Concurrent review affirms benefits for continuing medical necessity and appropriateness of continued treatment,
services or hospitalization. Review of ongoing care is conducted for inpatient hospitalizations that were previously
certified as well as for outpatient procedures and ongoing outpatient care that require benefit precertification.
Concurrent review may also occur in situations where benefit precertification was not obtained prior to the
hospitalization.
Retrospective Review:
Retrospective review is rendered when a service was performed but was not previously certified by Medical
Management. MHHSI will not rescind previous certifications except in cases of fraud, misrepresentation or where
the medical records differ from the information previously provided to MHHSI. Providers may request an appeal of
a clinical benefit non-certification for up to 180 days.
Case Management:
Case Managers work with physicians to coordinate benefits for complex catastrophic cases and are also available to
consult with physicians about difficult or unusual situations. In the event that a member needs services not available
through the MHHSI network, the case management staff can work with the physician to locate an appropriate
setting. Call the Customer Service phone number on the member’s ID card to reach a Case Manager.
Examples of services appropriate for case management include:
 Potential organ and bone marrow transplantation
 Ventilator dependency
 Chronic pain management programs
 Difficult post-discharge placement or post-discharge cases requiring multiple services
 High-risk obstetrics
Appeal of Clinical Non-Certification by Medical Management:
Providers may request an appeal of a clinical benefit non-certification for up to 180 days by calling the Customer
Service phone number on the member’s ID card or the number on the non-certification notice. Additional clinical
documentation may be requested to review the case adequately. The MHHSI physician conducting the review will
not be the reviewer who made the initial determination.
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Chapter 5 Medical Management
If MHHSI reverses the decision not to certify benefits, a written notice will be issued. If the initial determination not
to certify benefits is upheld, MHHSI will mail an explanation to the provider and the member.
If the standard appeal outcome is unsatisfactory, the provider may submit a written request for an additional level of
appeal, which involves a review completed by the same specialty as the requesting provider. Additional supporting
documentation or explanations should be sent to the address on the letter upholding the non-certification.
Subsequent appeal rights may be available depending on the arrangement with self-funded employer groups and on
state laws.
In Texas, if the member’s condition is life-threatening, the member is entitled to an immediate appeal to an
independent review organization and is not required to comply with procedures for an internal review of the
utilization review agent’s adverse determination. The decision based on this review is final.
Note: A participating provider may not bill the member for services determined to be non-medically
necessary or inappropriate under the member’s benefit plan unless the member has agreed in writing and in
advance to pay these charges and MHHSI has denied coverage.
Medical Review of Claims:
Upon receipt, complex claims are evaluated by MHHSI’s Medical Review Program physicians prior to processing.
The medical review, supported by claims system software, focuses on procedures that may be cosmetic, benefit plan
exclusions or limitations and possible coding irregularities.
Medical reviewers may approve the billed services for processing, suggest re-coding in order to expedite payment,
request additional documentation or recommend denial of payment of specific services.
A letter of explanation or Explanation of Benefits (EOB) will provide details of the determination. Providers may
request reconsideration of claims payment determinations, including re-coding recommendations, by calling the
Customer Service phone number on the member’s ID card or the number on the letter of explanation or EOB.
This section provides general billing guidelines and MHHSI claim submission requirements that are effective as of
8/1/2011, including information about electronic claims submission. Reimbursement changes will be posted to the
MHHSI website, www.mhhealthplan.org. Your contract with MHHSI requires that you keep all contract terms
confidential, including the payment information provided with this disclosure. Should you have questions about this
document, please telephone Network Services at 713-338-4801.
Participating providers must submit claims within 95 days of date of service or within the deadline established in
their Agreement with MHHSI.
MHHSI uses standard claim guidelines that are current as of the date of service. These guidelines have been
developed in part using such references as the guidelines developed by the American Medical Association found in
the Current Procedural Terminology (CPT) reference manual.
In the evaluation of claims, MHHSI uses various sources including, but not limited to, the AMA position statements
from its official publication “CPT assistant”, which is published monthly. The AMA also publishes other official
publications such as “CPT changes” annually. Additional sources of information include Medicare Guidelines,
updated quarterly, and specialty guidelines from sources such as the American College of Surgery, the Orthopedic
Society, The American College of Cardiology and the American College of OB/GYN.
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Chapter 6 Billing/Claims Coding and Submission
This section provides general billing guidelines and MHHSI claim submission requirements, including information
about electronic claims submission.
Participating providers must submit claims with 95 days of date of service or within the deadline established in their
Agreement with MHHSI and in accordance with state regulatory requirements.
MHHSI uses standard claim guidelines that are current as of the date of service. These guidelines have been
developed in part using such references as the guidelines developed by the American Medical Association found in
the Current Procedural Terminology (CPT) reference manual. MHHSI reserves the right to change its guidelines
from time to time without notice.
In the evaluation of claims, MHHSI uses various sources including, but not limited to, the AMA position statements
from its official publication “CPT assistant”, which is published monthly. The AMA also publishes other official
publications such as “CPT changes” annually. Additional sources of information include Medicare Guidelines,
updated quarterly, and specialty guidelines from sources such as the American College of Surgery, The Orthopedic
Society, The American College of Cardiology and the American College of OB/GYN.
Claims Submission Requirements:
Claims Filing Deadline – Fully Insured ONLY (MHHSI Insured):
SB 418 creates a statutory filing deadline of 95 days, which may be extended only by contract. Providers forfeit
payment for claims not filed within the statutory deadline. MHHSI must accept proof of filing the claim with
another carrier within the statutory deadline as meeting the requirements of this provision. A copy of the primary
carrier’s explanation of benefits form should be submitted with the claim.
There are also exceptions to the filing deadline for catastrophic events. After the effective date of SB 418, for your
provider contract, the statutory filing deadline overrides any the filing contractual provisions that provide a shorter
filing deadline.
Duplicate claims may not be submitted before Day 46. “Clean claims”, as defined by the state regulations, will be
processed within 30 days of receipt if submitted electronically and within 45 days of receipt if submitted on paper.
Claims Filing Deadline – Self Funded Plans
Self-Funded/ERISA plans vary by employer group.
Claims Address:
Claims should be submitted electronically or to the address indicated on the member’s identification card. The Payor
Number for the electronic submission of claims is MHHNP.
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Chapter 6 Billing/Claims Coding and Submission
Clean Claim Requirements for MHHSI:
Claims should be completed as required under the Texas Department of Insurance Clean Claims regulations, 28 Tex.
Admin Code sections 21.2801 et seq.
Under Senate Bill (SB) 418, carriers may pend claims when requesting information from the treating (billing)
provider. Once requested, the time frame for payment stops until a response is received from the provider. To
expedite payment of your claims, MHHSI encourages providers to submit routine documentation that is contained in
the Texas Payment Policy Disclosure, Section II, and Claims Submission Requirements, posted on MHHSI’s
website at Healthplan.memorialhermann.org.
Healthcare providers must submit claims to MHHSI as outlined in the Participating Provider Agreement; failure to
comply with this requirement may result in denial of claim payment. In the event that a claim is denied for failure to
comply, the member is to be held harmless (i.e., not billed). For claims that involve coordinating benefits with
another carrier or Medicare, the date of the other carrier’s Explanation of Benefits or Medicare’s explanation of
benefits may be considered by MHHSI when determining the eligible submission period. A copy of the primary
carrier’s Explanation of Benefits form should be submitted with the claim.
Claim & Reconsideration Appeal:
A claim appeal is a formal written request from a provider for reconsideration of a claim already processed by
MHHSI. A written appeal for reconsideration of a denied claim or a claim the provider believes has been incorrectly
paid should be submitted within 180 days from the date on the Explanation of Benefits along with a copy of the
claim and any supporting documentation. Use the Claims Appeal Form included in this manual or a detailed cover
letter and mail to:
MHHSI
Attention: Appeals
7737 Southwest Freeway, Suite C-97
Houston, TX 77074
1.
The following information must accompany the request in order to be reconsidered. Failure to supply the
necessary documentation could result in a delay in reconsideration.
a.
b.
c.
Copy of the original EOB indicating the claim being disputed by the provider.
Specific reason for reconsideration request
If applicable, the following should also be included:

Referral/Authorization Number

Copy of claim

Copy of corrected claim, if appropriate
2.
Requests will be reviewed by the Claims Review and Reconsideration Committee within 30 days of receipt
and provider will receive a determination either via an EOB.
3.
Requests for reconsideration involving denials due to an expired referral or a referral with exhausted visits,
or denials due to lack of referral or authorization will be forwarded to the Utilization Management Manager
for retrospective review. If after review, the Utilization Management Manger determines that additional
clinical information is required prior to retrospective review, the provider will be notified. However, if the
Utilization Management Manager determines that the request cannot be authorized, the Provider will
received notification of this determination.
4.
If the information supplied supports the request for reconsideration, the claim will be reprocessed and paid
according to the Plan’s guidelines. Notification to the provider will be provided via an EOB.
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Chapter 6 Billing/Claims Coding and Submission
If the information supplied does not support the basis of the reconsideration, the Provider will be notified
that the request has been reviewed; however, the initial determination stands.
5.
If Provider is unsatisfied with the decision of the Claims Review and Reconsideration Committee, Provider
has the ability to appeal the decision by submitting a request in writing to the following:
MHHSI
Attention: Appeals
7737 Southwest Freeway, Suite C-97
Houston, TX 77074
6.
MHHSI will provide a status report within 30 days of receipt of the appeal.
7.
Requests for appeal must include the same information as presented for review and reconsideration as well
as any additional information provider would like t present to further support the appeal.
8.
Appeals must be submitted within 30 days from the notification to provider regarding the determination
received from the Review and Reconsideration Committee.
9.
Appeals will be reviewed by the Medical Appeals Committee and/or a representative of the Plan not
involved in the Review and Reconsideration process. The Medical Appeals Committee meets monthly and
notifications regarding determinations will be provided to the appealing Provider within 30 days from the
meeting date of the Medical Appeals Committee.
10. If the denial is overturned, the Provider will be notified in writing that the appeal has been granted and the
claim will then be reprocessed.
If the denial stands after the Appeal, the Provider will be notified in writing and advised that appeal rights
have been exhausted and denial is final.
Explanation of Benefits:
An Explanation of Benefits (EOB) is issued upon claim finalization. EOBs are reimbursement reports that include
detail line information and a summary of the payment.
Member Liability:
The only charges for which the member may be liable and may be billed by a MHHSI participating hospital,
physician or practitioner are:
 Deductibles, co-payments and co-insurance amounts required by the member’s Benefit Agreement, and
 Medical services not covered by the member’s benefit agreement where the member has agreed in writing
in advance to accept financial responsibility.
MHHSI plan designs generally include a deductible that must be met before benefits are payable. Some plans may
also have benefit-specific deductibles. The member is financially responsible for the deductible amount(s). In
addition, the member is generally responsible for paying a copayment or coinsurance for services received after all
required deductibles have been satisfied. While co-payments and deductibles may be collected at the time the
services are rendered, MHHSI recommends billing the member for the co-insurance amount upon receipt of the
MHHSI Explanation of Benefit (EOB).
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Chapter 6 Billing/Claims Coding and Submission
To determine the member’s financial responsibility (i.e., his/her co-payment amount or whether s/he has satisfied
any required deductible) contact the toll-free customer service number listed on the member’s identification card.
This information is time-sensitive and subject to change upon adjudication of other claims.
Member Liability for Services Not Medically Necessary:
Participating physicians and practitioners may not charge a member for medical services denied as not medically
necessary under the member’s benefit plan unless the member has provided written agreement of financial
responsibility in advance of receiving such services. The member’s written agreement of financial responsibility
must be specific to the services rendered. If the amounts collected exceed the member’s responsibility, the
physician or provider is required to issue a prompt refund once the EOB is received.
Coordination of Benefits:
Coordination of Benefits (COB) determines responsibility for payment of eligible expenses among insurers
providing insurance coverage to the member. When a member has more than one health insurance, the primary and
secondary are normally determined in accordance with the Prime Carrier Rules or as required under the laws of the
state where the member’s benefit plan was issued.
Prime Carrier Rules are often used by insurance carriers industry-wide and have been incorporated into appropriate
MHHSI benefit agreements. These rules determine the payment responsibilities between MHHSI and other
applicable group insurers by establishing which insurer is the prime carrier and which is the secondary carrier.
NOTE: The MHHSI payment will not exceed the maximum allowable amount as determined in accordance with
the MHHSI fee schedule or as set forth in the provider Agreement, total charges or the member’s responsibility for
Covered Services, whichever is less except as otherwise required by law.
The Prime Carrier Rules normally do not apply to:
 Non-group policies (individual policies)
 Auto insurance policies
 Medicaid
 CHAMPUS/CHAMPVA
Third Party Liability:
Third Party Liability (TPL) occurs when a person or entity other than the MHHSI member is/may be liable or
legally responsible for the member’s illness, injury or other condition and is, therefore, responsible for the costs
associated with the member’s illness, injury or condition. MHHSI may be entitled to reimbursement from the
member from any settlement the member may receive in those situations.
Please direct questions to MHHSI’s PR department at MHHSI [email protected]
Overpayment and Recovery Procedures:
Please see our Overpayment Policy and Procedure for details.
In the event of an overpayment, MHHSI seeks recovery of all excess claim payments from the payee to whom the
MHHSI check was made payable.
If during this process, the payee disagrees with the request for a refund, he/she may contact MHHSI in writing at:
MHHSI Finance
7737 Southwest Freeway C-97
Houston, Texas 77074-1807
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Chapter 6 Billing/Claims Coding and Submission
In addition, Customer Service may be contacted with questions concerning overpayment recovery. In the event the
terms of your Provider Agreement differ from the process outlined above, the terms of your Agreement will control.
MHHSI System Edits:
All claims submitted will be monitored for appropriate coding guidelines via MHHSI’s claims adjudication logic
utilizing McKesson ClaimCheck® 10.0 with V49. ClaimCheck® assists the claims processor in evaluating the
accuracy of the coding and not the medical necessity of any submitted codes. MHHSI will utilize Claim Check,
coding guidelines mentioned above and other sources as well as our own analysis of medical and technological
advances.
The presence of a code in published references does not indicate or guarantee that payment by MHHSI is available
for the service. At MHHSI’s discretion, payment structures are based on benefit plans and provider agreements.
(A)
The types of services that will be evaluated by ClaimCheck® include the following:













Policies based on generally accepted coding practices
Age and gender-related billing
Assistant Surgeon and Assistant at Surgery billing
Bundling/unbundling of procedures
Experimental procedures
Incidental procedures
Medical visit billing
Modifier usage
Multiple procedures rendered together
Mutually exclusive procedures
Obsolete procedures
Pre-operative and post-operative billing
Unlisted procedures
Some claims may be subject to MHHSI medical review. The Medical Review Unit may review the claim and
medical records to ensure accurate billing. In the event the claim is not submitted in accordance with MHHSI
medical policy and coding guidelines current at the time of service, MHHSI may reject or recode the claim as
allowed under the MHHSI participating provider agreement.
MHHSI Fee Schedule, Reimbursement, Coding and Bundling Guidelines:
As outlined in the Provider Agreement, once a claim is determined to be payable, the maximum allowable rate is the
fee schedule associated with each code or such other payment arrangement specified in the Agreement. Unless
otherwise specified in the Agreement, MHHSI will pay the lesser of billed charges or the approved fee schedule.
Conversion factors and unit values are not included. Provider-specific fee schedules may be provided on paper, CDROM or emailed upon request.
MHHSI uses these guidelines for administrative purposes such as claims processing and the development of
guidelines for medical review and medical policy. For hospital claims MHHSI generally uses Milliman USA
guidelines along with MHHSI’s own medical policies, which are published on mhhealthplan.org.
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Chapter 6 Billing/Claims Coding and Submission
HCPCS and CPT Codes:
Current HCPCS and CPT manuals must be used, since many changes are made to these codes annually. These
manuals may be purchased at any technical book store or by writing to:
Book and Pamphlet Fulfillment OP-3411/8
American Medical Association
P.O. Box 10946
Chicago, IL 60610-0926, or by calling
HCPCS: (800) 633-7467
AMA/CPT: (800) 621-8335
We are pleased to announce that MHHSI will be in compliance with 5010 mandates effective 1/1/2012. The
following are MHHSI reminders related to 5010:
 Billing Provider Address must be a physical address which equates to Box 33 on CMS 1500. As a MHHSI
provider and per 5010 rules your billing provider/pay to provider address can no longer be a P O Box or
Lock Box. Therefore, if you have a P O Box or Lock Box, please confirm with your clearing house or
billing software vendor that this is mapped to the appropriate loop designated as your pay to provider
(which can be a P O Box or Lock Box) otherwise your claims will be rejected by MHHSI .
 Nine Digit Zip Codes – your claims must have the valid +four digits on the zip code – claims submitted to
MHHSI will be rejected and returned to providers if the zip code is not valid. You may go to
http://ZIP4.usps.com/ZIP4/welcome.jsp to obtain your valid zip code.
 Anesthesia Claims – Must report in minutes rather than units. If the procedure code has minutes in
description ok to continue reporting in units. All time should be in minutes – i.e., one hour 15 minutes = 75
minutes on bill. Obstetric Unit Anesthesia Count – A new quantity (QTY) segment called “Obstetric Unit
Anesthesia Count” is used to report additional complexities beyond those reported in the procedure and
anesthesia segments for service line information.
 NPI - Billing Provider MUST always be most detailed level of enumeration as determined by the provider.
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Chapter 6 Billing/Claims Coding and Submission
Additional 5010 Reminders:
 Expansion of number of diagnosis codes to 12
 Added Ambulance Drop off and Pick Up loops
 Added Condition Code HI segment
 Added freeform narrative note at line level
 Deleted Home Oxygen Therapy
Unlisted Procedure or Service: Physicians may perform services or procedures that are not found in the CPT
codebook. Specific code numbers have been designated for reporting unlisted procedures. A description of the
service should always accompany a bill for an unlisted procedure code. This information will expedite claim
processing. MHHSI’s Medical Review Unit will review these services. Medical record review may also be required
to determine benefits for an unlisted procedure or service.
Unlisted codes for home infusion therapy should be accompanied by the NDC.
Most Frequently Billed CPT Codes Which May Not be Eligible for Payment:
CPT Code 99070 - Supplies and materials provided by physician over and above those usually included with the
office visit or other services. Providers should use HCPCS Level II codes, which give a detailed description of the
service provided.
CPT Code 99354 - Prolonged physician service in the office or other outpatient setting requiring direct face-to-face
patient contact beyond the usual service. (E.g., prolonged care and treatment of an acute asthmatic patient in an
outpatient setting.
CPT Code 99358 - Prolonged evaluation and management service before and/or after direct face-to-face patient
care. (e.g. review of extensive records and tests, communication with other professionals and/or the patient/family).
CPT Code 99050 - Services requested after office hours in addition to basic service. Reimbursement for the office
visit will be payable. No additional charges for after-hours services will be allowed.
CPT Code 99053 - Services requested between 10pm and 8am at a 24-hour facility, in addition to basic service.
CPT Code 36000 - Introduction of needle or intra-catheter, vein.
CPT Code 99080 - Special reports such as insurance forms or more than the information conveyed in the usual
medical communications or standard reporting forms.
The Plan Document will always determine if a code is covered or not. Additionally, certain codes (typically this is
unlisted procedure codes), may be denied with a request for an op report or clinical notes.
Modifiers:
A modifier indicates that the procedure performed by the physician has been altered by some specific circumstance
but has not changed in its definition or code. The presence of a modifier in the current CPT, HCPCS or other
procedure manuals does not necessarily indicate that the service is payable by MHHSI. MHHSI retains discretion in
the determination of payment structures.
Modifiers may be billed in accordance with the CPT and HCPCS manual to indicate the following:
 A service or procedure requiring a professional or technical component. (Not all services are considered to
have professional or technical components; some procedures are professional only or technical only).
 A service or procedure performed by more than one physician and/or in more than one location.
 A service or procedure that increased or was reduced.
 A service or procedure rendered more than once.
 Partial procedure performed.
 Adjunctive services.
 Bilateral procedures.
 Unusual events occurred.
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Chapter 6 Billing/Claims Coding and Submission
Following are the most commonly used modifiers: (All claims are subject to review and to the terms described in
this manual)
Modifier 25 - Significant, separately identifiable evaluation and management service by the same physician on the
same day of the procedure or other service: This modifier is valid only for Procedures 99201 – 99499 and does not
affect the reimbursement rate.
Modifier 26 Clinical Pathology Codes - Modifier 26 is payable only when billed for select clinical pathology CPT
codes that require a separately identifiable professional interpretation beyond the technical component. The list of
pathology codes for which Modifier 26 may be payable may change from time to time and is based in part upon
CMS.
Services billed without a modifier 26 are considered to be global services. MHHSI does not accept a “GS” as a
modifier designate global services. Claims submitted with modifier “GS” will be rejected for having an invalid
modifier.
Cardiac catheterization services should be billed with Modifier 26 to reflect the professional component.
Modifier 50 Bilateral Procedure - The maximum allowable rate for the surgical service may be increased by up to
50% for the bilateral procedure unless the service is otherwise identified as a single code, if covered.
Modifier 51 Multiple Procedures - Multiple Surgical Reduction rule (100%, 50%, 50% of maximum allowable
rate) is normally applied to claims for multiple procedures performed at the same operative session, if covered.
Modifier 54 Surgical Care Only - Claim determination is normally based upon 70% of maximum allowable rate of
the surgical procedure, if covered.
Modifier 55 Postoperative Management - When billed with a surgical CPT code claim determination is normally
based upon 30% of the maximum allowable rate of the surgical procedure. If billed with an office visit code, there is
no value change, if covered.
Modifier 62 Co-surgeons - Claim determination is normally based upon 125% of maximum allowable rate and
50% is normally allowed to each surgeon, if covered.
Modifier 80 Assistant Surgeon - Claim determination is normally based upon 20% of the maximum allowable rate
of the surgical procedure, if covered.
Modifier 81 Minimum Assistant Surgeon - Claim determination is normally based upon 10% of the maximum
allowable rate of the surgical procedure. If more than one surgery is billed for the same date of service, the claim is
subject to medical review, if covered.
Modifier 82 Assistant Surgeon (when qualified resident surgeon not available) - If qualified provider, the claim
determination is normally based upon 20% of maximum allowable rate, if covered.
Modifier 99 Multiple Modifiers – All claims billed with this modifier are subject to medical review; if covered.
Modifier AS Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist services for assistant at
surgery: Claim determination is normally based upon 16% of the maximum allowable rate, if covered.
Modifier TC Technical Component: This code must be billed when a charge represents only the technical
component, if covered.

Anesthesia (Rendering a patient insensible to pain during surgical, obstetrical and certain other medically
necessary procedures caused by the administration of a drug or by other medical interventions.) Must
report in minutes rather than units. If the procedure code has minutes in description ok to continue
reporting in units. All time should be in minutes – i.e., one hour 15 minutes = 75 minutes on bill. Obstetric
Unit Anesthesia Count – A new quantity (QTY) segment called “Obstetric Unit Anesthesia Count” is used
to report additional complexities beyond those reported in the procedure and anesthesia segments for
service line information.
General anesthesia: A state of unconsciousness with the absence of pain and/or sensation, produced by
anesthesia agents that affect the entire body. Drugs that produce this state are administered intravenously,
rectally, intramuscularly or by inhalation.
Regional anesthesia. The absence of pain and/or sensation produced by introducing an agent that interrupts the
sensory nerve conduction to a specific area (region) of the body.
 Field block: Introduction of a local or topical anesthetic to produce the absence of pain and/or sensation to
an operative area of the body.
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Chapter 6 Billing/Claims Coding and Submission



Local anesthesia may be used in more than one area of the body. Any agent used to produce the absence of
pain and/or sensation other than to the entire body is a local anesthetic.
Topical anesthesia includes local agents applied to the surface in areas such as eyes and mucous
membranes where injections are not recommended or possible. Eye drops, creams and sprays are common
topical agents.
Nerve block: Introduction of an anesthetic close to a nerve so that conduction is cut off. Spinal and caudal
anesthesia are types of nerve blocks into the spinal column. These types of anesthesia are often desired for
abdominal or obstetrical surgery and affect a large area of the body.
Policy:
Charges for anesthesia administration may be eligible for contract benefits when:
 Provided by a physician, typically an anesthesiologist (MD, DO) or a Certified Registered Nurse
Anesthetist (CRNA); and
 Performed in conjunction with a covered surgical, medical, obstetric or radiology service.
Anesthesia Services Most Often Eligible for Payment:
 Services of an anesthesiologist or CRNA billed by a hospital on UB-04 are considered ancillary services
and reimbursed according to the terms of the hospital agreement
 Anesthesia, given in conjunction with a covered surgical or obstetrical procedure, where the
anesthesiologist or CRNA is in constant attendance with the patient administering anesthesia, monitoring
and managing life functions, managing unconsciousness, and/or managing fluid therapy (regardless of
where the surgery is performed). Such care includes pre-anesthetic evaluation, intra-anesthetic record
keeping and post-anesthetic follow-up.
Anesthesia services for continuous epidural on obstetrical procedures require the following information:
 Type of anesthesia (epidural, lumbar or caudal, or spinal)
 Start and stop time of labor anesthesia
 Start and stop time of delivery anesthesia
 Type of delivery performed
 Anesthesia, given in conjunction with certain covered non-surgical procedures, when the procedure requires
that the patient be kept absolutely still or is too painful to be performed without anesthesia as identified with
either a modifier code or a procedure code.
 Anesthesia services identified as qualifying circumstances (by the use of additional CPT codes 99100,
99116, 99135 and 99140).
 Anesthesia with Medical Direction (QK, QY, and QK) will allow for allocation of payment between
supervising Anesthesiologists and CRNA(s).
 Anesthesia physical status modifiers P1 and P2. (Modifiers P3 – P6 are normally eligible for payment in
accordance with ASA guidelines.
Anesthesia Services Often Not Eligible for Payment:
 Anesthesia given in conjunction with a non-covered surgery or non-covered medical procedure.
 Field block local anesthesia administered by the surgeon who performed the surgery. Field block local
anesthesia is included in the surgery value; however, the cost of the materials for the local (e.g., anesthetic
agent) is eligible for benefits.
 The usual preoperative and postoperative visits, anesthesia care during the procedure, administration of
fluids and/or blood and the usual monitoring services (e.g., ECG temperature, blood pressure, oximetry,
capnography and mass spectrometry).
Exception: The following unusual forms of monitoring are not included in the price of the anesthesia and may
be payable in addition to the anesthesia services:
 Intra-arterial, CPT 36620
 Central venous, CPT 36555-36558
 Swan-Ganz, CPT 93503
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Chapter 6 Billing/Claims Coding and Submission

Anesthesia services billed by the same provider (surgeon, radiologist or endoscopist) performing the
procedure requiring the anesthesia.
Special Circumstances:

Pain management. Intravenous administration of drugs, where a machine controls the dosage and
duration.



Patient Controlled Analgesia (PCA). MHHSI often allows the initial consultation or set-up. If
subsequent visits are billed, claims are subject to medical review for determination of medical necessity.
Continuous Epidural (non Obstetric). This is extremely rare and usually billed for hospice care end term
and is subject to Medical Review for benefit determination.
Nerve Block. Administered by a surgeon, and performed by injection for the purpose of anesthesia or
therapeutic pain control.
A nerve block procedure billed either with an anesthesia CPT or the nerve block procedure code with
Modifier 30 or Modifier AA through AG performed in conjunction with a surgical procedure is considered
anesthesia services. MHHSI normally reimburses anesthesia using the base anesthesia unit value only.
Time units are not allowed. Nerve block procedures not billed as anesthesia services are considered
therapeutic and reimbursed as surgery.
Exception: Obstetrical claims billed with a nerve block CPT procedure code may be reimbursed as
anesthesia.




Standby during Percutaneous Transluminal Coronary Angioplasty (PTCA).
Hypnosis. When used as anesthesia during surgery is subject to medical review.
Acupuncture. Billed as anesthesia service.
Unusual anesthesia. Billed with modifier 23. Indicates unusual circumstances. Documentation must be
provided to support the unusual circumstances and will be subject to medical review for determination.
Special Notes:
 When two or more anesthesia procedures are billed during the same operative session the anesthesia
allowable amount will be determined by the procedure with the greater anesthesia units plus time units.
 If a second procedure begins more than one hour after the anesthesia end time of the first procedure, both
procedures are considered separate operative sessions and the base and time units of each procedure
normally are considered separately.
Obstetrical Anesthesia:
The time for continuous lumbar epidural, caudal or spinal injection anesthesia when used during labor and delivery is
calculated at one unit for every hour or fraction (e.g., 01 – 60 minutes = one unit; 61 – 120 minutes = two units; 121 –
180 minutes = three units, etc.)
There are no longer separate codes for vaginal delivery and cesarean delivery. If a planned vaginal delivery results in
a cesarean delivery, the code for the continuous epidural, 01967, is billed with the anesthesia code for the cesarean
delivery, 01968.
Anesthesia Allowance:
The allowable amount for anesthesia services is determined by multiplying the sum of the base units for the service
and the time units expended by the appropriate conversion factor.
Anesthesia time units are normally calculated in units of 15 minutes (in increments of 5 minutes unless noted
otherwise).
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Chapter 6 Billing/Claims Coding and Submission
Anesthesia Time:
Anesthesia time units are normally calculated in units of 15 minutes unless noted otherwise. Total number of
minutes must be included on all anesthesia claims in field 24G of the CMS 1500.
Anesthesia Codes and Modifiers:
MHHSI only recognizes CPT anesthesia procedure codes 00100 – 01999 when billing for anesthesia services and
will not accept the practice of billing anesthesia services using surgical codes with a modifier.
When two or more surgical procedures are performed during the same operative session, only the anesthesia
procedure with the higher base unit value is allowed for reimbursement.
Anesthesia services are reimbursed with basic professional, accident rider and/or major medical benefits when billed
by the anesthesiologist or CRNA.
Unlisted Procedure or Service:
There may be services or procedures performed by physicians that are not found in the CPT code book. Specific
code numbers have been designated for reporting unlisted procedures.
A description of the service should always accompany a bill for an unlisted procedure code. This information will
expedite claim processing. MHHSI’s Medical Review Unit will review these services. Medical record review may
also be required to determine benefits for an unlisted procedure or service.
Multiple Surgeries:
Multiple surgery claims are normally priced based on major and minor procedures performed on the same date of
service during the same surgical session. The surgical procedure with the highest MHHSI unit value is considered
the major procedure and is priced at 100 percent of the unit value. The minor surgeries have a lesser unit value and
are normally reduced as follows:

Incidental Surgery – A surgical procedure that is performed as part of another surgery and should not be
billed separately (commonly referred to as “unbundling”). The charge for the incidental procedure is
included in the provider’s write-off.

‘As Is’ Surgeries – Surgeries outside the Integumentary System (CPT Range 10040 – 19499) that are
always subsequent procedures (e.g. additional segment, suture of additional nerve). These surgeries are
always billed with another surgery and never bill as stand-alone procedures.

Bilateral Surgery – Surgeries performed through separate incisions to matching parts of the body (e.g.
both shoulders). These surgeries are identified either with the surgical procedure and modifier 50, or the
surgical procedure billed twice with modifier 50 attached to the second procedure.

Block Procedures – Surgeries in the Integumentary System that consist of a parent code and subsequent
procedures, which merely increase the complexity of the parent procedure. The entire “block” is
considered one surgery.
When multiple surgeries are billed and none of the surgical services is identified as incidental or “as is”
procedures, minor procedures are paid at a reduced rate. The reduction for all multiple surgeries is as follows:





Major procedure – 100% normally
Second procedure – up to 50%
Third procedure – up to 50%
Fourth procedure – up to 50%
Fifth procedure – up to 50%
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Chapter 6 Billing/Claims Coding and Submission
Additional Information:
1.
Major and minor surgeries are priced line-by-line based on the MHHSI allowed amount and not by the
billed charges of the procedure on the claim.
2.
Surgeries in the medical rage (91000 – 99195) are normally NOT subject to the multiple surgery
reductions.
3.
The Medical Review Unit (MRU) will evaluate claims with :
a. More than five surgical procedures during the same operative session; or
b. One or more unlisted procedures
(Detailed operative reports may be required).
4.
Modifier 51 is used when multiple surgical procedures are performed and applies to the services of the
surgeon only.
Reimbursement for HCPCS Level II Codes:

Durable Medical Equipment, Supplies (including, but not limited to, infusion therapy supplies),
Prosthetics and Orthotics - The maximum allowable reimbursement is based on whether the equipment is
new, used or rented as identified by the HCPCS Level II Code Modifier. MHHSI may designate certain
items as “rental only” or “purchase only” or “rent to purchase”. For “rent to purchase” items, the
maximum allowable is the MHHSI determined purchase priced; rental will not exceed the purchase price.
Codes not identified by a modifier as “purchase” will be considered rentals.

Other HCPCS Codes – The maximum allowable reimbursement is based on MHHSI selected published
market data, including but not limited to sources such as Drug Topics Red Book, Medispan and First
Databank and are reviewed annually. Self-injectable drugs for home use and all oral prescription drugs
dispensed in the physician’s office will be denied as not payable and the physician may not bill the
member. These services must be provided by a licensed MHHSI network pharmacy for the member to
obtain the maximum benefit under the pharmacy benefit plan.
NOTE: MHHSI does not compensate for hot and cold packs when billed on the same date of service as other
codes.
Laboratory Claims:
Physicians must supply laboratories with a diagnosis, correct patient information (including full name and date of
birth) and appropriate billing information. This information is important to ensure that laboratories have appropriate
information to bill MHHSI.
There are currently 22 multichannel tests, also known as automated tests. If one or any combination is billed, the
number of tests are counted and priced based on the total number of tests billed. This methodology does not apply
when Claim Check is utilized.
Incidental Edit:
A code edit that identifies a procedure performed at the same time as a more complex primary procedure, and is
clinically integral to the successful outcome of the primary procedure. The incidental procedure is not reimbursed.
Rebundling:
MHHSI claims systems utilize code edits that replace two or more procedure codes used to report a service with a
single procedure code that represents the service.
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Chapter 6 Billing/Claims Coding and Submission
Electronic Claims:
MHHSI supports claims submission via Electronic Data Interchange (“EDI”), which helps provide increased
productivity, efficiency, and service. Other benefits of electronic filing include:

One address billing. Payor identification number MHHNP is the only number needed to
submit claims to MHHSI.

Cleaner claims. Front-end editing permits only claims that are virtually error free to be accepted
into our system. Edits prompt for information required to process claims.

Faster claims turnaround time.

Reduced mailing costs
What is EDI?
Electronic Data Interchange is the computer to computer exchange of common business transactions over telephone
lines using a standard electronic format. EDI can be compared to an electronic postal service that allows physicians,
hospitals, and other health care providers and payors to exchange vital information.
How does it Work?
A computer, modem, and telephone line enable electronic claims transmission. MHHSI receives submissions from
independent third party software vendors, clearinghouses and billing services.
Most of these partners are also linked to hundreds of health care EDI networks.
Working with Clearinghouses:
EDI clearinghouses use an EDI network to connect to multiple payors. The EDI network routes communications
between physicians and payors automatically formatting data into a standard MHHSI format.
Listed is the MHHSI approved clearinghouse for physician claims:
Availity
1-800-282-4548 or www.availity.com
Hard Copy Billing:
Participating healthcare professionals who are not set up to process claims electronically are required to submit all
hard copy claims on the CMS 1500 claim form (with scannable “red dropout ink”). All applicable data element
blocks must be complete. If the form is incomplete, it will be returned for additional information needed for
processing.
Claims should be submitted to the following address:
MHHSI
7737 Southwest Freeway, Suite C-97
Houston, TX 77074
Attn: MHHSI Claims Department
Common Reasons for Rejected, Returned and Denied Claims:
There are times when MHHSI must return a claim for further information. Many of these returned claims result
from incomplete or incorrect billing. The following are some of the more common reasons that a claim will be
returned:
Date of injury not provided. When charges represent an injury diagnosis, always provide a date of injury.
Duplicate billings. Overlapping dates of service for the same service(s) will create a questionable duplicate bill.
ICD-9 CM codes denied. Claims that are coded with a preliminary, rather than a definitive diagnosis, will be
mailed back for the definitive diagnosis.
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Chapter 6 Billing/Claims Coding and Submission
Medical records needed. MHHSI may require medical records before processing a claim. If medical records are
required but are not submitted with the original claim, then a request form will be sent. When sending the requested
records to MHHSI, it is imperative that the records be attached to the original request form. Do not reattach a new
copy of the claim.
Unlisted HCPCS codes submitted without description. When submitting claims electronically, enter the
description in the REMARKS field.
Unreasonable numbers submitted. Unreasonable numbers such as “9999” in the UNITS field.
No certification attached to claim. When submitting claims to MHHSI for processing, the Utilization
Management authorization form must be attached.
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Chapter 7 Reimbursement
This section provides information about claim pricing and reimbursement, including MHHSI payment and third-party
liability and coordination of benefits. Procedures for recovery of excess claim payments are also included.
Certification and Payment Determination:
The Claims system searches the Medical Management system for prior certification when a claim requiring
certification is received. Claims requiring precertification without precertification approval will be reviewed
retrospectively for benefit approval based upon the terms in the member’s certificate of coverage. Benefit certification
of treatment or services or a determination of medical necessity based upon criteria in the applicable certificate of
coverage does not guarantee payment and is subject to review by appeal.
Once a claim is determined to be payable, the maximum allowable amount is normally determined from the MHHSI
fee schedule. Payment is usually the lesser of the maximum allowable amount or the provider’s billed charges, less
any applicable patient responsibility.
Explanation of Benefits (EOB):
An Explanation of Benefits statement (EOB) is generated when a claim is finalized and includes information about
claim payment -- detail line information, a summary of the payment and the member’s responsibility, non-payment or
additional information that may be required.
The only charges for which the member may be billed are:

Deductibles, copayments and coinsurance amounts required by the member’s benefit agreement, and

Medical services excluded by the member’s benefit agreement if the member has agreed in advance in
writing to pay these charges.
Member Liability for Covered Services:
Members may be responsible for copayments, coinsurance and deductibles.
Member Liability for Services That are Not Medically Necessary:
Providers may not bill for non-medically necessary services unless the member has agreed in writing to pay these
charges and MHHSI has denied coverage. Documentation of the member’s written agreement should be included in
the member’s medical record.
Coordination of Benefits, Third Party Liability:
MHHSI will coordinate benefits to determine responsibility for payment of eligible expenses when there is more than
one insurer providing coverage to the member. Primary and secondary coverage is governed by Prime Carrier Rules
or as set forth in the member’s certificate of coverage. MHHSI payment will not exceed the maximum MHHSI
allowable amount, total charges or the member’s responsibility for covered services, whichever is less.
These rules do not apply to:
 Non-group policies
 Auto insurance policies
 Medicaid
 TRICARE/CHAMPVA
When the member’s illness, injury or other condition may be the legal responsibility of a third party, the third party
may be responsible for the associated costs. MHHSI may be entitled to reimbursement from the member from any
settlement made on behalf of the member.
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Chapter 8 Customer Service
Customer Service Representatives are available 6 am to 6 pm on weekdays and 9 am to 12 pm on Saturdays,
Sundays, and major holidays to assist members and providers with benefits and claim information.
Available Information:
Customer Service Representatives are responsible for providing information about the following:

Claim status

Eligibility

Benefit inquiries

Plan Limitations and/or Exclusions

Participating Provider Information

Provider Network Status
The contact information for Customer Service is 713-338-4683 or toll free 888-594-0671 or email
[email protected]. Online services are available 24 hours a day, seven days a week.
Please visit www.mhhealthplan.org for more information.
Customer Service is also available to assist providers with the following:
Demographic Updates
Appeals
Complaints
Online Web Access
Precertification Confirmations
Claim Status
Customer service is available to check provider claim status. Providers that require claim status for 3 or more
members are asked to visit our website with their user id and password, or use the Claims Status Form (attached) to
submit the request by fax. Most request are handled the same day, however, providers should allow 24 to 48 for
Customer Service to respond with the claim reference number, approved amount, paid amount, member
responsibility, check number, and date processed. Customer service will trace checks upon request for checks that
are greater than 60 days.
Eligibility
Providers that contact customer service to request eligibility verification will receive the member’s plan type,
effective date, and eligibility status at the time of the call. The information received is not a guarantee of coverage.
If a plan terminates after eligibility is verified, the plan will not be responsible for services rendered after the date of
termination.
Benefit Inquiries
Customer service verifies benefits based on eligibility and provider participation. Benefit inquires include
information regarding covered expenses as well as Plan limitations and Exclusions. Benefits include plan
specifics such as applicable copays, deductible and coinsurance amounts, as well as how much of each has been
utilized at an individual and/or family level.
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Chapter 8 Customer Service
Participating Provider Information
Information regarding Memorial Hermann Health Solution participating providers is available on our website
www.mhhealthplan.org 24 hours a day, 7 days a week, however, customer service is available to assist providers as
well as members with participating provider information upon request. This information includes the provider’s
address, telephone, and specialty.
Provider Network Status
Providers with questions regarding their network status may also contact customer service for additional
information. This includes any discrepancies between the information included on the website and the provider’s
records.
Additional Services
1.
Demographic updates can be completed using the Provider Change Form that is located on the website. If
the provider is unable to access the form, customer service will assist the provider in obtaining a copy of
the form and directing the provider appropriately through fulfillment of the update.
2.
Providers disputing a claim processing procedure or precertification decision may appeal the decision either
in writing or orally by contacting the Customer Service Department. The appeal request must be receive
within 180 days of the original decision and should include supporting documentation. There is an Appeal
Reference Form (attached) available to assist the provider with completing their appeal along with relevant
appeal procedures and forms (attached).
3.
Customer service will also take and process provider complaints by phone, fax, email or mail. All
complaints will be acknowledged within 5 business days and providers should expect a written response
within 30 calendar days of the date the complaint was received. Please see the Complaints Rights for
additional information (attached).
4.
Eligibility, benefit, and member claim information is available online for providers that sign up for access
by completing and returning the Provider Access Form available at www.mhhealthplan.org. Providers that
are already set up with an account and are having issues with accessing their provider account may contact
customer service for assistance. Customer Service is available to provide instructions for using the website,
and to unlock and reset passwords.
5.
Providers are able to access our standard precertification list on the website www.mhhealthplan.org.
Additionally, providers may contact customer service with the specific CPT code and verbal verification of
precertification requirements would be only seconds away.
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Chapter 9 Credentialing and Re-credentialing
Prior to acceptance into the MHHSI, Inc. network, healthcare facilities, ancillary providers and physicians must
undergo a formal credentialing process. This section describes the credentialing and re-credentialing processes,
MHHSI, Inc. Credentialing Committee and the appeal process for providers whose network participation has been
terminated.
Confidentiality:



Information obtained during the credentialing or re-credentialing process is confidential.
Discussions of the Credentialing Committee are protected by federal peer-review laws.
All Credentialing Committee meeting minutes and provider files are stored in a secure manner accessible
only to authorized personnel and are not reproduced or distributed except for credentialing/re-credentialing
purposes or peer review.
Credentialing Process
MHHSI, Inc. has identified and developed minimum acceptable criteria for the following types of medical
professionals
 Medical Doctors (M.D.)
 Doctors of Osteopathy (D.O.)
 Podiatrists (D.P.M.)
 Behavioral Health Providers (PhD., L.C.S.W.)
 Licensed Physical Therapists, Occupational Therapists
 Optometrists, Audiologists, Speech and Language Pathologists
 Registered Dieticians
 Chiropractors
 Acupuncturists
 Registered Nurse First Assistants]
 Physician Assistants, Surgical Assistants, Advanced Practice Nurses, Certified Midwives
Medical Professionals
The credentialing process involves:
1. Collection of application and verification of credentials and documentation, including:
a. Work history
b. State medical license
c. Education
d. History of state and/or federal sanctions
e. History of professional liability claims
f. Assessment of board certification for applicable providers
2. Review of completed credentialing files by the Credentials Committee. This committee is comprised of
participating network physicians and meets at least quarterly.
3. Formal notification to provider of the credentialing decision.
Ancillary/Facility
The credentialing process involves:
1. Collection of application and verification of credentials and documentation, including:
a. State facility license
b. CMS or State Department of Health survey report; or
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Chapter 9 Credentialing and Re-credentialing
Approval letter from CMS or State Department of health stating facility’s review date and
inspection results
d. JCAHO Accreditation Letter and Accreditation Decision Grid; or
e. Most recent survey results from the State Department of health if not currently accredited by
JCAHO, AAAHC or AAAASF
f. Professional Liability and General Liability Insurance Certificate, which list amounts and
coverage dates
g. Entity W-9 or copy of IRS 540 or 941
h. Lab Cert
i. CLIA
j. Pharmacy Permit
k. FDA ACR Cert (Mammography)
l. State Inspection Cert (X-ray)
m. Bedding/Upholstery License
n. State Professional License
o. Current Malpractice Insurance Policy Face Sheet
p. Professional School Diploma
Review of completed credentialing files by the Credentials Committee. This committee is comprised of
participating network physicians and meets at least quarterly.
Formal notification to facility/ancillary provider of the credentialing decision.
c.
2.
3.
Re-credentialing Process
A provider’s continuing participation in the MHHSI, Inc. network depends upon the successful completion of the recredentialing process. This process includes:
1. Verification of continued state licensure
2. Verification of current board certification (if applicable)
3. Review of history of state and/or federal sanctions
4. Query to the National Practitioner Data Bank
5. Review of professional liability claims history
Termination of Network Participation Status
A provider’s status may be terminated at any time when information is obtained that indicates he/she did not
continue to meet MHHSI, Inc.’s standards. Issues that are brought to MHHSI, Inc.’s attention about professional
performance, licensure status and federal sanctions will be investigated by MHHSI, Inc. in a fair and impartial
manner. The MHHSI, Inc. Credentials Committee will decide continued participation.
Grievance and Appeal Process
MHHSI provides a fair opportunity and process for any Participating provider to appeal unfavorable actions taken
by the Credentialing Committee that relate to the Provider’s network status and for any action taken by the Plan
related to the Provider’s professional competency or conduct. All grievances and appeals will be processed
following the guidelines and procedures as approved by the Credentialing Committee.
In compliance with the Civil Rights Act of 1964, MHHSI will not discriminate against any provider on the basis of
age, race, color, ethnicity, national origin, sex, or religion/creed.
PROCEDURE:
1. Any participating provider that is denied participation, suspension or terminated for cause by MHHSI shall
receive written notification Within (10) days of decision, including the reasons for rejection, suspension or
termination, by MHHSI Chief Medical Officer.
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Chapter 9 Credentialing and Re-credentialing
2. If a provider receives notice of an adverse action by MHHSI Credentialing Committee upon
recommendation by MHHSI Executive Committee, the provider is entitled to:
i.
ii.
iii.
a review by a grievance panel
a review that permits the participating provider to appear before the Credentialing Committee
panel and present relevant information
if dissatisfied with the decision of the grievance panel, a right to an appeal with individuals other
than those members of the Credentialing Committee upon written request up to two cycles, if
requested.
The request should be in writing, addressed to the Chief Medical Officer, and include a brief description of the
reasons for grievance. If the request for grievance is not received within thirty (30) days of notice, both parties
shall be deemed to have accepted the decision of the Credentialing Committee and it shall become final and
effective immediately.
3. Within ten (10) days of receipt of a request for grievance the Chief Medical Officer shall schedule and
arrange for grievance panel review and send notice to the provider. The grievance panel comprised of the
Credentials Committee and Executive Committee will discuss the matter with the participating provider.
Every attempt shall be made to conduct the review within thirty (30) days from receipt of the request. The
review process is intended to offer the participating provider an opportunity to address any special
circumstances that may apply, and to respond to questions the grievance panel may have. The participating
provider waives appearance rights with the panel should participating provider not appeal nor send written
notification of the request to reschedule grievance review date. Rescheduled date cannot be more than
thirty (30) days from first scheduled grievance review date. If a clinical peer of the provider is not
represented on the Credentialing Committee, an ad-hoc appointment of a peer matched provider who is not
otherwise involved in network management will be made.
4. The notice shall be sent to the participating provider, at the address shown on the application by certified
mail, return receipt request, of the place, time, and date of the hearing. Within thirty (30) days after receipt
of the Review panel recommendations, MHHSI Credentialing Committee shall render its decision. The
decision will be forwarded to the participating provider in writing by certified mail, return receipt
requested. This notification is approved and signed by MHSSI Chief Medical Officer.
5. If decision is unfavorable to provider, provider may request an appeal of the decision rendered by the
grievance panel.
6. The request should be in writing, addressed to the Chief Medical Officer and include a brief description of
the reasons for appeal. If the request for appeal is not received within thirty (30) days of notice, both
parties shall be deemed to have accepted the decision of the Credentialing Committee and it shall become
final and effective immediately.
7. Within (10) days of receipt of a request for appeal the Chief Medical Officer shall schedule and arrange for
an appeals panel review and send notice to the provider. The appeals panel, comprised of a special panel
appointed by the Executive Committee at its discretion, will discuss the matter with the participating
provider and reports its findings to the Credentialing Committee. The members of the appeals panel must
at a minimum be comprised of three qualified individuals who were not involved in earlier decisions
related to the appeal. At least one member must be a participating provider of MHHSI who is not
otherwise employed in network management and who is a clinical peer of the participating provider who
filed the appeal. Every attempt shall be made to conduct the review within thirty (30) days from receipt of
the request. The review process is intended to offer the participating provider an opportunity to address
any special circumstances that may apply, and to respond to questions the appeals panel may have. The
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Chapter 9 Credentialing and Re-credentialing
participating provider waives further appeal rights should participating provider not appear nor send written
notification of the request to reschedule appeals review date. Rescheduled date cannot be more than thirty
(30) days from first scheduled appeals review date.
8. The notice shall be sent to the participating provider, at the address shown on the application by certified
mail, return receipt requested, of the place, time and date of the hearing. Within (30) days after receipt of
the appeal panel recommendations, MHHSI Credentialing Committee shall render its decision. The
decision will be forwarded to the participating provider in writing by certified mail, return receipt
requested. This notification is approved and signed by MHHSI Chief Medical Officer.
9. If decision is unfavorable to provider, provider may request a second appeal of the decision rendered by the
first appeals panel. The request should be in writing, address to the Chief Medical Officer and include a
brief description of the reason(s) for appeal. If the request for appeals is not received within thirty (30)
days of notice, both parties shall be deemed to have accepted the decision of the Credentialing Committee
and it shall become final and effective immediately.
10. Within ten (10) days of receipt of a request for appeal the Chief Medical Officer shall schedule and arrange
for an appeals panel review and send notice to the provider. The appeals panel, comprised of a special
panel appointed by the Executive Committee at its discretion, will discuss the matter with the participating
provider and reports its findings to the Credentialing Committee. The members of the appeals panel must
at a minimum be comprised of three qualified individuals who were not involved in earlier decisions
related to the appeal. At least one member must be a participating provider of MHHSI who is not
otherwise employed in network management and who is a clinical peer of the participating provider who
filed the appeal. Every attempt shall be made to conduct the review within thirty (30) days from receipt of
the request. The review process is intended to offer the participating provider an opportunity to address
any special circumstances that may apply, and to respond to questions the appeals panel may have. The
participating provider waives further appeal rights should participating provider not appear nor send written
notification of the request to reschedule appeals review date. Rescheduled date cannot be more than thirty
(30) days from first scheduled appeals date. The decision of the second appeals panel shall be considered
final and no further rights of appeal shall exist.
11. If a participating provider is terminated, a participating provider or participating provider may reapply no
earlier than six (6) months from the termination date.
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Chapter 10 Pharmacy
Customer Care:
1-866-475-0056
Paper Claims:
CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136
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Chapter 11 HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) was passed to reduce healthcare administrative
costs, protect individuals’ privacy and insurability, and enhance measures to limit fraud and abuse. The Act
contains several components mandating continuing health benefit coverage in certain situations, privacy, electronic
data submission and code sets and medical record security.
MHHSI’s goal is to ensure our systems, supporting business processes, policies and procedures successfully meet
the mandated implementation standards and deadlines. We strive to be in full compliance with all applicable current
requirements and expect to be compliant with future requirements as they are due.
The MHHSI website at www.mhhealthplan.org provides information about rules governing coding, data
transmission and patient privacy.
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Chapter 12 Provider Rights and Responsibilities
INTRODUCTION
This section of the Provider Manual is to serve as a reference for those rights and commitments you have acquired
and agreed to through your contracted agreement with MHHSI.
PROVIDER RIGHTS
1.
You are encouraged to let MHHSI know if you are interested in serving as a member of MHHSI Clinical
Quality Management Committee or other committees that may be formed by MHHSI.
2.
MHHSI encourages your feedback and suggestions on how service may be improved for providers and for
members. Suggestions and feedback can be provided any many ways such as 1) through Provider
Relations (see Section 2 on How to Contact Network Services), 2) written correspondence, 3) MHHSI’s
annual Provider Satisfaction Survey, or 4) via the Physician Advisory Committee.
3.
If an acceptable patient-physician relationship cannot be established with an MHHSI member who has
selected you as his/her physician, you may request that MHHSI remove that member from your care.
4.
You may have any claims submission reconsidered for re-adjudication which you feel was not paid
appropriately. (See Section 6 for instructions regarding the claims reconsideration process.)
5.
You may appeal any action taken by MHHSI that affects your status with the network and/or that is related
to professional competency or conduct. (Please see Section 9 Grievance and Appeals Process for more
information.)
6.
MHHSI encourages your attendance at meetings and participation in the activities of MHHSI as requested.
GENERAL RESPONSIBILITIES OF THE PROVIDER
1.
Primary Care Physicians (PCP) must provide continuous 24-hour, 7 day a week access to care for MHHSI
members. The PCP is responsible for arranging for a backup PCP when he or she is not or will not be
available, and for assuring that the covering physician will abide by Plan policies and procedures. During a
period of unavailability or absence from the practice, PCPs should notify the Provider Relations department
of the physician who will be providing coverage during their absence within 5 to 7 days before leaving.
(See Section 2 for applicable phone numbers).
2.
Medical records for members must be maintained for 60 months from the last date in which service was
provided to the member.
3.
In the event that a participating provider is temporarily unavailable, or unable to provide patient care or
referral services to MHHSI members, you must arrange for another physician (the “Covering Physician”) to
provide such services on your behalf. This coverage cannot be provided by an Emergency Room. Please
provide MHHSI the name of your Covering Physician so that claims will be processed correctly.
4.
You have agreed to treat MHHSI patients the same as all other patients in your practice, regardless of the
type or amount of reimbursement.
5.
You have agreed not to discriminate on the basis of age, sex, handicap, race, color, region or national
origin.
6.
You have agreed to provide continuing care to participating members.
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7.
You have agreed to utilize MHHSI’s participating physicians, laboratories and facilities when services are
available and can meet your patient’s needs. Based on member’s plan benefit, prior approval may be
required when referring members to providers who are outside the contracted network (non-network
providers).
8.
You have agreed to participate in MHHSI’s quality improvement, utilization management, credentialing,
peer review, grievance and other policies and procedures established and revised by MHHSI from time to
time which also includes participation in evidence-based patient safety programs.
9.
You may not balance bill a member for providing services that are covered by MHHSI. You may only bill
members for applicable deductibles, co-payments and/or co-insurance amounts. You many not bill for
charges which exceed contractually allowed reimbursement rates.
10. You may bill member for a service or procedure that is not a covered benefit:
a.
If the member did not inform you that he or she was an MHHSI member or,
b.
If the member was informed that the services were non-covered and he/she agreed in advance (in
writing) to pay for the services. An agreement to pay must evidenced by written records which
includes: 1) provider notes written prior to receipt of the services demonstrating that the member
was informed that the services were non-covered and the member agreed to pay for them; 20 a
statement and/or letter written by the member prior to receipt of the services, acknowledging that
the statements written by both the member and provider following receipt of the services that the
member, prior to receipt of the services, agreed to pay for them, knowing that the services were
non-covered).
General agreements to pay, such as those signed by the member at the time of admission, are not
evidence that the member knew specific services were non-covered.
11. You have agreed to supply comprehensive health services to the members depending on the needs of
MHHSI.
12. You have agreed to prepare and complete medical and other related records in a timely fashion for all
members being cared for by you. Maintaining contemporaneous clinical records that substantiate the
clinical rationale for each course of treatment, periodic evaluation of the efficacy of treatment and the
outcome at completion or discontinuation of treatment.
13. You have agreed to abide by MHHSI rules and regulations and also by all other lawful standards, policies,
rules and regulations.
14. You have agreed to allow access to medical records for review by appropriate committees of MHHSI and,
upon request, must provide the medical records to representatives of governmental entities and/or their
contracted agencies.
15. You have agreed to inform MHHSI within twenty-four (24) hours in writing, of any revocation or
suspension of the physician’s Drug Enforcement Agency (DEA) number, certificate or other legal
credential authorizing the physician to practice in the state of Texas, or any other state. Failure to comply
with the above could result in termination from the Plan.
16. You have agreed to inform MHHSI immediately in writing of any changes in licensure status, tax
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identification numbers, phone numbers, addresses, status at participating hospitals, loss of liability
insurance, and any other change, which would affect practicing status with MHHSI.
17. Unless otherwise indicated in your agreement with MHHSI, you have agreed to provide or assist MHHSI in
obtaining Coordination of Benefits/Third Party Liability Information. If you receive a payment from
another commercial carrier, you must do one of the following:
18. Refund the amount received from the other carrier to MHHSI; or
19. Return the payment to the commercial carrier with a letter stating you filed incorrectly and then ensure that
you file with MHHSI. Please copy MHHSI at the bottom of your letter and send a copy to MHHSI.
DISPUTE RESOLUTION PROCESS
MHHSI distinguishes disputes by the following categories: 1) Administrative Disputes or 2) Disputes Concerning
Professional Competence and Conduct. These categories are defined as follows:
 ADMINISTRATIVE DISPUTES
Administrative Disputes may include, but are not limited to, a participating provider’s written notice to MHHSI
challenging, appealing or requesting reconsideration of a claim denial or payment, factual determinations by
Utilization Management, and/or contractual concerns.
The dispute resolution process is available to any participating provider who wishes to initiate it. Participating
providers have the right to have their administrative disputes reconsidered by an authorized representative of the
Plan who was not involved in the initial decision that is the subject of the dispute.
Administrative Disputes involving the categories below have specific dispute resolution processes and those
processes can be found in the following sections of the Provider Manual:
Claims Disputes – See Section 6 Claim and Reconsideration Appeal
Determination by Utilization Management – See Section 6 Claim and Reconsideration Appeal
Disputes involving contractual concerns or other Administrative Disputes not addressed in the two categories above,
such as contractual disputes, can be initiated by the Provider submitting written notification to the Plan that includes
the following:





The Provider’s name and/or practice
Contact’s name and number
A clear explanation of the issue
The provider’s position on that issue
Additional information or documentation that supports the provider’s position
The written notification should be forwarded to the following:
MHHSI
Attention: Appeals – Administrative Disputes
7737 Southwest Freeway, Suite C-97
Houston, TX 77074
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MHHSI will provide written determination to the Provider within 30 days of receipt. However, if the issue requires
more than 30 days to resolve, the provider will be notified by the Plan and given the projected time frame for
resolution.
Please note: Participating provider disputes are not subject to the Plan’s Dispute Resolution Processes if the
Provider’s dispute involves a Plan requirement explicitly stated within the Provider’s agreement (which includes the
Provider Manual by incorporation).
 DISPUTES CONCERNING PROFESSIONAL COMPETENCE OR CONDUCT
Non-administrative disputes involve actions by the Plan that relate to a participating provider’s status within the
Plan’s provider network and any action by the Plan related to a participating provider’s professional competency or
conduct. For disputes related to actions taken by the Plan regarding a participating provider’s network status, and/or
their professional competency or conduct, please see Section 9, Grievance and Appeals Process and Provider Rights
number 5 of this section.
 DELEGATED ENTITIES
If performing delegated activities, provider is required to comply with URAC and any and all accrediting standards
that MHHSI is required to meet. If provider performs a delegated function on behalf of MHHSI via their contract
with the MHHSI, the provider shall not delegate, assign, or otherwise transfer the performance of any of the
Delegated functions to any person or entity without the prior written consent of MHHSI. Any further delegation,
assignment, or transfer shall not release provider from liability for performance under the delegated activities and
shall be in writing and shall subject the person or entity to whom tasks are further delegated, assigned or transferred
to the identical terms contain within the provider’s agreement with MHHSI and shall be further subject to URAC
and any and all accrediting standards that MHHSI is required to meet.
 SANCTIONING AND FAIR HEARING
Special Procedures
Procedure for Unusual Provider Practice Patterns
Whenever a concern regarding clinical quality of care and services provided arises, all available records and related
correspondence are screened by the Quality Improvement Director. The concerns are then forwarded to the Chief
Medical Officer for review and determination of any potential quality issues.
Individual concerns that do not represent a pattern of behavior or do not seriously jeopardize patient care/welfare
may be individually addressed by the Chief Medical Officer and summarized to the Quality Improvement
Committee (QIC) at its next regularly schedule meeting. The QIC process outlined below.
When individual concerns or patterns of behavior represent a serious threat to member care or welfare, the Chief
Medical Officer shall immediately act upon the behalf the QIC.
A QIC meeting will be called at the first possible opportunity, not to exceed 7 business days. The QIC will review
the information available and render a decision on behalf of the health plan regarding the involved provider.
When the QIC program determines that inappropriate or substandard services have been provided or services should
be have been furnished have not been provided, the Chief Medical Officer and QIC shall be notified. The QIC is
responsible for assuring that corrective actions are implemented and follow-up monitoring occurs.
Additionally, a provider’s practice pattern will be considered an exception to the norm or standard if:
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
Data indicates that the pattern is greater than two standard deviations above or below the mean for the peer
group (for those studies in which such measurement is available and relevant).

More than three complaints or grievances in a single category which have been filed during the period, as
defined in the customer services process.

A pattern of documented failures to follow administrative procedures established by MHHSI, after
counseling by the Chief Medical Officer.

Any actions or offense identified as reportable by state or federal law, or contract requirements.
If the QIC agrees that a deviation exists, the membership may request that the Chief Medical Officer counsel the
provider. Such counseling should begin with written notification. The notification will include an opportunity for
the physician to respond to the concerns identified. They physician is given the option to respond in writing or in
person within 30 days of receipt of the letter. Failure to respond to the letter within the designated timeframe may
be interpreted by the UM/QIC as agreement by the practitioner with the concerns and recommendations contained in
the Chief Medical Officer’s letter.
Responses by the provider will be reviewed by the QIC and used for evaluating the situation under review.
The committee may also direct that the Chief Medical Officer and provider develop a jointly agreed to plan of
action. The Chief Medical Officer and provider will agree on a time frame for correcting the problem. After
evaluating the plan and the time frames for correcting the problem, the QIC will make both an interim and final
recommendation to the Plan regarding continued participation. After the time for correction has passed, the Quality
Improvement Committee (QIC) will review the provider’s data again to determine if the practice pattern has been
modified. Resolutions of the matter which is acceptable to the QIC will lead to a recommendation to MHHSI that
continued participation be approved. Failure to resolve the matter (including disagreement by the affected provider
as to the committee’s assessment and position on the matter) may lead to a recommendation to MHHSI that
continued participation be denied. Such a decision is considered a sanction. In such cases, an appeal process is
available to the Provider, called a Fair Hearing. The Fair Hearing Process will be as follows:
Note: When a situation occurs that is deemed to pose an immediate threat to the health and safety of consumers,
the Chief Medical Officer may, on behalf of MHHSI, QIC and the Credentials Committee, act to immediately
revoke, limit or suspend the privileges of a participating provider. The affected provider will be immediately
notified as will other affected parties (i.e., Provider Relations, Utilization Management, Quality Management, Plan
Administration and Network Development Department). In such an event, the QIC will be assembled at the earliest
possible time to hear the situation and support or override the Chief Medical Officer’s decision
Provider Notification
Providers will be notified by letter, Certified Mail-Return Receipt Requested, of the decision of the QIC. Providers
may appeal decisions and actions of the QIC by submitting a written request for an appeal or reconsideration and by
providing additional information either in writing or in person.
The Sanctioning Process and Fair Hearing Procedure
The Sanctioning Process of MHHSI will follow the Healthcare Quality Improvement Act of 1986. Due process will
be conducted as follows:
Notice of Proposed Action
The provider will be notified at the address included on the provider’s application or the address maintained in
MHHSI’s system for provider payment or communication:
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



that a professional review action has been proposed;
the reasons for the proposed action;
that the provider has the right to request a hearing on proposed action within 30 days after receipt of the
notice;
a summary of the hearing process.
Notice of Hearing
MHHSI shall provide notice and a fair hearing to a provider in any case, except in cases of automatic suspension or
limitation, in which action is proposed to be taken by MHHSI to restrict, suspend or terminate the provider’s ability
to provide health care services, if same action is based on professional competence or professional conduct which
affects or could adversely affect the health, safety or welfare of any patient and/or is reasonably likely to be
detrimental to the delivery of quality patient care. If MHHSI takes an adverse action against a provider following
the conduct of a fair hearing as provided in the Fair Hearing Procedure, MHHSI shall report such adverse action to
the National Practitioner Data Band, pursuant to the federal Health Care Quality Improvement Act and, as required
by applicable state law, to the applicable state licensing/examining board.
Final Proposed Adverse Action: The procedures described in this Fair Hearing Procedure shall apply whenever an
action is proposed to be taken by MHHSI Chief Medical Officer on behalf of the QIC to restrict, suspend or
terminate a provider’s ability to provide health care services to patients because of deficiencies in the provider’s
quality of care, professional competence or professional conduct which affects or could adversely affect or is likely
to be detrimental to the health, safety or welfare of any patient or to the delivery of quality patient care, the outcome
of which if adverse would be required to be reported to the National Practitioner Data Bank under the federal Health
Care Quality Improvement Act of 1986 or to the State licensing board/agency under applicable state law.
Role of Plan Chief Medical Officer: The Chief Medical Officer shall appoint a hearing panel on behalf of the QIC
in fulfilling it’s duties under Fair Hearing Procedure
Summer Action: Nothing contained in this Fair Hearing Procedure shall limit or otherwise affect the authority of
the Chief Medical Officer or QIC to take action on behalf of MHHSI’s Policy and Procedure for Restriction,
Suspension or Termination of MHHSI’s Provider, including the duty to respond on an urgent basis to situations that
pose an immediate threat to the health and safety of consumers. The terms of the summary action shall remain in
effect pending the outcome of any hearing initiated by the provider pursuant to Section of this Fair Hearing
Procedure.
Initiation of Hearing
Grounds for Hearing: Any one or more of the following actions, when taken or made based upon deficiencies in
the quality of care, professional competence or professional conduct of a provider shall constitute “adverse actions”
and ground for a hearing:

Termination of provider’s ability to provide health care services to patients at any time.

Imposition or voluntary acceptance of restrictions on a provider’s ability to provide health care services to
patients for thirty (30) or more cumulative days in any twelve (12) month period.

Imposition for a summary action, as set forth above, which remains in effect for a period of more than
thirty (30) days.
Notice of Adverse Action: In all cases where an adverse action is proposed to be taken against a provider
constituting grounds for a hearing as set forth above, MHHSI Chief Medical Officer shall, within ten (10) days after
making his or her decision to take adverse action, give practitioner written notice of the following:
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That an adverse action has been made or is proposed to be taken against the provider, which if adopted, shall be
reported to the national Practitioner Data Bank pursuant to the Federal Health Care Quality Improvement Act of
1986, as amended, and the applicable State licensing board or agency pursuant to the applicable state law;
The reasons for the proposed adverse action (a specific statement of charges need not be include in the written
notice);
That the provider has a right to request a hearing on the proposed adverse action in accordance with this Fair hearing
Procedure within (thirty (30) days after receipt of the notice; and a summary of the provider’s rights in connection
with the hearing, as specified in this Fearing Hearing Procedure.
Request for Hearing:
A provider shall have thirty (30) days following his/her receipt of notice of an adverse action to request a hearing on
the proposed action. The request shall be given in writing to MHHSI’s Chief Medical Officer by personal delivery
or by certified or registered mail and shall be deemed given upon receipt.
Waiver: Failure of the practitioner to request a hearing within the time and in the manner described in above shall
constitute a waiver of the hearing and of any review. In the case of such waiver, the provider shall be deemed to
have accepted the Quality Improvement Committee (QIC) proposed action, and the proposed action shall become
effective pending final action by the Board of Directors. The QIC proposed action shall be forward to the Executive
Committee for review and final action of ratification.
Hearing Prerequisites
Notice and Time for Hearing: Upon receiving notice, MHHSI Chief Medical Officer shall set up hearing to occur
within 45 days of receipt of the request for hearing. The Chief Medical Officer shall send written notice to the
provider of the place; time and date of the hearing at least fifteen (15) days prior to the established meeting date.
The notice to the provider shall contain: (i) a list of the specific or representative patient records in question or
other reasons or subject matter forming the basis for the adverse action; the (ii) a list of the witnesses, if any,
expected to testify at the hearing. The notice shall specify that the provider may submit to the Chief Medical Officer
within ten (10) days following receipt of the notice a list of witnesses expected to testify on behalf of the provider.
The notice may state that the Chief Medical Officer reserves the right to amend the list of documents, information
and witnesses. If so amended, notice shall be give to the provider.
Request for Postponement:
A request for postponement of a hearing and/or extension of time beyond the times stated in this plan shall be
permitted only upon mutual agreement of the parities or by the hearing officer upon showing of good cause.
Failure to Appear and Proceed:
The personal presence of the provider who requested the hearing shall be required. Failure of the provider, without
good cause, to appear and proceed at the hearing shall constitute a waiver of his/her right to a hearing and a
voluntary acceptance of the adverse action, which shall become effectively immediately. The matter shall be
forwarded to the Executive Committee for review and final action or ratification.
Hearing Panel and Officer:
If a hearing is requested on a timely basis (as per above) the hearing shall be held before a hearing panel of not less
than three individuals appointed by MHHSI who did not participate in the prior decision. One member of the panel
members should be a participating provider who is not otherwise involved in network management and who is a
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clinical peer of the participating provider who is subject to the appeal.
A hearing officer shall be appointed by MHHSI, and shall maintain decorum and ensure that all participants have an
opportunity to present relevant oral and documentary evidence. The hearing officer shall determine the order of
procedure and make ruling on issues and matters.
A person shall be disqualified from serving as a hearing officer or on a hearing panel if he/she has participated in
initiating the matter at issue (including participation in the original decision) or if he or she is in a personal or
professional relationship with the provider. An individual serving as a hearing officer or as a member of a hearing
panel need not be a physician or other health care provider. A confidentiality and conflict of interest statement will
be obtained from this individual as well as panel members.
Hearing Procedures
Representation: The provider who requested the hearing shall be entitled to be represented by an attorney or other
person of his/her choice. The QIC/MHHSI shall also be entitled to be represented by an attorney or its choice and
shall designate one or more persons to represent the facts in support of the adverse action and examine witnesses.
MHHSI’s Chief Medical Officer shall appoint a representative of the QIC to present committees proposed action
and the facts in support of such action, to examine witnesses and to present evidence.
Rights of Parties at Hearing: Within reasonable limitations, during the hearing parties shall have the following
rights: (i) to be provide with all of the information and evidence made available to the hearing officer; (ii) to have a
record made of the proceedings, copies of which may be obtained by the provider upon payment of any reasonable
charges associates with the preparation thereof; (iii) to call and examine witnesses on relevant matters; (iv) to
present and rebut evidence determined to be relevant by the hearing officer, regardless of its admissibility in a court
of law; (v) to introduce exhibits and documents relevant to the issues; and (vi) to submit a written statement at the
close of the hearing, provided, however, that these rights are exercised in an efficient and expeditious manner. If the
provider does not testify on his/her behalf, he/she may be called by the QIC and examined as if under crossexamination.
Upon completion of the hearing, the provider shall have the following rights: a) to receive the written
recommendation of the hearing panel, including a statement of the basis for the recommendation(s); and (b) to
receive a written decision of the Executive Committee, including a statement of the basis for the decision.
Admissibility of Evidence, Examination of Witnesses: The hearing need not be conducted strictly according to
rules of law relating to the examination of witnesses or presentation of evidence and the parties may present
evidence determined to be relevant by the hearing officer, regardless of its admissibility in a court of law. Any
relevant evidence shall be admitted by the hearing officer if is the sort of evidence on which responsible persons are
accustomed to rely in the conduct of serious affairs, regardless of its admissibility in a court of law. The hearing
officer may question the witnesses or call additional witnesses if it deems it appropriate. The hearing panel may
request that oral evidence be taken only on oath or affirmation administered by a person entitled to notarize
documents.
Burdens of Presenting Evidence and Proof: The burden of presenting evidence and burden of proof during the
hearing shall be as follows:
The QIC shall have the initial burden of presenting evidence, which supports the final proposed adverse action. The
provider shall have the burden of presenting evidence in response.
The provider shall have the burden of proving, by clear and convincing evidence, that MHHSI adverse action lacks
any substantial factual basis or that the conclusions drawn are arbitrary and capricious or unreasonable.
Record: A record or sufficiently accurate summary of the hearing shall be kept. The hearing officer may select the
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method to be used for making the record.
Adjournment: The hearing panel may recess, adjourn and reconvene the hearing without further notice for the
convenience of the participants or to obtain additional evidence or consultation, with due consideration for reaching
an expeditious conclusion to the hearing.
Conclusion of Hearing: At the conclusion of the presentation of evidence, the hearing shall be closed. The parties
may, at the close of the hearing, submit a written statement. The hearing panel shall then, at a time convenient to
itself, privately conduct its deliberation, reach a decision and adjourn the hearing.
Decision of Hearing Panel
Basis for Decision: The decision of the hearing panel shall be based on the evidence produced at the hearing,
including all logical and reasonable inferences drawn from the evidence and the testimony. This evidence may
consist of the following: (i) oral testimony of witnesses; (ii) briefs or written or oral arguments presented in
connection with the hearing; (iii) any material contained in the QIC files regarding the practitioner who requested
the hearing; and (iv) any other evidence deemed admissible.
Decision of Hearing Panel: Within fifteen (15) days after adjournment of the hearing, the hearing panel shall
prepare a written decision or report stating its findings of fact and recommendations, including a statement of the
basis for the recommendation, and shall forward it to the QIC who requested the hearing, and the Executive
Committee. If the provider is currently under suspension, however, the time for rendering the decision shall be
seven (7) days.
If the proposed action adversely affects the ability of a provider to provide health care services to patients for a
period longer than thirty (30) days and is based on deficiencies in the providers quality of care, competence or
professional conduct, then the recommendation shall state that the action, if adopted, will be reported to the National
Practitioner Data Bank and the applicable State licensing board.
Right of Second Appeal
There shall be a second appeal of the decision of the hearing or panel upon request of the Provider that was
Sanctioned by MHHSI’s Quality Improvement Committee (QIC).
The hearing panel and hearing officer shall consist of three qualified individuals who have not participated in prior
decisions in this matter. At least one member of the panel shall be a participating provider who is not otherwise
involved in network management and who is a clinical peer of the provider who is subject of the appeal.
Time frames for request, notice and conduct of meeting shall be as per the first appeal (hearing).
Failure of the Provider to request a Second Appeal within the specified time frame (30 days) will constitute an
agreement with the decision rendered.
Notice of Decision to MHHSI’s Quality Improvement Committee
Review by the QIC: At its next regularly scheduled meeting after receipt of the written recommendation of the
hearing panel, the QIC shall (i) review the report and recommendation of the hearing panel, the hearing record, any
written statements and all other documentation relevant to the matter; and (ii) consider whether to affirm or reject
the recommendation of the hearing panel, or to refer the matter back to the hearing panel for further clarification.
Final Decision by QIC: Upon completion of its review of the Hearing Panel’s information and recommendations,
QIC shall render a final decision concerning the restriction, suspension or termination of the provider’s ability to
provide health care services to patients, or any other corrective action.
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The decision of the QIC shall (i) be in writing, (ii) specify the reasons for the action taken, (iii) include the text of
the report which shall be made to the National Practitioner Data Bank and applicable state licensing board, if any,
and (iv) be delivered to the provider under review and the Chief Medical Officer/Executive Committee at least ten
(10) days prior to submission of a report to the National Practitioner Data Bank or the state licensing board.
Except where the matter is referred for further review and recommendations, the decision of the QIC following
completion of the procedures set forth in this Fair Hearing Procedure shall constitute the final action of MHHSI
against the provider, shall be immediately effective and final and shall not be subject to further hearing or appellate
review.
Further Review: If the matter is referred back QIC or the hearing panel for further review, the QIC or hearing
panel shall promptly conduct its review and make its recommendation to the hearing panel and Executive
Committee. This further review process and report back to the hearing panel and Executive Committee shall in no
event exceed thirty (30) days in duration except as the parties may otherwise stipulate.
No further appeal rights: No provider shall be entitled as a matter of right to more than two appeals fair hearing
on any single matter which shall have been the subject of an adverse action.
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Chapter 13 Glossary
Adjudication
The evaluation of a claim for health care services in order to determine the financial responsibility of both the
patient and the health benefit plan according to the provisions, terms, and conditions of the patient’s health
benefits under the plan.
Adjudication Reason Code
A code established and utilized by MHHSI to identify the outcome of the adjudication process as applied to a
medical claim. Generally such codes identify the network rate at which charges are allowed, the reason for any
denial or limitation of coverage, or the benefits which applied to the service.
Adjustment
Reprocessing a given claim for health care services because of an error that occurred during initial processing.
Such errors do not require a formal appeal on the part of a plan participant or provider.
Admission Deductible
See Hospital Admission Deductible.
Admitting Physician
The physician who admits a patient to a hospital and is responsible for coordinating the patient’s care during the
hospital stay.
Allowance
A monetary benefit that participants in a health benefit plan are offered which provides for 100% coverage (plan
responsibility) for any services specifically designated as covered by the allowance up to a predefined limit and
usually within a given period of time such as a benefit year. An example of such a benefit is a well-baby allowance
which gives parents of a newborn additional funds to have necessary checkups and immunizations. Once the funds
in the allowance are exhausted, additional services received within the same period typically revert to regular
medical benefits. See also Wellness Allowance.
Allowed Amount
The maximum charge for a given service that a health benefit plan recognizes for reimbursement under the plan for
covered services or supplies. For participating providers this is a contracted rate, whereas for non-participating
providers this is typically a usual and customary rate. Non-participating providers may invoice plan participants the
difference between the allowed charge and their original billed charge. See also Balance Billing, Usual and
Customary Charge.
Ambulatory Surgery Center (ASC)
A health care facility specializing in elective same-day or outpatient surgical procedures as well as some
diagnostic and pain management services in an outpatient setting. ASCs do not customarily offer emergency
care.
Ancillary Services
Services that are customarily ordered to assist in patient diagnosis or treatment such as medical equipment or
supplies, and laboratory, pathology, or radiology services. Providers of ancillary services typically are not
primarily responsible for patient clinical management. If such services are performed during a physician office
visit, they are customarily considered a separate covered benefit from the office visit by health benefit plans.
Anniversary Date
The first day of the plan year, typically the beginning of a calendar month, this date is usually preceded by the
annual enrollment and is usually when the enrollment selections of employees and their dependents become
effective. See also Open Enrollment.
Annual Enrollment
See Open Enrollment.
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Appeal
A request for reconsideration of an earlier determination of a claim or of a previous attempt to get a service
precertified. An appeal may be requested by a provider or plan participant and typically involves the submission
of additional documentation as supporting evidence.
Appropriate
Term used to describe health care services the benefits of which are expected to exceed any potentially negative
results, thereby justifying their use.
Approved
Term that can be used to describe benefits or services which are covered under a health benefit plan as well as
treatments or procedures that have been certified by utilization review. See also Utilization Review.
ASC
See Ambulatory Surgery Center.
Attending Physician
A physician who may have either principal or consulting responsibilities during a patient’s hospital stay.
Depending on the complexity or severity of the patient’s condition or the presence of multiple medical
conditions, there may be more than one attending physician providing treatment at the same time.
Authorization
See Precertification.
Balance Billing
The practice of a provider invoicing a patient for any remaining balance after receipt of all payments from a
health benefit plan and from the patient (for any responsibility assigned by the plan such as copays or
coinsurance). Participating providers are generally prohibited by their network participation agreements from
billing above their contractual rate for services. Non-participating providers generally have no such restrictions
and are free to balance bill their patients even after having received reimbursement for part of their charges from
both the patient and the health benefit plan.
Behavioral Health
See Mental Health.
Beneficiary
An individual eligible to receive various benefits offered by an employer. See Plan Participant for more specific
information concerning beneficiary eligibility and coverage under an employer health benefit plan.
Beneficiary Liability
See Plan Participant Liability.
Benefit Year
The period of twelve months used when administering an employee health benefit plan especially for purposes
of determining maximum plan responsibility and plan participant responsibility (copays, deductibles,
coinsurance, and out-of-pocket costs) for covered services over that period of time. Typically this period
corresponds to the calendar year, but for some plans it may be the fiscal year of the employer.
Benefits
The specific services covered under a health benefit plan.
Billed Charges
The amount billed by a health care provider on a claim for services, treatment, or supplies. This amount may
vary among providers of differing specialties and geographic locations or due to the complexity of the services
rendered. The amount may also be set solely at the provider’s discretion.
Calendar Year
The twelve consecutive months beginning on January 1st and ending on December 31st.
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Calendar Year Maximum
A limitation sometimes placed on specific benefits either for a maximum dollar amount or a maximum quantity
(usually days, units, or visits) that a plan will consider covered during a given benefit year. For most plans the
benefit year corresponds to the calendar year; hence the name. For plans with benefit years tied to a fiscal year,
any reference to calendar year maximum in their summary of benefits actually means fiscal year maximum.
Call Note
Electronic documentation of a call to MHHSI’s Customer Service Department.
Care Guidelines
A set of widely-accepted medical practices or treatments which are endorsed by a national or professional
organization as appropriate for a particular group of patients (e.g., females) or for a particular condition (e.g.,
coronary artery disease). See also Utilization Review.
Case Management
The coordination of medical care rendered to patients with catastrophic or high cost medical conditions in order
to improve continuity and quality of care as well as manage costs. MHHSI employs Certified Case Managers to
perform these duties. See also Case Manager.
Case Manager
An experienced professional (usually a nurse) who works with patients that have catastrophic or high cost
medical conditions and their providers to coordinate any needed health care services. The goal of a case
manager is to communicate with patients a plan of medically necessary and appropriate health care while
striving to improve the quality of care as well as manage costs.
Centers for Medicare and Medicaid Services (CMS)
The federal agency within the Department of Health and Human Services formerly known as the Health Care
Financing Administration (HCFA) which oversees Medicare and Medicaid programs and conducts research to
support them. Generally it oversees the administration of each state’s Medicaid program while directly
administering the national Medicare program.
Certificate of Coverage (COC)
A written certification documenting proof of medical coverage, including historical coverage, for purposes of
confirming the duration and type of coverage for a given plan participant.
Claim
A request for reimbursement by a provider of health care services related to patient evaluation, care, or treatment
and submitted to the patient’s health benefit plan. Generally, claims are submitted in a nationally recognized,
standard format (either electronically or on paper). See also CMS-1500, UB.
Claims Administrator
The organization which manages the day-to-day operations of a health benefit plan including claims processing,
eligibility status verifications, utilization review, and customer service. Generally the claims administrator does
not assume financial responsibility for plan participant covered benefits. MHHSI performs this role for various
employer health benefit plans. See also Plan Administrator.
Clean Claim
A claim with no defects, improprieties, or special circumstances such as incomplete documentation which could
cause a delay in timely processing. A claim is considered clean when it contains all data elements in their proper
format as required for processing.
Client Account Manager
An MHHSI employee who performs the role of primary liaison between MHHSI and the employers who have
retained the services of MHHSI as third party administrator of their health benefit plans. Employers are assigned
specific account managers in order to strengthen relationships both with the employers and their plan
participants.
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Client Health Care Advocate
An MHHSI employee whose role is to provide a higher level of support to participants in client employer health
benefit plans than the support typically performed by the Customer Service Department. This encompasses
helping participants navigate confusing issues with medical claims, authorizations, appeals, and provider
invoices (including following up to ensure claims and invoices are processed properly), visiting a participant’s
worksite to offer one-on-one problem-solving, and providing detailed interpretations and explanations of plan
benefits, exclusions, and limitations.
CMS
See Centers for Medicare and Medicaid Services.
CMS-1500
The standard form for submitting claims for professional health care services as established and maintained by
the Centers for Medicare and Medicaid Services. See also Professional.
COB
See Coordination of Benefits.
COBRA
The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. One of the requirements of this
federal law is for employers to offer continued health insurance coverage for a certain period of time to
employees and their dependents whose group health insurance coverage has been terminated.
COBRA Continuation Coverage
The right established by COBRA of any plan participant to continue coverage under the plan when the
participant ceases to meet the eligibility requirements for coverage. Typically such a continuation requires the
participant to contribute a more substantial portion of the plan premiums and is limited in duration depending
upon the individual circumstances of the participant. See also COBRA.
Coinsurance
A common feature of health benefit plans which require some cost-sharing of covered services between the plan
and plan participants. Responsibility for costs are typically divided according to a fixed percentage which may
differ by type of health care service received and frequently comes into play after a participant has met any
applicable copayment and/or deductible. Most plans limit participant responsibility to an individual or family
maximum per calendar year.
Comfort Items
See Personal Comfort Items.
Comorbidity
A medical condition or diagnosis (secondary, tertiary, etc.) which a given individual has at the same time and not
necessarily related to the individual’s primary condition.
Condition
See Diagnosis.
Continuation Coverage
See COBRA Continuation Coverage.
Continuity of Care
The practice of granting a new health benefit plan participant the authorization to continue receiving services from
specific health care providers who may not participate with the network of the plan but who had been rendering care
to the participant prior to enrollment. Typically this authorization is granted due to special care needs such as a lateterm pregnancy or cancer treatments. Every request for continuity of care received by MHHSI is reviewed
individually by a Medical Director. See also Medical Director.
Coordination of Benefits (COB)
When a plan participant is covered by more than one health benefit plan, each plan frequently has provisions to
determine the order of plan responsibility for coverage of any health care services received by the participant.
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This provision is employed to avoid duplicate payments for services and to ensure that no more than 100 percent
of the actual cost of services is reimbursed. Standard rules determine which of two or more plans, each having
COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.
Copayment (Copay)
A cost-sharing arrangement in which a plan participant pays a specified flat amount for a service (such as $20 for
a physician office visit) before the application of any plan responsibility and usually at the time the service is
rendered. Some plans combine copayments with other categories of participant responsibility such as
deductibles or coinsurance in which case the copayment is usually applied to allowable charges first.
Copayments are typically nominal amounts to avoid becoming a barrier to care, and unlike coinsurance which is
generally based on some percentage of allowed charges, copayments usually do not vary with the cost of the
service. Most health benefit plans do not include copayments in the annual out-of-pocket maximum participant
responsibility.
Cost Containment Penalty
A reduction in benefits applied to services which require precertification when a provider (and plan participant)
fail to ensure that precertification is obtained. The provisions of some health plans reduce the benefit even when
the services are retroactively authorized.
Cost Sharing
An arrangement whereby a plan participant and the health benefit plan share the costs of health care services.
Participant responsibility can take multiple forms such as copayments, deductibles, and coinsurance which are
assigned to various health care services according the summary of benefits of the plan. Another form of costsharing typically borne by participants is a portion of the premium for coverage.
Covered Benefit
For a health benefit plan, this is a service related to health care that is specifically covered under the provisions
of the plan. Such a service is usually medically necessary, but not every medically necessary service is
considered a covered benefit. Examples of services which may be medically necessary but which many plans do
not consider covered benefits include treatment of sleep disorders, procedures related to obesity such as lap band
surgeries and gastric bypasses, and custodial care. Services which are not medically necessary may be
considered covered benefits solely at the discretion of the plan such as travel expenses related to a transplant or
because of a government mandate such as breast reconstructive surgery following a mastectomy. Plans typically
delineate covered benefits with a detailed list in their summary plan descriptions.
Covered Expense
See Covered Benefit.
Covered Person
Typically an employee or dependent that is covered under a health benefit plan. See also Plan Participant.
Covered Service
See Covered Benefit.
CPT
See Current Procedural Terminology.
Credentialing
A review process for providers who are attempting to gain or maintain participation status with a network, health
care plan, group, panel, or a hospital medical staff organization. Customarily the review encompasses the
provider’s credentials such as training, demonstrated ability, and experience as well as verification of licensure,
evidence of insurance, professional association memberships, certifications, award of a degree in the field, and
investigations into historical actions or sanctions.
Creditable Coverage
According to the Health Insurance Portability and Accountability Act of 1996, most coverage under a group
health plan (including governmental or church plans) is creditable. Examples include health insurance (either
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group or individual), Medicare, Medicaid, a military-sponsored health care program, a State high risk pool, the
Federal Employee Health Benefit program, a public health plan, and a health benefit plan provided for Peace
Corps members. Creditable coverage does not include coverage only for accidents, disability income insurance,
liability insurance, supplemental policies to liability insurance, workers’ compensation insurance, automobile
medical payment insurance, credit-only insurance, coverage for on-site medical clinics, or limited-scope dental,
vision, or long-term care insurance.
Current Procedural Terminology (CPT)
One of the health care industry’s standards for reporting services and procedures rendered by physicians and
other health care providers, it is a list of descriptive terms and identifying code numbers created and revised
yearly by the American Medical Association. It serves to provide a uniform language for accurately describing
medical, surgical, and diagnostic services with each identified by its own unique 5-digit code.
Custodial Care
Care rendered to a patient who has a physical or mental disability that is expected to be prolonged and to cause
the patient to need a controlled, monitored, or protected environment and assistance with daily activities. This
can include aid in walking and getting out of bed, bathing, dressing, feeding, or supervision over medication that
could normally be self-administered.
Customer Service
The MHHSI Department primarily responsible for verification of eligibility and benefits in addition to being the
first resource for plan participants and providers when attempting to resolve any issues, disputes, or questions.
Date of Service
The date on which health care services were provided.
Deductible
A part of a plan participant’s health care expenses that the participant must pay out of pocket each calendar year
before coverage from the health plan begins (for any health care services which are assigned first to the
deductible by the plan). This amount typically resets to zero at the beginning of the next calendar year. Most
plans have individual and family deductibles, and many set differing deductibles for services rendered by innetwork providers vs. out-of-network providers. Plan rules delineate whether deductibles contribute to
maximum out-of-pocket. See also Family Deductible, Participating Provider, and Non-participating Provider.
Dependent
A person eligible for benefits through the eligibility of a primary beneficiary whom most plans typically name
the subscriber. Dependents can be spouses, natural children, adopted children, or children through marriage.
Diagnosis
Typically a named disease, illness, injury, or condition or state of health for which a patient needs, seeks or
receives medical attention.
Diagnosis Related Group (DRG)
A standard coding system developed originally for Medicare which aims to categorize hospital inpatient cases
into a specific grouping (the DRG) based upon the expectation that the cases will have a similar usage of hospital
resources. The cases are grouped according to a number of factors such as the procedures rendered to the
patient, the patient’s age and gender, the patient’s principal diagnoses as well as any complications or
comorbidities. Medicare and various health plans employ DRGs to determine hospital inpatient reimbursement
as clinically similar patient cases are expected to use the same amount of hospital resources.
Disability Status
See Total Disability.
DME
See Durable Medical Equipment.
DRG
See Diagnosis Related Group.
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Drug Formulary
A list approved by a given health plan of prescription medications and their appropriate dosages considered to be
the most useful and cost effective for patient treatment. The listing is subject to periodic review and
modification by the health plan and often consists of varying tiers of preferred drugs which plan participants may
access for different costs. These tiers typically fall into generic and brand name pharmaceuticals. Plans that
have adopted open formularies usually add a third tier of "non-formulary" medications at a higher cost to the
participants.
Durable Medical Equipment (DME)
Equipment that is primarily and customarily used to serve a medical purpose and in fact is generally not of use to
a person in the absence of an illness or injury. This equipment normally withstands prolonged and repeated wear
and is suitable for use in the home; however, it is not for training or exercise. Personal comfort items are not
considered durable medical equipment. See also Personal Comfort Items.
E&M
See Evaluation and Management.
EAP
See Employee Assistance Program.
Effective Date
The date on which provisions of coverage under a health plan take effect.
Eligibility
The satisfaction by an individual of all requirements for enrollment in a health benefit plan.
Eligibility Date
The date on which an individual meets all of requirements for enrollment in a health benefit plan. The eligibility
date usually comes after any waiting period imposed as a condition of eligibility.
Eligible Classes of Dependents
Those individuals who meet all of requirements for enrollment in a health benefit plan whose coverage is
dependent upon a primary beneficiary or subscriber who also must meet all eligibility requirements.
Emergency
A situation requiring immediate intervention of a qualified health care provider to prevent serious suffering or
the loss of life, limb, sight, or body tissue.
Emergency Care
The services rendered by a health care provider as an immediate intervention that, if not given, would jeopardize
the life or health of an individual. See also Prudent Layperson.
Employee Assistance Program (EAP)
‘This program is a plan, service, or set of benefits designed for handling family or personal problems which can
include issues related to mental health, substance abuse, addictions, marriage, parenting, financial pressures, or
emotional problems. It is customarily a service provided by an employer and designed to assist employees in
getting help for these issues so that they may remain on the job. This program is not a service offered or
administered by MHHSI. EAP benefits are considered different from behavioral and mental health benefits or
benefits to treat substance abuse all of which are typically covered under a health benefit plan.
Employee Retirement Income Security Act of 1974 (ERISA)
Also known as the Pension Reform Act, the Employee Retirement Income Security Act of 1974, as amended,
regulates most private pension and employer funded group benefit plans, including health coverage.
Employer Health Benefit Plan
A plan established or maintained by an employer for the purpose of providing medical care to employees and
their dependents through insurance, direct reimbursement, or an insurance-like arrangement by which the plan is
responsible for claims for health care services rendered to plan participants.
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Enrollee
See Plan Participant.
Enrollment
This term is used to describe both the total number of participants enrolled in a health benefit plan as well as the
process utilized by the plan to register groups and individuals for membership in the plan.
Enrollment Date
This date is the first day of coverage under a health plan. Most plans that require a waiting period for coverage
consider the first day of the waiting period as the enrollment date.
EOB
See Explanation of Benefits.
EOP
An Explanation of Payment. See Remittance Advice.
EPO
See Exclusive Provider Organization.
ERISA
See Employee Retirement Income Security Act of 1974.
Evaluation and Management (E & M)
Term used to describe the health care services rendered by a physician, nurse practitioner, or physician’s assistant
during an office visit or consultation. Such services can take place in settings other than the physician’s office such
as a clinic, hospital, emergency room, or nursing home, and the visit can vary in duration and intensity depending
upon any medical complications or unusual circumstances of the patient that require more of the physician’s time.
Key components of any visit include focusing on the patient’s history, an examination, and medical decisionmaking. Health care professionals utilize specific codes to bill for evaluation and management services in order to
indicate the place of service and complexity of the visit, whether the provider is seeing the patient for the first time,
and to distinguish consultations from other visits.
Exclusion
This is a charge for a medical condition, service, treatment, or supply that is not considered a covered expense by
a health plan meaning that no plan benefits will be payable for it. This customarily applies whether it is deemed
medically necessary or is approved, prescribed, recommended, or already rendered by a provider of health care
services.
Exclusionary Period
The period during which any diagnosis for which a newly enrolled health plan participant receives services,
treatment, or supplies may be investigated to determine whether it is a pre-existing condition. Most plans
impose this for twelve months for regular plan enrollees and eighteen months for late enrollees; however, all
plans will reduce the length of a particular participant’s exclusionary period commensurately (day for day) for
any prior creditable coverage. See also Creditable Coverage, Late Enrollee, Pre-existing Condition.
Exclusive Provider Organization (EPO)
This term is derived from Preferred Provider Organization (PPO). Many health benefit plans that utilize PPOs
for their primary network of health care providers allow plan participants to receive services from nonparticipating providers (at an out-of-network benefit level); whereas those which utilize EPOs typically do not.
In contrast, MHHSI customarily employs the term ‘EPO’ solely to designate the health benefit plans it
administers which use the Memorial Hermann Freedom of Choice Network for their primary network and ‘PPO’
to designate plans it administers which use other networks. See also PPO.
Experimental and Investigational Services
These are services, supplies, or treatments which as of the date they are received are not yet considered within
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the range of accepted medical practice by a substantial segment of the medical community or government
oversight agencies. Many health benefit plans exclude such services, supplies, and treatments from the range of
covered benefits.
Explanation of Benefits (EOB)
A statement sent to health plan participants which explains any services, supplies, or treatments that providers of
health care services have rendered to them and subsequently submitted to their health benefit plan for
reimbursement. Each statement includes the total billed charges, allowed and any non-covered charges, and any
responsibility assigned to the participant in the form of copays, deductible, or coinsurance. The statement also
notes any amounts paid by the health plan and the check number assigned with any payments. Lastly most
EOBs document any adjudication information such as the benefits according to which the submitted charges
were paid or denied and any balances such as wellness allowances or maximum out-of-pocket met by the
participant (or family) year-to-date.
Explanation of Payment (EOP)
See Remittance Advice.
Family Deductible
This is customarily the maximum deductible that a health benefit plan will assign to a family independent of the
number of individuals who comprise that family. Once the family deductible is met for a given period (typically
a benefit or calendar year), no more deductible is assigned to any individual in the family even if a particular
family member has not met the maximum individual deductible for the period. See also Benefit Year, Calendar
Year, Deductible.
Flexible Spending Account (FSA)
An account offered as a benefit by employers which allows employees to set aside pre-tax dollars to pay for
future medical services for themselves and their dependents or child care services for their dependents. FSAs
typically allow an extended range of services, supplies, or treatments under medical benefits that may not be
considered covered under traditional health benefit plans. Once the funds that a participant has designated as the
maximum contribution for a plan year are exhausted, no additional benefits are available for that plan year. Any
funds not utilized by the end of plan year are forfeited. See also Health Savings Account.
Formulary
See Drug Formulary.
Freedom of Choice Network (FOC)
See MHHSI Network.
FSA
See Flexible Spending Account.
Full-time Student
Many employer health benefit plans extend health coverage eligibility to dependents of employees after they
have turned 19 years of age who are full-time students at accredited institutions of higher learning. Most such
plans do terminate the coverage benefits of such dependents that drop below full-time student status.
Group Insurance
A health plan which offers coverage to groups of employees (and typically their dependents) under a single
policy. Such coverage is customarily issued by an employer or other group entity.
HCFA
See Centers for Medicare and Medicaid Services.
HCFA Common Procedural Coding System (HCPCS)
A national standard set of codes maintained by the Centers for Medicare and Medicaid Services and utilized by
the health care industry to describe the services, supplies, and treatments typically rendered by health care
professionals and entities and not addressed by standard CPT codes. Examples of services covered by HCPCS
codes are ambulance charges, injections, durable medical equipment, orthotics, and prosthetics.
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HCFA-1500
See CMS-1500.
Health Benefit Plan
See Employer Health Benefit Plan.
Health Care Financing Administration (HCFA)
See Centers for Medicare and Medicaid Services.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
This law protects workers by improving the portability and continuity of health insurance coverage, limiting
exclusions for pre-existing medical conditions, giving rights to enroll in any health benefit plan offered by their
employers upon losing other coverage or experiencing a qualifying event such as marriage or birth of a child,
and prohibiting discrimination in enrollment and in premiums charged to employees and their dependents based
on health status-related factors. HIPAA also strictly protects the confidentiality of Protected Health Information.
See also Protected Health Information.
Health Maintenance Organization
A payer that covers health care services obtained by plan participants only when those services are rendered by
providers who have contracted with the payer. One typical feature of an PPO plan is that participants are
required to select a primary care physician whom they must see exclusively for general health care and who must
refer them to any secondary care physicians whose services they deem necessary. MHHSI is not an PPO.
Health Savings Account (HSA)
An account made available by some employers which allows employees who are concurrently enrolled in a high
deductible health plan (HDHP) to set aside pre-tax dollars through payroll deductions to pay for future medical
services for themselves and their dependents. HSAs typically allow account holders to use their funds on a tax
free basis to pay for an extended range of medical services, supplies, or treatments that may be considered noncovered benefits under traditional health benefit plans. Plan participants may pay for the services they receive
with cards tied to the HSA which function like debit cards or by paying out of pocket and submitting
documentation of the expenses for subsequent reimbursement. If not spent, funds in an HSA continue to
accumulate each year since they are actually owned by the employee. For this reason the funds in an HSA can
be invested similar to funds in an Individual Retirement Account (IRA), and they remains available should the
employee switch to a non-HDHP offered by the same employer or terminate employment for any reason. See
also Flexible Spending Accounts.
High Deductible Health Plan (HDHP)
A qualified High Deductible Health Plan with a Health Savings Account (HSA) provides comprehensive
coverage for high cost medical events and a tax-advantaged way to help build savings for future medical
expenses by allowing plan participants to set aside pre-tax dollars in an HSA to cover qualified medical
expenses. An HDHP satisfies certain statutory requirements with respect to minimum deductibles and out-ofpocket expenses for both single and family coverage.
HIPAA
See Health Insurance Portability and Accountability Act of 1996.
PPO
See Health Maintenance Organization.
Home Health Care Services
Incorporates the full range of medical and other health-related services such as physical therapy, occupational
therapy, speech therapy, nursing, medical supplies, laboratory services, counseling, and social services that are
delivered in the home of a patient by a health care provider (typically under the supervision of a physician or
registered nurse). Such services do not customarily include housekeeping.
Hospice
Term used to describe a facility or the care provided for the terminally ill.
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Hospital Admission Deductible
A form of patient responsibility utilized by some health benefit plans that is triggered only when a plan
participant has an inpatient admission. Most are of a nominal, predefined monetary limit per inpatient stay and
function more like a copayment than a traditional deductible.
Hospital-Based Physician
A health care professional who is typically a secondary care physician that contracts (either full-time or parttime) rather than is employed with a hospital or a group medical practice to render clinical support services in a
hospital setting. The physicians who most commonly are considered hospital-based include anesthesiologists,
emergency room physicians, hospitalists, pathologists, and radiologists.
Hospitalist
A physician primarily based in a hospital for purposes of handling all admissions (sometimes from a specific
practice, group, or health plan) and who is responsible for coordinating all treatments, procedures, supplies, and
pharmaceuticals (including those rendered or prescribed by other health care providers) during a patient’s
hospital stay. Such physicians usually specialize in family or general practice, internal medicine, pulmonology,
or pediatrics, and they are often hired to handle on-call services for other physicians after hours or on weekends
and holidays. Because the hospital is their primary practice site and they are often more familiar with its system
and functions, they can allocate much more of their time to patients than those patients’ primary care physicians
with whom they maintain communication during the patients’ hospital stay.
HSA
See Health Savings Account.
ID Card
See Member ID Card.
Individual Plan
Health coverage for individuals (and their dependents) which may be acquired independently of participation in
any employer or group plan.
In-network Provider
See Participating Provider.
Inpatient Care
The care (including treatment, procedures, supplies, and pharmaceuticals) rendered to a registered patient who
has been admitted to a hospital or other medical institution such as a skilled nursing facility, long-term acute care
facility, or nursing home.
Institutional
Term used to define health care services rendered by a hospital, skilled nursing facility, dialysis center, hospice,
home health agency, or other facility. See also Professional.
Internal Medicine
The branch of medicine dedicated to the study and treatment of internal organs and body systems as well as
diseases that do not require surgery. Internal Medicine encompasses many subspecialties, and Internal Medicine
physicians (or Internists) often serve as primary care family physicians.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Most who are familiar with ICD-9 know it as the 6-digit, alphanumeric system for coding a patient’s diagnosis
on a claim for health care services, but it is a standard employed internationally to document the incidence of
disease, illness, injury, and mortality. A universal classification system of diagnoses and procedures that aids in
the collection of uniform, comparable health information, ICD-9 is used to group patients into DRGs, generate
hospital and physician billings, and prepare cost reports. The most recent version (Ninth Revision) was issued in
1979 and is still utilized today, although ICD-10 always seems to be looming on the horizon.
Late Enrollee
A plan participant who enrolls for coverage under a health benefit plan after the first 31-day period during which
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he or she is eligible to enroll for coverage and who does not enroll during a special enrollment period. See also
Special Enrollment.
Lifetime
This term is employed by health benefit plans to reference the period of coverage for a plan participant during
which maximum benefits are payable by the plan. It can also refer to the period during which services,
treatments, and supplies received by the participant may be subject to limitations of quantity, duration, or
occurrence. Lifetime is understood to mean the entire period during which an individual participates with the
plan and not the individual’s actual lifetime.
Lifetime Maximum
A limitation sometimes placed on specific benefits either for a maximum dollar amount or a maximum quantity
(usually days, units, or visits) that a plan will consider covered during a participant’s lifetime. See also Lifetime.
Limitation
This is a provision of many health benefit plans which while not excluding certain services, treatments, supplies,
or pharmaceuticals does cap or limit the benefit within a given time period (such as a calendar year or lifetime)
regardless of medical necessity. Such a cap may be applied to the total amount payable by the plan, the total
number of days a service or treatment may be received, the total number of visits allowed to a health care
provider or for a particular type of service, or the quantity of supplies or pharmaceuticals that may be received.
For health benefit plans which allow participants to seek services from both in-network and out-of-network
providers, limitations customarily apply regardless of the providers’ network status.
Long-Term Care
The complete range of care (health care services, personal care services, and social services) in an institution or
at home which is required by individuals who have lost or never had some degree of functional ability (for
example, the aged, chronically ill, or mentally or physically impaired). This term is frequently employed to refer
more narrowly to such services rendered in an institutional setting (such as a nursing home or facility for the
mentally impaired), with services such as long-term home health care seen as an alternative. Many traditional
employer health benefit plans either limit or do not offer coverage for such care.
Maximum Out-of-pocket
According to the design of most health benefit plans; this is an arbitrary dollar limit to the portion of covered
health care expenses that can be assigned to plan participant liability within a given period of time such as a
calendar year or lifetime. Health plans can vary in the type of costs that are considered included in the out-ofpocket maximum, but coinsurance is customarily included. Copays, deductibles, and even premiums may also
apply with some plans. Costs which typically never apply are cost containment penalties, any amounts over
charges the plan considers usual, reasonable, and customary, and the amounts charged by providers for noncovered benefits (exclusions, limitations, and balance billed charges). See also Calendar Year Maximum,
Lifetime Maximum, and Plan Participant Liability.
Medical Director
A physician who customarily is employed by a hospital or health plan to serve in an administrative and medical
capacity as liaison for the medical staff with the governing body and administration. Such a physician provides
guidance in the form of planning and direction of many aspects of an organization’s medical policies and
programs and is responsible for ensuring that clinical programs comply with regulation. Medical Directors
customarily maintain a strategic clinical relationship between the organization and physicians. They also
frequently oversee the development of clinical content in marketing materials and communiqués.
Medical Management
The MHHSI Department primarily responsible for case management and utilization review.
Medically Necessary
Describes a service or supply that must be necessary and appropriate for the prevention, diagnosis and treatment
of an illness or injury based on generally accepted current medical practice. It must be consistent with the
condition, illness or injury of the patient and be provided in accordance with the approved and generally
accepted medical or surgical practice prevailing in the geographical locality where, and at the time when, the
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service or supply is ordered. The fact that any particular physician may prescribe, order, recommend or approve
a service or supply does not, in and of itself, make that service medically necessary. A service or supply will not
be considered as medically necessary if (a) it is provided only as a convenience to the covered person, (b) it is
not appropriate treatment for the covered person’s diagnosis or symptoms, or (c) it exceed (in scope, duration or
intensity) the level of care which is needed to provide safe, adequate and appropriate diagnosis and treatment.
Member
See Plan Participant.
Member Advocate
See Client Health Care Advocate.
Member ID Card
Form of identification given to participants in a health benefit plan that carries information for providers of
health care services about standard patient responsibility (for example, office visit copays and ER copays) as
well as important contact information for verifying participant eligibility, benefits, authorization requirements,
provider networks the participant may access, and addresses for claims submission.
Mental Health
An individual state of psychological well-being that many health benefit plans may simplify to be the absence of
any emotional illness or mental disorder (e.g., bipolarism, depression, manic depression, neurosis,
psychoneurosis, psychopathy, psychosis, etc.). Coverage for treating such emotional illnesses or mental
disorders under a health benefit plan differs from an Employee Assistance Program benefit. See also Employee
Assistance Program.
Mental Health Provider
A psychiatrist, professional counselor, social worker, hospital, or other facility licensed to provide mental health
services.
MHHSI Network
Formerly known as Freedom of Choice (FOC), MHHSI employs this provider network established by Memorial
Hermann Health Network Providers as the primary network for its client employer health benefit plans.
Participants in such plans are offered the freedom to choose the health care providers who will render their care
from a roster of those who are part of the network. Alternatively some employer health benefit plans
administered by MHHSI allow participants the freedom to choose services from health care providers not in the
MHHSI Network (although at less favorable benefit levels).
MHHSI Network Service Area
The 6-county geographic region of southeast Texas in which the majority of the health care professionals,
facilities, and ancillary service providers in the MHHSI Network are located. This region is comprised of the
Modifier
A standard set of codes established and maintained by the American Medical Association which may be paired
with professional service codes (CPT or HCPCS) to indicate that a rendered service has been modified by some
specific circumstance but not in its nature or basic definition. For example, modifiers can be employed to
indicate procedures performed by more than one physician, or on one specific side of the body, in conjunction
with another procedure, or distinctly separate from a concurrently performed procedure.
National Accrediting Standards
URAC standards and any and all accrediting standards that MHHSI is required to meet.
Network
See Provider Network.
Network Inadequacy
Refers to a situation which arises when the provider network of a health benefit plan lacks a provider with the
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necessary qualifications, licensure, skills, equipment, supplies, facilities, or amenities to render a particular
service or set of services needed by a given plan participant. This may be due to a lack of such providers located
within a reasonable distance from the participant. Health plans may deal with such a situation by authorizing the
participant to receive services from an out-of-network provider at the same benefit level as when services are
received from an in-network provider.
Non-participating Provider
A physician, facility, or other provider of health care services that has not signed a contract to participate with a
health plan or with a provider network. Such a contract would customarily require that the provider accept
discounted reimbursement for services in exchange for certain payment guarantees and access to a large, defined
population of potential patients. If a plan participant receives services from such a provider, also known as an
out-of-network provider, many health plans will pay for the services at a reduced benefit level or not at all.
Participants who receive services from such providers also run the risk of being balance billed by the providers
even when their plans cover some of the cost of the services. See also Network Inadequacy.
Open Access
The ability of participants in some health plans to self-refer for specialty care.
Open Enrollment
The annual period of time when eligible employees may elect or change their benefits. Including their enrollment
in health care coverage, customarily a month or two before the beginning of the next plan year when the
elections will then take effect. Health benefit selections made during this time typically remain in effect until the
following plan year unless there is a special enrollment event. To the extent previously satisfied, coverage
waiting periods and pre-existing condition limits are usually considered satisfied when plan participants change
from one benefit option under their employer health benefit plan to another. With the exception of participation
in flexible spending accounts, most employers retain all previously chosen benefits for employees who do not
make any elections during open enrollment. See also Qualifying Event, Special Enrollment.
Out-of-area Benefits
For health benefit plans which utilize networks of health care providers that are limited in geographic reach to a
specific area or region, these benefits come into play when plan participants reside or travel temporarily outside
the service area of the network. Some health plans have arrangements whereby the primary network are is
"wrapped" by one or more secondary networks of health care providers (each again for specific geographic
ranges) who are to be utilized in such circumstances. Other plans offer only emergency care as a benefit outside
the primary network service area and expect beneficiaries to return to the primary area for elective services. See
also Wrap Network.
Out-of-area Enrollee
A plan participant who resides outside the primary service area of the network of the health benefit plan in which
he or she is enrolled. See also Out-of-area Benefits.
Out-of-network Benefits
Many health benefit plans allow plan participants to receive services only from providers who are contracted
with their chosen network. Others, however, give their participants the freedom to choose between receiving
services from either participating providers or non-participating providers. Such plans usually segregate plan
benefits into an in-network tier and out-of-network tier for classifying services received from participating and
non-participating providers, respectively. The latter are customarily treated at a reduced benefit level (with a
higher patient responsibility in the form of larger copays, deductibles, coinsurance, or out-of-pocket maximums).
Participants who receive services from out-of-network providers also run the risk of being balance billed by the
providers even when their plans cover some of the cost of the services.
Out-of-network Provider
See Non-participating Provider.
Out-of-pocket Expenses
See Plan Participant Liability.
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Out-of-pocket Maximum
See Maximum Out-of-pocket.
Outpatient Care
This is a designation generally applied to the care (including treatment, procedures, supplies, and
pharmaceuticals) provided and used at a hospital and typically under the direction of a physician to a person who
has not admitted as a registered bed patient. The term is sometimes used within the health care industry to
describe services rendered in a physician’s office, by a laboratory or other diagnostic testing facility, at an
ambulatory surgical center, or even in the patient’s home.
Participant
See Plan Participant.
Participating Provider
A physician, facility, or other provider of health care services that has signed a contract to participate with a
health plan or with a provider network. Such a contract customarily requires that the provider accept a
discounted reimbursement for services in exchange for certain payment guarantees and access to a large, defined
population of potential patients. A typical health plan contract prohibits the provider from balance billing
patients for any charges not covered under the benefits of the plan.
Patient Advocate
See Client Health Care Advocate.
Paycode
See Adjudication Reason Code.
Payer
A company that processes medical claims for reimbursement.
PBM
See Pharmacy Benefits Manager.
PCP
See Primary Care Physician.
Pended Claim
A claim that has been removed from the regular process of adjudication and reimbursement in order to obtain
missing information or to update the claims processing system in order to finalize the claim.
Personal Comfort Items
Personal comfort items are equipment or supplies such as, but not limited to, air conditioners, air purification
units, bath tub and shower seats, blood pressure instruments, breast pumps, elastic bandages or stockings,
electric heating units, first aid supplies, humidifiers, nonhospital adjustable beds, nonprescription drugs and
medicines, orthopedic mattresses, and scales.
Pharmacy Benefits Manager (PBM)
An organization that administers prescription claims for a health benefit plan and tracks the utilization of
pharmaceuticals prescribed for participants in the plan.
PHI
See Protected Health Information.
Place of Service Code
A standard set of codes established and maintained by the Centers for Medicare and Medicaid Services which
are submitted with claims for professional health care services and used to indicate the location or setting of
those services such as physician’s office, patient’s home, inpatient hospital, outpatient hospital, emergency
room, and independent laboratory.
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Plan Administrator
The entity which administers a health benefit plan, including establishing the policies and practices of the plan.
The plan administrator has the maximum discretionary legal authority to interpret provisions and terms of the
plan as well as to make final determinations (including factual determinations) concerning issues regarding
participant eligibility, resolution of disputes, and interpretation of benefits. Such interpretations and decisions
are considered final and binding on all parties. The plan administrator customarily serves without compensation
although any expenses incurred for administration are paid by the plan. Often the plan administrator will
procure the services of a claims administrator to manage daily plan operations. See also Claims Administrator.
Plan Document
The document which incorporates all of the provisions, terms, and conditions of an employer health benefit plan.
Unlike the Summary Plan Description of the same employer health benefit plan, the Plan Document may be
written in technical terms. See also Summary Plan Description.
Plan Enrollee
See Plan Participant.
Plan Participant
Any individual who is eligible and enrolled in a health benefit plan in order to receive health coverage benefits
as either a subscriber or a dependent.
Plan Participant Liability
Also referred to as out-of-pocket expenses, this is the amount plan participants must pay providers for services
which may include both specific amounts assigned by their health benefit plan for covered expenses
(copayments, deductibles, and coinsurance) as well as the amounts charged by providers for non-covered
expenses (exclusions, limitations, and balance billed charges). Some calculations incorporate the participant’s
contributions for coverage (premiums).
Plan Year
A 12-month period beginning with the anniversary date of a health benefit plan and which may or may not
coincide with the actual calendar year. Generally, all of the provisions, terms, and conditions of the plan are
fixed for this period.
PPO
See Preferred Provider Organization.
Precert Penalty
See Cost Containment Penalty.
Precertification (Precert)
A formal process by which health care providers and health plan participants receive assurance that the health
plan considers any recommended care or treatment a covered benefit. Usually determined by a utilization review
nurse under the oversight of the plan’s Medical Director, precertification involves determining the medical
necessity of the proposed care as well as the appropriateness of the requested duration of treatment and the
location at which the provider plans to render the service. One primary purpose of precertification is to prevent
non-emergency care that is expensive or likely to be overused or abused. Another aspect of the process assists in
the determination of whether services will be covered at an in-network or out-of-network benefit level for plans
that offer both to their participants. Most health benefit plans provide information to participants regarding
services and procedures which require prior authorization. Common among these are inpatient hospital
admissions.
Precertified
Pre-authorized. See also Precertification.
Pre-Existing Condition
This is defined by law as a condition (injury or illness) for which medical advice, diagnosis, care, or treatment
was recommended or received within six months prior to the date an individual enrolled for coverage under a
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health benefit plan (which is the earlier of the first day of health coverage or the first day of any waiting period
for coverage). Genetic information is not, by itself, a condition. Treatment includes receiving services, supplies,
consultations, diagnostic tests, or prescribed medications. Many health benefit plans do not cover services
received for a pre-existing condition, although by law this exclusion is limited to twelve months from the
enrollment date (eighteen months for late enrollees). Under HIPAA, plans must give individuals credit for the
length of time they had prior continuous health coverage, without a significant break in coverage, thereby
reducing or eliminating the 12-month (or 18-month) exclusionary period. See also Creditable Coverage,
Exclusionary Period, HIPAA, and Significant Break in Coverage.
Preferred Provider Organization (PPO)
A network of health care providers such as physicians, hospitals, clinics, and ancillary service providers which
have all contracted to provide their services at a discount on a fee-for-service basis. Many health benefit plans
that utilize PPOs for their primary network of health care providers allow plan participants to receive services
from non-participating providers (at an out-of-network benefit level).
Premium
The fee which plan participants pay on a regular basis to be enrolled for coverage with a health benefit plan.
Typically COBRA premiums are higher than those required of subscribers who are currently working for the
employer which offers the plan. See also COBRA.
Preventive Care
Comprehensive health care which focuses on prevention, maintaining the health of patients, and early detection
and treatment in order to reduce health care costs in the long run. Examples of such care are routine physical
exams, well woman exams, immunizations, and screenings such as colonoscopies, mammography’s, PAP
smears, and PSA tests. See also Wellness, Wellness Allowance.
Primary Care
Basic or general health care which focuses on wellness as well as the treatment of routine illnesses and injuries.
It is typically provided by a primary care physician or nurse practitioner. See also Primary Care Physician,
Secondary Care.
Primary Care Physician (PCP)
A physician who specializes in family practice, general practice, internal medicine, pediatrics, and occasionally
obstetrics and/or gynecology. See also Primary Care.
Privileges
Permission granted by a health care facility within defined limits for a health care professional such as a
physician to render patient care within the facility. Such permission is based upon a number of factors including
the professional’s education, licensure, competence, abilities, experience, health, and judgment.
Professional
Term used to define health care services rendered by a non-institutional provider such as a physician, nurse
practitioner, or supplier of medical equipment. See also Institutional.
Protected Health Information (PHI)
Any information, whether oral or recorded in any form or medium, that is created or received by a health care
provider, health plan, public health authority, employer, life insurer, school or university, or health care
clearinghouse and that relates to the past, present, or future physical or mental health or condition of anyone; the
provision of health care to anyone; or the billing, reimbursement, or reporting on the provision of health care to
anyone. PHI, including any individually identifiable health information, is strictly protected by HIPAA. See
also HIPAA.
Provider
A health care facility (such as a hospital, clinic, or ambulatory surgery center), professional (such as a physician,
nurse practitioner, or physician’s assistant), or ancillary services provider (such as a diagnostic testing facility,
laboratory, or supplier of medical equipment) that renders medical services to patients. Health plans, insurance
carriers, and managed care organizations are not providers; rather they are payers. The distinction between the
two is sometimes blurred when providers manage or create health plans or when payers own or manage
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providers of medical services. See also Payer.
Provider Network
The health care providers, including physicians, hospitals, clinics, and ancillary service providers, which have
contracted with an organization, typically a health plan or insurer, to provide medical services, treatment,
supplies, and pharmaceuticals to plan participants or those covered by the insurer for a reduced reimbursement in
exchange for certain payment guarantees and access to a large, defined population of potential patients.
Prudent Layperson
A standard typically applied to emergency care when evaluating whether it can be considered a true emergency.
A prudent layperson is a normally clear-thinking adult who has an average knowledge of health and medicine. A
true emergency is therefore a situation that causes such an individual to think that there is a grave medical
condition requiring immediate medical attention in order to prevent serious suffering or to protect someone’s
life, body, or health.
Qualified Beneficiary
A plan participant who must by law be offered COBRA continuation coverage under a health benefit plan when
specific circumstances known as qualifying events are met. This typically includes an employee, the employee’s
spouse, and any dependent children who were covered under the plan on the day before a qualifying event
occurs. See also Qualifying Event.
Qualifying Event
Depending upon the circumstances, a specific event that allows an individual to enroll for regular coverage under
a health benefit plan or gives an individual whose coverage has terminated the right to COBRA continuation
coverage. Typical qualifying events include termination of employment, divorce or legal separation (for
dependents), death of the covered employee, loss of dependent child states, birth or adoption of a child, and
marriage. See also Special Enrollment.
RAP Benefit
See RAP Provider.
RAP Provider
A hospital-based physician who does not participate with the network of a given health plan but whose services
are generally covered at the same benefit level as those of the facility at which they were rendered. In order to
steer participants toward in-network facilities which are typically reimbursed at a reduced cost, health plans will
offer this ‘RAP Provider’ benefit to prevent the hospital-based physicians’ services from being treated at an outof-network benefit level. As they have no contract to dictate the terms of reimbursement, many health plans may
attempt to negotiate single-patient agreements with the physicians or just allow full billed charges in order to
avert any balance billing of their plan participants. Other plans prefer to reimburse only usual and customary
charges. Most health plans consider the services rendered by radiologists, anesthesiologists, and pathologists
(hence ‘RAP’) as falling under this rule. Occasionally a plan may expand the definition to include emergency
room physicians, hospitalists, and even consultants.
Recovery
See Subrogation.
Referral
The recommendation of one physician for a patient to receive care from another physician. Very often primary
care physicians refer their patients with more complicated or specific needs to specialists. While PPOs typically
require that their plan participants first visit their primary care physicians for all referrals, most plans which use
EPOs or PPOs as their primary network allow participants to self-refer.
Refund
See Subrogation.
Remittance Advice
A statement sent to health care providers which details how a payer has processed claims for health care services
which the providers have submitted for reimbursement. Each statement includes the total billed charges, allowed
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and any non-covered charges, and any responsibility assigned to the patient in the form of copays, deductible, or
coinsurance. The statement also notes any amounts paid by the health plan and the check number assigned with
any payments as well as any adjudication information such as the benefits according to which the submitted
charges were paid or denied.
Rollover
A provision of some health benefit plans which credits a plan participant’s accumulated deductible balance for
the current year with any amount assigned to the same participant’s prior year deductible for services received
during the fourth quarter of the prior year.
Schedule of Benefits
An outline of the benefits of a health plan (sometimes with exclusions and limitations) which notes how much
the plan will contribute toward the coverage of a given health care service. This is typically broken into innetwork and out-of-network benefit levels for plans which offer both.
Secondary Care
Health care services rendered by medical specialists who generally do not have the routine first contact with
patients of primary care physicians.
Secondary Care Physician
A physician who typically has advanced education and training in a specific branch of medicine such as
cardiology, dermatology, otolaryngology, urology, etc. Many health plans that use EPO or PPO provider
networks allow participants to self-refer to secondary care physicians rather than require them to obtain a referral
from their primary care physicians as in the PPO model.
Secondary Coverage
The coverage of the health plan that is not considered primarily responsible for benefits when applying
coordination of benefits rules when an individual is enrolled in two health plans simultaneously. See also
Coordination of Benefits.
Self-funding
Situation in which an employer assumes full or partial responsibility (or shared responsibility with plan
participants) for the health care expenses of its employees and their dependents that enroll in the employer’s
health benefit plan. In such an arrangement the employer customarily sets up a fund to cover health care
expenses and contracts with an independent organization, commonly referred to as a third party administrator
(TPA) to handle the administrative functions of the plan such as claims processing. When employers self-fund,
they do not pay full coverage premiums to an insurance carrier (as in a fully-insured arrangement). Instead the
employer assumes much of the risk for plan participant health care costs and pays only an administrative fee to
the TPA. Very often those individuals covered by the health plan do not notice any difference between the selffunded and fully-insured models since most documents and identification cards appear the same with both.
Self-insurance
See Self-funding.
Self-Referral
The decision by a health plan participant to obtain the services of a medical specialist without the need to acquire
a referral from a primary care physician. This is a common feature with health plans which use EPO and PPO
networks of health care providers.
Service Area
The region in which a majority of providers participating with a given network offer their services. Many health
plans which contract with specific networks in order to obtain discounted health care services for their
participants often require those participants to utilize network providers for any services rendered within the
region. Some plans with such an arrangement usually define the region as a geographic area with specific
boundaries (such as states, counties, or even ZIP codes), while others designate a specific travel distance
(typically thirty minutes) from the provider’s location. It is also common for such plans to treat any services
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received by their participants within the service area from non-participating providers at an out-of-network
benefit level.
Significant Break in Coverage
A period of sixty-three days or more during which an individual did not have any creditable coverage. By law
this does not include any waiting period required for enrollment for coverage under a health plan.
Special Enrollment
The right of individuals to enroll for coverage under a health benefit plan outside the regular open enrollment
period due to the occurrence of a qualifying event. Generally health plans do not apply a coverage waiting
period to individuals whose enrollment is permitted under special enrollment rules, nor are such individuals
considered late enrollees. See also Late Enrollee, Open Enrollment, and Qualifying Event.
Specialist
See Secondary Care Physician and Tertiary Care Physician.
Specialty Care
See Secondary Care and Tertiary Care.
Spouse
Most health benefit plans define this as the person recognized as a covered employee’s husband or wife under
the laws of the state where the covered employee resides.
Subrogation
The assignment of the right of recovery and refund from a responsible third party which is given by plan
participants when they enroll for coverage under a health benefit plan as fully described in their summary plan
document. The plan can exercise this right when an action (typically an injury or illness) that results in the
plan’s having to cover medical expenses is actually the fault or responsibility of another party (for example, an
automobile accident) regardless whether the medical expenses incurred represent covered benefits. In such a
situation, "recovery" implies the right of the plan (to the extent of medical expenses incurred) to all funds paid or
payable to the participant by way of a judgment, settlement, or otherwise to compensate for all losses caused by
the injury or illness. "Refund" means reimbursement to the plan for any payments toward the care and treatment
of the participant as a result of the injury or illness. In effect, the plan has the right to place a lien upon the
participant’s claims for medical charges against the other party.
Subscriber (Health Insurance)
Someone, typically an employee, who is eligible and enrolled in a health benefit plan and who is primarily
responsible for payment of premiums. Dependents are generally not considered subscribers.
Subscriber (Workers’ Compensation)
An employer which purchases workers’ compensation insurance (or an employer which opts into the Texas
workers’ compensation system).
Substance Abuse
A disorder characterized by the continued and excessive use of drugs such as alcohol, controlled substances, or
prescription medications that impairs someone’s ability to function both alone and in society like a healthy
individual and can lead to serious consequences such as illnesses, injuries, or even death if not treated. Coverage
for treating such a disorder under a health benefit plan differs from an Employee Assistance Program benefit.
See also Employee Assistance Program.
Summary Plan Description
A written explanation as required by ERISA of the provisions, terms, and conditions of a health benefit plan,
including requirements for eligibility, a description of available benefits, allowances, and any exclusions or
limitations. See also ERISA, Plan Document.
Termination Date
The date that coverage under a health benefit plan ends. This may or may not be the date that an individual no
longer meets the eligibility requirements for coverage depending upon the rules of termination as provided by
the plan.
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Termination of Coverage
When an individual’s coverage under a health plan ends. Typically this occurs when either the plan itself ceases
to exist, the covered person is no longer in a class eligible for coverage, or the covered person fails to pay any
necessary premiums to maintain coverage. Some plans allow coverage to continue to the end of the month that a
person loses eligibility, while others terminate coverage immediately.
Tertiary Care
Health care services rendered by highly specialized providers which often must take place in a facility setting
and requires sophisticated technology or equipment. Very often these services have developed because of
diagnostic and therapeutic advances acquired through basic and clinical biomedical research.
Tertiary Care Provider
Highly specialized health care providers whose services often require sophisticated technology or equipment and
must be rendered in a facility setting. Some of the specialized fields of medicine of these providers include
intensive care, neurology, neurosurgery, and thoracic surgery.
Third Party Administrator (TPA)
An organization such as MHHSI that offers administrative services like claims processing and utilization review
to employer health benefit plans. TPAs usually have greater expertise and capability to administer all or a
portion of an employer’s health benefit plan and at a lower overall cost than the employer itself.
Third Party Recovery Provision
See Subrogation.
Timely Filing Limit
The grace period during which health care providers must submit claims for services they have rendered to
participants in a health plan. This is typically one year from the date of service, but may be as brief as sixty days
depending on the plan rules or any contractual arrangement between the plan and the provider. Claims
submitted after the timely filing limit are denied as non-covered services, and participating providers are not
permitted by their network agreements from seeking compensation from the patients.
Total Disability (Totally Disabled)
In the case of a dependent son or daughter, this means the complete inability as a result of an injury, illness,
disease, or genetic condition to perform the normal activities of a person of similar age and gender who is in
good health. Most health benefit plans consider totally disabled dependents to meet the requirements of
eligibility for coverage under the plan regardless of age.
TPA
See Third Party Administrator.
U&C
See Usual and Customary Charge.
UB
A standard form used by institutional providers for submitting claims to payers for medical services rendered to
patients as established by the Uniform Billing Code of 1992. As opposed to the CMS-1500 and its successors,
the UB-04 (formerly known as the UB-92 and CMS-1450) and its successors are reserved for facility and
inpatient services as well as for providing information about hospital admissions. See also Institutional.
Urgent Care
Health care services rendered as an immediate intervention and that may take the place of emergency care
depending upon the capabilities of an urgent care center to provide appropriate treatment or services based on the
severity of the illness, injury, or condition of the patient.
Urgent Care Center
A specialized facility dedicated to the delivery of minor emergency medical care in a non-hospital setting
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generally on an unscheduled, walk-in basis. Unlike a typical hospital emergency room, some urgent care centers
operate on reduced hours rather than remaining open on a continuous basis.
Usual and Customary Charge
The amount determined by a health plan to be a reasonable reimbursement to a health care provider for services
rendered.
Utilization
The use of health care services, supplies, treatment, or drugs.
Utilization Management
See Utilization Review.
Utilization Review
A process that evaluates the medical necessity, efficiency, and appropriateness of requested health care services
taking into account established care guidelines and criteria. For an inpatient service, this includes an evaluation
of the appropriateness of the admission, the ordered services, the length of stay, and discharge criteria. The
utilization review process often incorporates the use of clinical protocols, data, or benchmarks against which a
specific patient case can be compared. Reviews can be made prospectively, concurrently, or retrospectively.
See also Care Guidelines, Medical Management.
Visit
A professional consultation, examination, and/or evaluation of a patient, typically though not always rendered in
a physician’s office setting by a physician, physician’s assistant, or nurse practitioner. At the conclusion of the
visit, the health care professional will customarily deliver or prescribe a regimen of care for the patient. See also
Office Visit.
Waiting Period
The period of time an individual must wait before becoming eligible to enroll for coverage under a health benefit
plan. Alternatively this is the period of time a plan participant must wait for a service that is intended to treat a
specific condition to be considered a covered benefit, otherwise known as an exclusionary period. See also
Enrollment Date, Exclusionary Period, and Pre-Existing Condition.
Wellness
The condition of physical and mental well-being in the absence of an illness or injury. Preventive medicine and
wellness programs sponsored by health plans or employers are an attempt to aid individuals in maintaining a
healthful lifestyle with the goal of reducing health care utilization and costs in the long run. Such programs
emphasize the importance of remaining physically fit, reducing stress levels, maintaining a healthful diet,
avoiding generally unhealthful activities such as smoking, and scheduling regular wellness examinations and
immunizations. See also Preventive Care.
Wellness Allowance
An allowance established by some health benefit plans to encourage their participants to seek wellness services
such as health screenings and annual checkups in order to reduce health care utilization costs in the long run.
Typically the plan will set up a predefined sum that participants may access for 100% coverage (plan
responsibility) for wellness services until the benefit is exhausted. See also Allowance.
Wrap Network
An additional network of health care providers to which plan participants have access when outside the service
area of the primary network of a health benefit plan. See also Out-of-area Benefits.
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