ivingwell
WWW. C HCVA.CO M
HOW
JENNIE
TY PENNINGTON
GARTH ADVOCATES
COPESFOR
WITH
HEART
ADULT
HEALTH
ADHD
FALL 2013
-
A COVENTRY MEMBER MAGAZINE
TIME FOR
BALANCE
Avoid these 6 missteps
healthy people make
PAGE 4
BUILDING
BLOCKS
What to expect as
your child grows
PAGE 10
JOINING FORCES
- Coventry now has a new
parent company—Aetna.
What does this mean to you?
>>
page
page66
Learn more on PAGE 5.
HE ALTH SPARKS
Welcome to Living Well
From our baby’s first smile and clumsy, unbalanced first
When her mother and sister were diagnosed with high
steps to hearing “mama” and “dada” come from their
blood pressure, Garth promised she’d be the exception
small mouths, being a parent means a sense of joy as
to the family rule, visiting the doctor every year—only
each new milestone is reached. We sometimes wish
to learn that she herself had a leaky heart valve. Now
we could stop time and keep our children as they are:
an advocate for the American Heart Association’s Go
children. As a father of six-year-old twins, I have watched
Red campaign, Garth urges others to change the script
my two go from diapers to kindergarten in the blink of
on heart disease by talking to their doctor and making
an eye. Unfortunately—and fortunately (if part of being
important lifestyle changes. To learn more, read “Jennie
a child means coloring the walls red and yellow with
Garth’s Role of a Lifetime,” page 6.
ketchup and mustard)—growing up is inevitable.
We hope you enjoy these articles and more in our
If you’re new to the parenting sphere or just want to
fall/winter issue of Living Well. As always, thank you for
relive the glory days, read “Building Blocks: A Guide
reading. From Charlottesville to Richmond, Roanoke to
to Child Development,” page 10.
Danville—and everywhere in between—we truly appreci-
Jennie Garth grew up in the most popular ZIP code of
ate all of our members and look forward to continuing our
the 1990s: Beverly Hills 90210. While her television life
commitment to you and your family’s health care needs.
was made for the screen, her real life provided a different
If you ever have a question, please don’t hesitate to call
storyline: a family history of heart disease. After her father
us at 800-627-4872.
had a heart attack at age 37, Garth says, “I watched
[my dad] go from training horses, baling hay and driving
tractors to fearing that too much exercise would prompt
another heart attack.”
Brian Corbey, President
Your feedback is important
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Coventry Health Care of Virginia, Inc. administers PPO products underwritten by Coventry Health and Life Insurance Company in the State of Virginia. LivingWell is published by
McMurry/TMG, LLC © 2013. All rights reserved. No material may be reproduced in whole or in part from this publication without the express written permission of the publisher.
This publication is not intended to and does not constitute medical advice, and no doctor/patient relationship is formed. The accuracy, completeness, adequacy or currency of this
publication is not warranted or guaranteed. The publication is not intended to be a substitute for professional medical advice, diagnosis or treatment. You should always seek the
advice of physicians or other qualified health providers with any questions regarding a medical condition. You should never disregard professional medical advice or delay in seeking it
because of something in this publication. Coventry Health Care of Virginia, Inc. does not recommend or endorse any specific tests, products, procedures, opinions or other information
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© Rob Kim/FilmMagic/Getty Images (page 6).
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livingwell
3
YOUR WELL-BEING
6 Mistakes
Healthy People Make
These smart moves sometimes get overlooked.
Y
ou eat right, you don’t smoke
and high blood pressure, and may
and you fit in exercise
weaken your immune system. It can
whenever you can. Give
also make it harder to concentrate
yourself a big pat on the back for
during the day, and has been linked to
making healthy choices.
emotional issues including depression.
But even the healthiest people can
make mistakes. Here are six of the
Adults should get 7 or 8 hours a day;
children and teens need even more.
biggest and most common.
Overuse of antibiotics and
Skipping routine doctor’s visits.
medical tests.
Seeing your doctor once a year, or
Only take antibiotics for bacterial infec-
as often as recommended based on
tions, not viral infections like a cold
your health, is one of the best things
or the ﬂu. Otherwise, you can build
you can do to stay healthy. Regular
up a resistance and they won’t work
checkups can alert you to health prob-
when you really need them. Also avoid
lems before they start or at the earliest
unnecessary medical tests. If your
stages, when they’re easiest to treat.
doctor thinks tests are needed, find out
why and if there’s any alternative.
Taking the “weekend warrior”
approach to exercise.
Choosing unhealthy drinks.
Kudos for finding time to exercise,
Soda and sweetened beverages
but limiting it to weekends makes
are nothing but empty calories.
you much more prone to injuries. It’s
Even diet soda isn’t the best option,
smarter to fit activity into your routine
because of the artificial sweeteners
most days. If the weekends really are
and other chemicals it contains. Stick
your only chance, be sure to warm up,
to water, unsweetened iced tea or
cool down and stretch.
coffee instead.
Skimping on sleep.
HAVE YOU
HAD YOUR
CHECKUP
YET?
4
livingwell
Skipping your ﬂu shot.
Lack of sleep can contribute to obesity,
This one is really a no-brainer. Flu shots
heart disease, kidney disease, diabetes
are your best defense against the ﬂu. =
If not, it’s time to schedule
a visit to the doctor for
yourself—and the rest of
your family as well.
While you’re there, ask
if it’s time for any routine
screenings or tests, like
those that check for high
cholesterol or cancer. It
may be time for vaccinations and booster shots, too,
especially for the kids.
Have a candid discussion
about eating and exercise
habits or anything else
that’s affecting your physical or mental health. Don’t
forget your ﬂu shot. If this
year’s vaccine isn’t available
yet, ﬁnd out when it will be
and be sure to follow up.
AT YOUR FINGERTIPS
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livingwell
5
SPOTLIGHT
Jennie
ROL
LI
H
Being an advocate for heart he
Garth talked about how difﬁcult it
was to see his health decline.
“I watched him go from train-
I
ing horses, baling hay and driving
tractors to fearing that too much
exercise would prompt another
heart attack.”
Garth said that caring for him
through the years and seeing how
his disease affected her family
T MAY BE HARD TO PICTURE
prompted her to take action on
ACTRESS JENNIE GARTH AS
her own health.
ANYTHING BUT THE SASSY
“Make good choices
and take action,”
Garth once said.
“I refuse to let heart
disease take me
from those I love
too soon.”
6
livingwell
TEEN SHE PORTRAYED ON
Family Risk Factors
BEVERLY HILLS 90210.
There were risk factors on her
But from a relatively young age,
mother’s side of the family to
Garth had to face the adult realities
consider too. Her maternal grand-
of a strong family history of heart
mother died of a stroke at age 46.
disease. Garth’s personal history
Her mother and sister were both
with heart disease began when her
diagnosed with high blood pressure
father had a heart attack at age 37.
in their 40s, and a half-sister also
While serving as a spokesperson
for the American Heart Association’s Go Red for Women campaign,
has high blood pressure.
When she promised herself to see
a doctor every year starting at age
Garth’s
E of a
FETIME
ealth started with her family—and herself.
What Tests
Can Tell You
There’s a lot your doctor can
tell about your risk for heart
disease with two simple tests to
check your blood pressure and
cholesterol. Numbers above the
normal range mean you could
be headed for trouble.
Your doctor will check your
blood pressure every time you
visit, which should be at least
once a year. Starting at age 20,
30, Garth really thought she’d be the
Balanced, healthy meals are essen-
exception to the family rule. But she
tial. Some of Garth’s favorite choices
was diagnosed with a leaky heart
are Greek yogurt with slivered
valve, which she can sometimes feel
almonds or whole oats, and salmon
ﬂuttering in her chest.
with balsamic onions.
Most leaky heart valves don’t cause
She’s an advocate for regular
problems or symptoms, and can
exercise and quitting smoking.
occur even in healthy people. In other
Most important, she urges women
cases, leaky heart valves can be
to see their doctor every year armed
serious, limiting the ﬂow of blood.
with a list of questions about risk
Like Garth, anyone with a strong
family history of heart disease or
symptoms of heart valve problems—
you should have a full cholesterol panel run at least every
ﬁve years—and more often if
you have risk factors such as
being overweight or having a
family history.
Talk to your doctor about
how often you should get
these easy, but important,
factors like high blood pressure and
tests. If your numbers are too
cholesterol.
high, your doctor can recom-
Although her father lost his battle
mend lifestyle changes and, if
like shortness of breath, dizziness
with heart disease in 2008, Garth
needed, medication to get you
or swelling of the feet and ankles—
has said his struggles inspired her to
back in the healthy range.
should see their doctor for thorough
live better. At age 41, she’s a mother
testing.
of three and continues to work,
recently developing a sitcom
Never Too Late to Make Changes
with former Beverly Hills 90210
Fortunately, as Garth has put it, “the
co-star Luke Perry.
heart is a very forgiving organ.” That
“Make good choices and take
means even if you haven’t been lead-
action,” Garth once said. “I refuse to
ing a healthy lifestyle, it’s never too
let heart disease take me from those I
late to make positive changes.
love too soon.” H
livingwell
7
PRE VENTION
SOME GOODLOOKING FOODS
Bugs Bunny was on to
something. Carrots are
one of the many foods
that can actually improve
the health of your eyes.
Foods high in antioxidants, beta carotene,
lutein, zinc and vitamins
A, C and E can all help
prevent eye disease.
Fruits and vegetables
Crisp
and Clear
Vision
See what a difference
taking care of your
eyesight can make.
including kale, spinach,
red berries, broccoli, zucchini, red and green bell
peppers, kiwi, tomatoes,
avocadoes and sweet
potatoes are all good
choices, as are orange,
grapefruit and guava
W
hen was your last eye exam? If it’s been
thy affects the blood vessels of the retina. the
more than a year, consider scheduling
disease causes progressive damage to those
that appointment.
blood vessels, eventually causing blindness if it’s
An eye exam can detect many common vision
juices.
not treated. The best defense is good control
problems early, when they’re easiest to treat.
of blood sugar and blood pressure, and early
foods include eggs,
What’s more, early diagnosis may even prevent
diagnosis and treatment— usually with laser
salmon, seafood, red
vision loss.
surgery—can help prevent vision loss.
Other vision-boosting
meat, poultry, nuts,
ﬂax seed, dried beans
and whole grains.
Breakfast
cereals and
other foods
Just having the right glasses or contacts—
GLAUCOMA. Most cases of glaucoma
known as refractive correction—can make all the
are caused by an increase in the normal ﬂuid
difference in how you see the world. According
pressure inside the eyes. Sometimes, though,
to the Centers for Disease Control and Preven-
glaucoma can develop even when eye pressure is
tion, 11 million Americans age 12 and older could
normal. Glaucoma damages the eye’s optic nerve
improve their vision with refractive correction.
and can cause peripheral vision loss and, eventu-
You also want to be on the lookout for other
vision problems. Here are three of the most
delay the progression of glaucoma. Laser and
zinc can
common.
conventional surgery may also be recommended
help too.
CATARACTS. The world’s leading cause of
livingwell
to reduce the buildup of ﬂuid in the eye.
blindness, a cataract clouds the eye’s lens. Cat-
Other than vision changes, these conditions
aracts can form at any age and cause cloudy or
usually don’t have any symptoms, especially in
blurry vision, poor night vision or double vision.
the early stages. Even the vision loss caused by
They can also create glare or make lights seem
these conditions can be so gradual that it can
too bright, and can cause colors to look faded.
go unnoticed until the disease has progressed.
Cataract removal surgery is safe and effective,
That’s why it’s essential to see an eye doctor as
and improves vision for 90 percent of patients.
often as recommended based on your own vision
DIABETIC RETINOPATHY. A common
and health history. Simple exams can detect these
complication of diabetes, diabetic retinopa-
8
ally, blindness. Eye drops or medication can often
fortified with
eye problems early and protect your sight. =
LIFEST YLE CHANGES
Are You Headed for
DIABETES?
Prediabetes gives you fair warning—and the chance to take
preventive steps.
B
efore they develop type 2 diabetes,
- Am I overweight with related conditions
many people have prediabetes. This
like high blood pressure, high cholesterol,
means their blood glucose levels are
a family history of diabetes or a personal
LIVE WELL
WITH TYPE 2
higher than normal, but not high enough to
history of gestational diabetes?
If you already have type
warrant a diabetes diagnosis.
Does my heritage put me at higher risk
2 diabetes, here are six
for diabetes because I’m African-Ameri-
daily habits to help
research shows that damage can be done to
can, Mexican-American, American Indian,
prevent complications.
the body even at the prediabetes stage, espe-
Native Hawaiian, Pacific Islander or
cially to the heart and cardiovascular system.
Asian-American?
Still, it’s not a free pass. In fact, some new
Even more important, taking steps when
you have prediabetes can help delay or even
prevent the onset of diabetes.
It can be tough to know you have predia-
-
- Am I older than 45, even without other
risk factors?
- Am I over age 45 and overweight?
If you answered “yes” to any of these
betes, because the symptoms often come on
questions, you could be headed for potential
so gradually you might not notice them. But
trouble. Talk with your doctor about simple
some of the symptoms of prediabetes (and
tests that can determine if you have predia-
diabetes) include:
betes.
- Extreme thirst
- Frequent urination
- Blurred vision
- Excessive fatigue
- Frequent infections
The good news is that two simple lifestyle
changes can often help control type 2
diabetes.
You can reduce your odds of developing
type 2 diabetes by 58 percent by losing
Here are some questions to ask yourself to
7 percent of your body weight—that’s just
help determine if you could have, or could be
15 pounds if you weigh 200 pounds—and
at risk for, prediabetes.
getting moderate exercise, like walking, for
30 minutes a day, five days a week.
This may be all it takes to return your
blood glucose levels to the normal range.
When you talk to your doctor, be sure to ask
about follow-up tests to keep you
on the right track. =
GET MOVING.
About 30 minutes of
moderate exercise
most days is ideal.
EAT RIGHT. Fresh
veggies, fruit, lean
protein and whole
grains are staples.
And watch those
portion sizes.
CHECK IN. Testing
your blood glucose
levels is the best
way to know if
what you’re doing
is working.
FOLLOW ORDERS.
If you’re on medication, take it just as
prescribed.
STRESS LESS.
Too much stress is
bad for your blood
glucose control.
Find ways to reduce
stress, like meditation or hobbies.
BRUSH UP. People
with diabetes are at
higher risk for gum
disease, so brush
your teeth at least
twice a day and ﬂoss
at least daily.
livingwell
9
FORWARD THINKING
BUILDING
A Guide to Child
What to expect as your child
I
t’s a joy watching your baby grow into a child.
Every milestone—the first laugh, the first step,
the first word—is a precious moment.
These milestones are also an important
way to watch for signs that your child may be
having developmental difficulties that are best
addressed early.
Here are some of the key milestones to look for
based on age.
= TWO MONTHS: Your baby begins to smile,
makes cooing and gurgling sounds, and turns his
or her head toward sounds. Babies start paying
attention to faces and looking at you, and can hold
their head up when lying on their stomach.
= SIX MONTHS: Your baby should now recognize
familiar faces. Babies at this age respond to their
own name. Showing curiosity and looking around
is typical, as is rolling over in both directions and
sitting without support.
= NINE MONTHS: By now, your baby understands
the word “no” and starts making more sounds like
“mamama.” Babies can get into a sitting position,
crawl and stand when holding on to something.
10
livingwell
BLOCKS:
Development
or your baby.
of babies develop colic,
which causes them to
cry inconsolably, pull up
their legs and pass gas.
Their stomachs may be
Stick to a schedule of well-child visits. They’re
arms and legs to help with dressing and
a great opportunity to discuss any developmental
responding to basic instructions. They
concerns with the doctor.
can also use simple gestures like waving
Colic is no fun—for you
An estimated one-fifth
grows.
= ONE YEAR: Most children start extending
Coping
With Colic
Start with every two months, then every
bye-bye and say simple words like “dada”
three months as your child nears the 1-year
and “uh-oh.”
mark. By 18 months, visits every six months are
recommended. Below is a table showing the
distended too.
Colic usually goes away
between age four and six
months. Some soothing
strategies to try include
recommended schedule for well-baby visits up
not overfeeding your
ably saying single words and walking alone.
to age 30 months. Annual checkups begin at
baby and walking or
Children at this age start showing more
about age 3.
rocking your baby. Some
= TWO YEARS: By now, your child is prob-
independence and can stand on tip-toe
and kick a ball.
SCHEDULE FOR
WELL-BABY VISITS
= THREE YEARS: Most children can dress
Newborn
and undress themselves and show a wide
3-5 days
range of emotions. They can speak two or
1 month
three sentences at a time, work toys with
2 months
buttons and levers, and turn book pages
4 months
one at a time.
6 months
babies respond to lying
across your legs on their
stomach while you rub
their back.
If you’re nursing, eliminate foods like caffeine,
9 months
milk products, onions and
12 months
other foods that can irri-
their first and last name. They start
15 months
18 months
tate your baby. If you’re
understanding the idea of counting and
remember parts of a story. They’ll also
24 months
begin copying some capital letters and
30 months
= FOUR YEARS: Children can say
doctor if your baby may
have a food sensitivity.
using scissors.
At each doctor’s visit, ask about any vaccina= FIVE YEARS: Children speak very clearly
using formula, ask your
tions to make sure your child stays on schedule.
Be sure to talk to your
doctor about your baby’s
by now. They can count to 10 or more and
print some letters or numbers. Children this
MORE MILESTONES
colic, so any other medi-
age can use a fork and spoon and (happy
You’ll find more detailed checklists about child-
day!) use the toilet on their own.
hood milestones at www.cdc.gov/ncbddd/
cal conditions can be
actearly then click “free materials.” =
ruled out.
livingwell
11
MEN’S HE ALTH
BE AWARE:
Younger
Adults at Risk
Younger adults are
having more strokes
than they used to,
according to a study
published late last year
in an online issue of
Neurology magazine. In
fact, about one in ﬁve
Men, Get the
Scoop on STROKE
Knowing the facts just may save your life.
strokes occur in people
ages 20 to 55.
The researchers
think an increasing
rate of obesity, high
A
stroke can be debilitating or even
WARNING SIGNS
deadly. But up to 80 percent of
The signs of a stroke are serious, and prompt
strokes are preventable, says the
medical attention is the best way to prevent
National Stroke Association.
Do you know the risk factors for stroke?
long-term disability. If you notice any of these
signs in yourself or someone else, call 911
cholesterol, diabetes
How about the warning signs? About one-
right away.
and other risk factors
third of men can’t recognize a single stroke
- Sudden numbness or weakness in the face,
could be contributing.
Tools such as MRI
scans may also be
resulting in a higher
number of cases being
diagnosed in young
people.
Lifestyle changes
like losing weight and
getting more exercise
can help reduce stroke
risk. If you have risk
factors for stroke, talk
to your doctor about
necessary tests and
preventive measures.
symptom—and they’re at higher risk of having
arm or leg, especially if it’s only one side of
a stroke than women.
the body
So wise up, guys (and gals). Here’s what
you need to know.
RISK FACTORS
Not all of the risk factors for stroke are preventable, such as gender, family history or
increasing age. African-Americans are also
livingwell
coordination
- A severe headache that comes on suddenly
with no known cause
at increased risk.
There are plenty of risk factors you can
In some cases, the warning signs may
control, though. These include high blood pres-
disappear after just a few moments—but that
sure, heart disease, diabetes, high cholesterol,
doesn’t mean you should ignore them. Even
being overweight or inactive, and smoking.
though the symptoms go away, they’re the sign
If you have one or more of these control-
of a transient ischemic attack (TIA), also known
lable risk factors, it’s time to make changes.
as a mini-stroke, and require immediate medi-
Tackle lifestyle improvements one at a time:
cal attention just like any stroke does.
Quit smoking, then start getting more exercise
Do the right thing. Taking steps to prevent
and losing weight. Those three things alone are
stroke, and knowing what to do if one occurs,
good ways to start managing most of the other
could save your life. =
risk factors.
12
- Confusion
- Trouble speaking or understanding speech
- Sudden vision changes in one or both eyes
- Trouble walking, including loss of balance or
STAY HE ALTHY
Quality Improvement
Program
Our goal is to help you get the best care possible.
W
e aim to help you take better
All doctors and staff involved in the
care of yourself and your family.
QI program respect the private nature of
Our Quality Improvement (QI)
information they see.
program works to ensure that all of our
IMPORTANT
NOTICE
services meet high standards of quality
ANNUAL QUALITY IMPROVEMENT
and safety. As part of the QI program, we
PROGRAM EVALUATION
help you take care of your health and get
The Quality Improvement program is
If you go to a non-par-
the best service possible.
evaluated on an annual basis. The results
ticipating emergency
We look for problems and seek oppor-
are used to develop and prioritize the
room and/or receive
tunities to make improvements. The QI
annual quality work plan for the upcoming
program looks at ways to improve:
year in order to ensure the effectiveness of
treatment from a
- Member satisfaction
- Safety of care
- Services
and availability to
- Access
the program. For more information, please
non-participating
go to our website.
physician, you may
network providers
If you have any questions about our
QI program, you can call the number on
your Member ID card or write to us at:
be balance-billed by
those providers for
amounts above what
Coventry Health Care of Virginia, Inc.
your health plan pays
services. This is done by building goals
QI Department
into our Quality Improvement program and
9881 Mayland Drive
in addition to your
working toward meeting these goals.
Richmond, VA 23233
Each year we strive to improve our
The goals and objectives of the
copayment, coinsurance or deductible. To
QI program are to:
locate a participating
- Make sure that reliable methods
provider or facility, visit
are used to measure results of
our services.
- Involve staff to support the
www.chcva.com then
click Find a Doctor.
quality improvement process.
- Focus on quality issues of
high importance.
- Remain sensitive to the cultural and
language needs of those we serve to
enhance health care delivery.
- Ensure that all state and national
regulatory requirements are met.
- Maintain accreditation for the health
plan. Accreditation is earned from the
National Committee for Quality Assurance (NCQA).
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13
CARE NOTES
You Have the
Right to Appeal
Our Decision
e have both a complaint and
individuals not involved in any previous
EXTERNAL REVIEW: You have the right
an appeal procedure available to
adverse determination. You will be notified
to request an external review if 1) you have
our members to resolve Member
of the Appeal Committee’s decision within
exhausted the health plan appeal process
30 calendar days of the date we received
and received a final adverse determination;
the appeal request. If the appeal involves
or 2) you file an appeal with the health plan
RECONSIDERATION: If we have denied
a denial based on medical judgment, the
and a written decision is not issued within
a request for services on the basis that the
appeal will be reviewed by a panel that
the established appeal timeframes. The
services are not medically necessary or are
includes a clinical peer reviewer who was
request for an external review must be
experimental or investigational, your treat-
not involved in any previous adverse
made within 120 days after the date of
ing provider, on your behalf, may request a
determination. If the appeal is a pre-service
receipt of the final adverse determination.
reconsideration. Your treating provider must
medical appeal you will be notified of
request a reconsideration within 90 calendar
the Appeal Committee’s decision within
have the right to file an expedited external
days of the date you receive written notifica-
30 calendar days of the date we received
review request. You may request an expe-
tion of the initial denial. The reconsideration
the appeal request. If the appeal is a post-
dited external review at the same time you
process is optional.
service medical appeal, you will be notified
request an urgent care appeal from us. For
of the Appeal Committee’s decision within
fully-insured groups and self-insured groups
APPEAL: If we have denied a request for
60 calendar days of the date we received
that have opted into the state process, the
authorization or for payment of a service,
the appeal request.
forms to request an external review are
W
inquiries, complaints and appeals.
Under certain circumstances, you may
available at www.chcva.com > Services &
including a denial in whole or in part based
on medical judgment or the failure to cover
URGENT CARE APPEALS: You may
Support > Members > Other Important
services because they are determined to be
request an urgent care appeal when a delay
Information. All other self-insured
experimental/investigational or not medically
in care could seriously jeopardize your life,
groups, should contact the health plan
necessary, you or your authorized represen-
health or your ability to regain maximum
for information on how to file an external
tative can appeal our decision. You have
function; when your treating physician
review request.
180 calendar days from the day you receive
determines the care needed is urgent
written notification of the initial denial to
or determines that a delay in care would
plan Complaint and Appeal procedures,
submit a written request for appeal. You may
subject you to severe pain that could not be
please review your health plan documents
provide us with any additional documents,
adequately managed without the treatment
or contact Customer Service at the number
records or information that are relevant to
requested; or if you are a cancer patient and
listed on your ID card. =
your appeal. You or your authorized repre-
the delay in care would subject you to pain.
sentative may request access to and copies
An urgent care appeal may be made by
of documents, records and information
telephone, facsimile or in writing. A decision
relevant to the appeal. We will provide you
will be made no later than 72 hours from the
shall be subject to termination or
with that information free of charge.
time of the request, or if related to the treat-
otherwise penalized due to the
ment of cancer pain, no more than 24 hours
filing of a complaint or appeal.
If your appeal is an administrative appeal,
the appeal will be reviewed by a panel of
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from the time of the request.
For a complete description of the health
No Member who exercises the
right to file a complaint or appeal
YOUR PL AN
What You Need To Know
Learn all about our UM program.
U
tilization management (UM) is a
when the services are reviewed via our UM
system for reviewing eligibility
program. The provider is advised that the
for benefits for the care that has
decision is a payment decision and not a
and the existence of coverage.
denial of care. The responsibility for treat-
- We do not reward practitioners,
been or will be provided to patients.
- UM decision making is based only on
appropriateness of care and service
The UM department is composed of:
ment remains with the attending physician.
providers or other individuals conducting
+ Preauthorization
+ Concurrent review
+ Case management
The medical director is available to discuss
utilization review for issuing denials
denials with attending physicians and other
providers during the decision process.
of coverage or service care.
- The compensation that we pay to
practitioners, providers and staff assisting
Medical necessity is based upon
Notification is sent to the member, pro-
in utilization-related decisions does not
clinical standards and guidelines as well
vider and facility within three working days
encourage decisions that result in under-
as clinical judgment.
after receiving all necessary information
utilization or barriers to care or service. =
All clinical standards and guidelines used
to make the medical necessity deter-
in the UM program have been reviewed
mination. This notification includes the
and approved by practicing, participating
criteria used and the clinical reason for the
physicians in our network. Providers can
adverse decision. It includes instructions
receive a copy of our clinical standards and
for reconsideration and a contact person’s
guidelines by calling their Network Manage-
name, address and telephone number.
ment/Provider Relations Representative.
The facility, attending physician or the
All members receive notification of any
preauthorization decisions.
member may request an appeal.
The policy on payment for services
ensures that the UM decision-making pro-
DOCTORS MAKE THE DECISIONS
cess is based on consistent application of
The medical director makes all final decisions
appropriate criteria and policies rather than
regarding the denial of coverage for services
financial incentives.
UM STAFF
are available
Monday though Friday, 8 a.m. to
5 p.m., for questions regarding UM
decisions. They can receive fax
communication after hours. Phone
and fax numbers are listed on our
website under Plan Members >
Member Contact Information.
You may also call the Customer
Service number on the back of
the member ID card.
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15
PRESORTED
STANDARD
U.S. POSTAGE
PAID
FLORENCE KY
PERMIT NO. 313
Coventry Health Care of Virginia, Inc.
9881 Mayland Drive
Richmond, VA 23233
Helpful Prescription
Drug Information
On Our Website
Y
ou can access the following
- Copayment and coinsurance
pharmacy information on our
requirements, and the medications
website at www.chcva.com >
or classes to which they apply.
Members > Prescription Documents:
- A list of preferred pharmaceuticals,
- Procedures for step-therapy, prior
authorization, generic substitution,
including any restrictions and/or
preferred-brand interchange and
preferences
therapeutic interchange.
- A list of medications which require
- Information on the use of
prior authorization, and applicable
pharmaceutical management
coverage criteria.
procedures.
- A list of medications which require
- Criteria used during the evalu-
step-therapy, including the medications
ation of new medications for
which must be tried/failed prior
inclusion on the formulary.
to coverage.
- A list and explanation of medications
which have limits or quotas.
- A description of the process
for requesting a medication
coverage exception.
SH
Always verify with Customer Service that services we mention in LivingWell are covered under your benefit plan.
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Customer Service
800-627-4872
www.chcva.com