Useful plan information - Provider - REG ANH

Useful health plan information

The following information provides a useful guide to our programs, requirements, policies and guidelines. If you would like copies of any of this information sent to you, please contact your provider relations representative.

 Electronic transactions

Learn about our electronic transaction options and enroll to receive your claim vouchers and payments electronically.

 Member rights and responsibilities

Members have the right to:

  • Receive information about our company and services, as well as the physicians, dentists, other health care professionals and facilities (providers) in our network.
  • Receive information about your member rights and responsibilities.
  • Make recommendations regarding our company's rights and responsibilities policy.
  • Be treated with respect and dignity.
  • Privacy of your personal information.
  • Participate in decisions about your care with your doctor and other health care professionals.
  • Openly discuss with your doctor the appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
  • Voice complaints or appeal decisions made by your health plan or about the care provided to you.

Members have the responsibility to:

  • Provide as much information as possible to your plan, practitioners and providers in order for them to provide the right care.
  • Follow plans and instructions for care that you and your doctor have agreed to.
  • Understand the condition of your health and participate in developing mutually agreed-upon treatment goals, as much as possible.
  • Know and confirm your benefits and eligibility before receiving services.

Learn more about member rights and responsibilities in the appeals for members section of our Administrative Manual.

 We encourage practitioners to freely communicate with patients

Practitioners are responsible for their relationship with each patient and are solely responsible for the medical care provided, including the discussion of treatment alternatives. Your Agreement does not limit your right to communicate freely with your patients, including the right to inform them services are appropriate or necessary, even if we determine the services are not covered by their plan.

 Use of practitioner and provider performance data

Measuring and reporting health care quality is important. Affiliated network practitioners and providers acknowledge and agree that the plan may use the performance data collected for quality improvement activities. Performance data collected includes, but is not limited to, member experience, HEDIS performance and appointment access data that is used to implement quality initiatives to improve care and service, as well as providing patients with information and tools to help them make informed choices to pursue the best available care.

 Referring patients to our Care Management program

Our Care Management program is dedicated to delivering a personalized model that focuses on each member holistically. This model provides members with the greatest unmet health care needs with a single care manager to support their medical and behavioral health. Our care managers are an extension of the member's provider team and support each member in meeting their health care goals. Care Management is one of our core clinical services that is fully integrated within our robust suite of programs committed to the triple aim of improving the member experience, improving member health, and lowering health care costs.

Care Management goals include:

  • Advocating for members and their support systems
  • Improving care through close collaboration with providers
  • Assisting members as they navigate the health care system
  • Educating members about their care options, benefits and coverage
  • Ensuring full compliance with national quality standards, including those established by NCQA
  • Supporting members with information to make educated decision regarding their health care
  • Improving members' clinical, functional, emotional and psychosocial status by supporting their health and wellness needs, as well as their individual autonomy

Case managers are experienced registered nurses and social workers. They work with members and their providers to support the physician's treatment plan with development of a care plan based on the patient's needs, social support system, benefits and physician input.

Members experience highly personalized services because we integrate personal preferences, benefits and high-quality contracted providers to achieve optimum long-term outcomes both medically and financially.

Case managers work closely with disease managers and behavioral health clinicians to meet the needs of participants with chronic illness or coexisting conditions such as chemical dependency and depression.

A case manager's role includes:

  • Coordinating care and removing barriers to care
  • Contributing to the member's safety and quality of life
  • Achieving maximum value for the member's medical benefits
  • Developing care plans based on the member's unique situation
  • Acting as member advocate by providing expert advice and navigation
  • Monitoring and assuring delivery of timely, medically appropriate and effective interventions.

You can also refer members to participate in the program by contacting our care management team or completing the care management referral request:

 Disease Management program

Our disease management programs (Disease Management for our fully-insured members and Asuris Condition Manager for our administrative services only members) include registered nurses and/or care advocate staff focus on helping members close gaps in care related to one or more of the following conditions:

  • Asthma
  • Diabetes
  • Coronary artery disease (CAD)
  • Congestive heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD)
  • Depression (managed as a co-morbidity)

How we work with your patients in the program

We identify members who are eligible for the program and invite them to enroll. You can also refer members to participate in the program by contacting our disease management nurse or completing the Care Management Referral Request. For all patients who enroll in the program, we offer:

Low-risk members receive:

  • Program welcome letter
  • Access to 24/7 nurse line
  • Bi-annual disease management newsletter
  • Monthly review of claims data for re-stratification
  • Quarterly condition-specific newsletters (ASO only)
  • Member and provider notifications when gaps in care are identified (ASO only)
  • Option to engage with disease management nurse (even though the member is not high risk)

High-risk members receive all low-risk interventions services plus:

  • Condition-specific educational guide
  • Comprehensive condition-specific assessment
  • An individualized care plan in collaboration with provider
  • Ongoing disease management nurse education and support
  • An individualized care plan in collaboration with the provider
  • Member and provider notifications when gaps in care are identified

How we communicate with you

Providers will receive notification by letter or fax of their patient's agreement to participate in the condition-specific disease management program. Providers will be an active participant in the care of the member through collaboration with the disease manager and through direct member contact.

Contact our care management team:

 Clinical Practice and Preventive Guidelines

Clinical Practice and Preventive Guidelines are systematically developed statements on medical practices that help physicians and other practitioners make decisions about appropriate health care for specific medical conditions.

The Plan adopts guidelines to assist health care professionals in recommended courses of intervention, but not as a substitute for an individual clinician's judgment. CPGs also help form the basis for designing appropriate disease management program interventions, coaching and wellness program content, and other health care programs at Asuris.

 Policy prohibiting financial decisions for staff who make utilization management decisions about care and service

Utilization management decisions are based only on appropriateness of care and service and the existence of coverage. There are no rewards or incentives for practitioners or other individuals for issuing denials of coverage, service, or care. There are no financial incentives for utilization management decision-makers to encourage decisions that would result in underutilization.

 Access and network adequacy standards and policies

We are committed to providing our members the necessary information to:

  • Be able to use their health plan benefits
  • Have reasonable access to health services
  • Be assured the number of physicians, other health care professionals and facilities will be appropriate to satisfy their health care needs.

Learn more about our accessibility and availability standards(href: /web/asuris_provider/accessibility-and-availability-standards").

 Obtaining utilization management criteria

You can obtain a copy of the clinical rationale, diagnosis and treatment codes and their meanings, as well as any other information used to make utilization management decisions, free of charge, by calling 1 (855) 238-9318. For pharmacy inquiries, please call 1 (844) 765-6827.

 How to contact our utilization management staff

Utilization management (UM) staffs are available from 7:00 a.m. to 5:00 p.m., Pacific Time, and from 8:00 a.m. to 6:00 p.m. Mountain Time. Staff can receive inbound communication regarding UM issues after normal business hours via voice mail and by fax. Communications received after normal business hours are returned on the next business day.

Utilization management staff are also responsible for pre-authorization requests. Utilization management staff can be reached at the toll-free numbers listed for the following lines of business:

 Pharmaceutical management
 Practitioner Rights

Providers have the right to review information submitted to support their credentialing application, including review of information submitted from outside sources, e.g., malpractice insurance and state licensing boards. Providers may also request information about the status of his/her application or reapplication. All requests should be submitted by email to the Credentialing department. Application status requests are responded to and tracked in the providers credentialing file. Information that is allowed to be shared is the current status, outstanding requests and process timeframes. Peer protected and confidential information prohibited by law cannot be disclosed.

In the event that erroneous or conflicting information is discovered in a credentialing application, the provider will be notified in writing of the right to dispute and/or correct the information (subject to any restrictions provided by a verification source, or otherwise prohibited by law). The provider must submit a detailed explanation of all clarifications and corrections in writing, within fifteen (15) business days of the request, to the credentialing staff via e-mail or by fax at (888) 335-3002. The credentialing staff documents receipt of corrected credentialing information in the provider's credentialing file.

Learn more about the credentialing process and eContracting.

 Practitioner appeal process

Learn more about our appeal process for providers in our Administrative Manual.

 Medical record documentation

View the requirements for medical record keeping.