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Provider Requirements Office Visits/Appointments Submitting the Information Health Indicator Criteria and Testing HIPAA Provider Payment ID Cards and Benefits Provider RequirementsQ: What is required of me if my patients are members of HealthbyChoice IncentivesSM? Within 90 days of the member's effective date of coverage, you need to complete and submit a qualification form to Priority Health that notes if the member meets the criteria for three health indicators. Members are responsible for contacting you and scheduling an appointment, if required, in a timely manner. If the member does not meet any one of the health indicators, he or she has the option to complete a fasting cholesterol and fasting blood glucose (HbA1c) test and to agree to a treatment program. This information must also be noted on the form and received by Priority Health within 90 days of the member's effective date of coverage. The information on the qualification form can also be submitted via the Patient Profile tool or the new HealthbyChoice Incentives tool. Q: Am I required to complete a qualification form or the online information every year? Yes. The health plan is set up so that members must qualify for or re-qualify for the Choice level of benefits every year. Each year they have a 90-day qualification period in which to meet the requirements, which includes completion of the qualification form. Office Visits/AppointmentsQ: Are members required to make an appointment to have their qualification form completed? In most cases, members will need to meet with their providers in order for the health indicators to be measured and the qualification form completed. However, if a member has been seen within six months of his or her effective date of coverage and the required information is available, you can use that information to complete the qualification form. Members need only contact your office and ask that the information be forwarded to Priority Health by a specified date (90 days from the member's effective date of coverage.) Q: Are members required to see their PCP or can they see any provider to have the qualification forms completed? Members in any HealthbyChoice Incentives HMO or PPO option can see any physician, although we encourage HMO members to see their PCP. At this time, only a physician or physician's office can report the health indicator criteria. Qualification forms cannot be completed and submitted by wellness providers, walk-in clinics or other providers. Q: What if a patient cannot get in for an appointment with me within the 90 days of their effective date of coverage? Priority Health network providers are held to appropriate access standards to ensure that our members can obtain appointments within their 90-day qualification period. However, members are given instructions up to five months in advance of their qualification cutoff date. It is up to your office to determine if you can accommodate patients who call for appointments at the last minute. Please keep in mind that members that do not have their qualification forms completed and submitted by their providers within 90 days of their effective date of coverage may be moved to a benefit level that requires them to pay a greater share of their health care costs. Q: We encourage members to get a physical once every two years. Why does HealthbyChoice Incentives require them to visit their provider every year in order to verify that they meet the health indicator criteria? Measurement of the health indicators does not require a full physical. However, if someone's health indicators decline we want to move them to the appropriate benefit level and encourage them to take corrective action. The rate relief offered by this health plan requires that we do everything possible to ensure that members are meeting the program requirements. Q: What should I bill for this visit? You should bill for the appropriate service performed. This may be a routine visit, follow-up care, a nurse-only visit, a physical or even an allergy injection. If you are completing the form but don't need to see the patient for an office visit, you may not bill the patient for completing the form. Q: Do patients pay a copayment for their visit to have the health indicators measured and/or the qualification form completed? Copayments are applied for the office visit as usual. However, if a member is there only to drop off a form for your office to complete because he or she was seen recently (within six months of their effective date of coverage), no copayment should be taken. Submitting the InformationQ: How do I get the qualification form? Qualification forms will be distributed to members at enrollment, or you can download one now (99KB PDF). Q: Are there other ways to report the required information rather than using the qualification form? The information can be submitted using the HealthbyChoice Incentives tool or the Patient Profile tool, both of which can be accessed in the Provider Center. Q: Do I have to complete the qualification form if the required information is already in the Patient Profile tool as part of the PIP requirements? If the required information for a specific patient is in the Patient Profile, the HealthbyChoice Incentives tool will automatically be populated with information for that patient. Likewise, when data is entered into the HealthbyChoice tool, the Patient Profile will automatically be populated with the relevant data. Q: How will I know if a patient's health indicator criteria in the Patient Profile are up-to-date and fall within the qualification guidelines (six months of member's effective date of coverage)? When you query a specific patient, that patient's information will appear in Patient Profile. Dates associated with the health indicator measurements will also appear. The member is responsible for informing you of his or her effective date of coverage. Q: What happens if the information I submit is incomplete? Paper qualification forms with missing information will be returned via fax with a form indicated that information is missing. If the information is submitted via the Patient Profile or the HealthbyChoice Incentives tool, feedback will be provided in real time. Q: How do I forward the completed qualification form to Priority Health? You can fax the paper form to Priority Health at 616 942-0616. If you use the HealthbyChoice Incentives tool or Patient Profile, the information goes directly to Priority Health. Can I fill out the form and let the member send it to Priority Health? No. Priority Health requires that providers record and submit the information on behalf of members. Q: Can the information be entered online by my office staff? Yes. The log on to the system counts as the "provider signature." You can authorize your staff to enter the required information using the HealthbyChoice Incentives or Patient Profile tools. Q: Can a nurse practitioner or physician's assistant sign off on the qualification form? Yes. Q: What happens if my office did not send in the qualification form by the member's cutoff date for maintaining the Choice level of benefits? Priority Health has set up procedures to capture information that is reported late. In cases where members are moved to a different benefit level and we later receive provider documentation that they met their requirements within the 90-day qualification period, members will be moved back to the appropriate benefit level. Claims will be adjusted. We anticipate these situations being very rare. Health Indicator Criteria and TestingQ: What are the health indicator criteria that must be noted on the qualification form? The health indicator criteria are:
Q: The criteria for these health indicators do not represent optimal health. Why were they selected? The health indicator criteria represent controllable health behaviors commonly associated with chronic illnesses and other health issues. Members that meet these criteria, or who agree to the alternatives provided, are taking steps toward healthier lifestyle choices. They meet what we have determined to be the minimum criteria for qualifying to maintain the Choice level of benefits. (They are also required to complete an online health risk assessment.) Q: What is the HIPAA-mandated alternative for patients who do not meet the health indicator criteria? Members who do not meet any one of the health indicators can still maintain the Choice level of benefits if within the same 90-day window they complete a fasting blood sugar test (or HbA1c test) and a fasting cholesterol test, and agree to their provider's treatment program in the areas where health risks have been identified. Q: If the patient must undergo the additional testing, am I required to report the lab results on the qualification form? No. You only need to note on the form that the lab work has been ordered. It is the responsibility of the member to have the tests completed in a timely manner. If proof is not received via a claim that the test was performed, the member will be moved to the Standard benefit level. Q: Am I required to define or outline any treatment program in which I ask the patient to participate? No. You only need to have the member sign the form noting that he or she agrees to participate in the program. Q: What if a patient's pregnancy causes her to have a BMI above 30? Is she required to agree to the alternatives in order to maintain the Choice level of benefits? No, not unless she does not meet any of the other health indicator criteria. We recommend that you allow women who are pregnant to meet the BMI criteria. However, you may use your discretion in these cases. HIPAAQ: Should I be concerned about any HIPAA violations regarding the information on the qualification form that I am providing to Priority Health? Submitting the form to Priority Health falls under the category of normal health care operations. In addition, the form includes a HIPAA privacy statement that members sign off on before the form is submitted. Q: What does Priority Health do with the information on health indicator criteria and any lab results? Whether or not a member meets the health indicator criteria, or whether the member agrees to complete the alternatives provided, is used to determine a member's benefit level. Priority Health also uses this information for wellness resources and services programming. All information reported on the qualification form or via the HealthbyChoice Incentives tool (or Patient Profile), whether obtained from the provider or from an outside lab, will be stored in the member's Patient Profile record. This information is only available to members and their providers. Provider PaymentQ: Are providers compensated for their time in completing the qualification form? Yes. Priority Health will pay $30 per member for each completed form submitted via the web and $15 for each faxed form. Q: If the information is already available in the Patient Profile, will I still be entitled to the $30 payment for submitting the information via the HealthbyChoice Incentives online tool or the $15 payment for faxing the qualification form? Yes. Q: Will I be compensated for completing and submitting the qualification form even if I did not see the plan member? Yes, as long as the information you provide was gathered during an office visit within six months of the member's effective date of coverage. Q: What if one of my patients is currently covered by another insurer but will be switching to the HealthbyChoice Incentives plan? You may still complete the form with current information or information from up to six months prior to the patient effective date with HealthbyChoice Incentives. You will still be reimbursed for completing the form. Q: How often will payments be made for the qualification forms? Providers will be paid quarterly, soon after calendar quarters end. Q: How can my office match payments with specific providers and/or patients? Checks will be accompanied by a payment register which contains the name of the provider submitting the qualification form information and the name of the patient for which the information was provided. This way, providers' offices can match each payment to individual providers and patients, if they so choose. Q: How is compensation handled in cases in where multiple providers enter information or complete and submit the qualification form? In certain cases, multiple providers may receive payment for completing the qualification form. However, in most cases only a single provider will receive payment. Q: If I saw a patient and gathered the required information on the qualification form within six months of their effective date of coverage, but another insurer covered the patient at the time, will I still be compensated for completing the qualification form without seeing the patient again? Yes, as long as the information was gathered within six months of the member's effective date of coverage in HealthbyChoice Incentives. ID Cards and BenefitsQ: What will the ID card look like? ID cards will display the name HealthbyChoice Incentives as the health plan product and list copayments for the specific benefit level (Choice or Standard.) Q: Will patients receive new cards if their benefit level changes after their initial 90-day qualification period? Yes. If a member of HealthbyChoice Incentives does not meet the requirements to maintain the Choice benefit level and is moved to the Standard benefit level, the member and any covered dependents will receive new ID cards. We suggest using Member Inquiry through the Provider Center to ensure you have the most up-to-date information on a patient. Q: Can a plan member and his or her spouse have different benefit levels? No, not if they are both covered under the same plan. We require both spouses to meet the requirements to maintain the Choice level of benefits. If one does not meet the requirements, both will be moved to the Standard level of benefits. Q: What benefits will providers see if they inquire about a patient between 91 days on the patient's plan and the time a valid qualification form is received by Priority Health? Since Priority Health will wait a few weeks for all information to be received before actually moving members to the Standard level of benefits if they do not meet the requirements, the provider will still see the patient's Choice benefits past day 90. It will be emphasized in provider training that the patient may actually be moved to the Standard level of benefits retroactive to day 91. Q: If a member has been transferred to the Standard level but presents an ID card with the Choice level of benefits, do I have to honor the Choice level copayments? We suggest using Member Inquiry through the Provider Center to ensure you have the most up-to-date information on a patient. Q: What happens when someone is added to the plan mid-year? Members who enroll during the first three quarters of the plan year are treated as any other member. They have the same 90 days from their effective date to meet requirements to maintain the Choice level of benefits. Members who enroll in the last quarter are placed on the Choice level of benefits and will re-qualify for them the next year. Contracts that lapse and are reinstated within 180 days are placed into their previous level of benefits. Anyone reinstated after 180 days is treated as a new hire.
Last modified
02/12/10
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