Selecting the Right Medical Billing Service - 5 Things to Consider

Medical billing is crucial part of any health care facility even though it is not the main line of activity in such workplaces. There are many time consuming issues related to medical billing. Medical professionals are often overworked, and may not have time to attend to such issues. But ignoring this function may lead to severe repercussions such as drying up of funds, or even legal complications related to Medicare frauds. Therefore, this function deserves due respect.

One way to reduce medical billing procedures encroaching upon the health care functions is to off load the function to specialized medical billing services. Such offloading is advantageous even for smaller medical practices, as it leaves more time on hand for the professional work. There are many medical billing service providers. It becomes difficult to select the right one from these. In order to get the right medical billing company, following five points need to be considered.

1.    Where is the medical billing service located?
Location of such services is crucial because patients often have queries regarding their medical bills. Services of overseas medical billing companies are cheaper, but they may prove to be expensive for patients. In addition, there can be other issues such as accent or lack of familiarity with procedures in the country where health care facility is located.


2.    Is the medical billing company adequately experienced?

Experience is very important in this field. This is because terminology related to medical billing is quite different from other types of billing. In addition, billing is linked to medical reimbursements. Therefore, any such billing information should be accurate. It should also comply with all relevant legal stipulations.

3.    How efficient is the medical billing service in getting reimbursement?

Medical billing is a set of smaller functions like entering data, submitting claims for getting reimbursement, patient billing, payment posting, and follow up for reimbursement, and handling denial issues. The company that offers comprehensive service should be preferred over others. In addition, the company that systematically and regularly obtains the reimbursements in shorter time should be preferred.

4.    What sort of reports can the company generate, and how frequently?

Medical billing is not exclusively about generating bills, and obtaining reimbursements. It is also about generating different reports from the available data. Such reports should give the medical professional an idea about the financial health of the practice or health care facility as the case may be.

5.    Does the company guarantee data security?

There are legal stipulations relating to patient’s rights to privacy. Security of medical billing data is therefore important because information on it can lead to Medicare and other frauds, which could implicate the health care facility and lead to protracted legal battles.

what is complete claims?

Complete claims


For proper payment and application of deductibles and coinsurance, it is important to accurately code all diagnoses and services (according to national coding guidelines). It is particularly important to accurately code because a member’s level of coverage under his or her benefit plan may vary for different services. You must submit a claim for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member at the time of service.

To assist you in understanding how your claims will be paid, UnitedHealthcare’s Claim Estimator includes a feature called Professional Claim Bundling Logic which helps you determine allowable bundling logic and other claims processing edits for a variety of CPT (CPT is a registered trademark of the American Medical Association) and HCPCS procedure codes. Note: Only bundling logic and other claims processing edits are available under this option.

Pricing and payment calculations are not included.

Allow enough time for your claims to process before sending second submissions or tracers, then check their status online at UnitedHealthcareOnline.com. If you do need to submit second submissions or tracers, be sure to submit them electronically no sooner than forty-five (45) days after original submission.

Complete claims include the information listed under the Complete Claims Requirements section of this Guide.
We may require additional information for particular types of services, or based on particular circumstances or
state requirements.

If you have questions about submitting claims to us, please contact Customer Care at the phone number listed on the member’s health care ID card. For questions specific to electronic submission of claims, please review the information at UnitedHealthcareOnline.com  Claims and Payments  Electronic Claims Submission (EDI ). If you need additional information on EDI , contact the EDI Support Line at (800) 842-1109, Option 3.

Learn about the many tools available to help you prepare, submit and manage your UnitedHealthcare claims at UnitedHealthcareOnline.com including: Claim Estimator with bundling logic and Real-Time Adjudication. Training tools and resources including Frequently Asked Questions (FAQs), Quick References, Step-by-Step Help and Tutorials are available by clicking “Help” at the top of any page.

Note: At the time of publication of this Guide, the Claim Estimator is not available for Medicare
products.

To order 1500 HIC F (CMS-1500) and UB-04 (CMS-1450) forms, contact the U.S. Government Printing Office, call (202) 512-0455, or visit their Web site at cms.hhs.gov/CMSForms.

5 tips for prompt claim processing

Prompt claims processing


We know that you want your claims to be processed promptly for the covered services you provide to our members.

We work hard to process your claims timely and accurately. Here’s what you can do to help us:

1 Review the member’s eligibility at UnitedHealthcareOnline.com, using swipe card technology or keying
in the member’s information.

You can also check member eligibility by phone by calling the United Voice Portal at (877) 842-3210 or the
Customer Care number on the back of the member’s health care ID card.

Disclaimer: Eligibility & benefit information provided is not a guarantee of payment or coverage in any specific
amount. Actual reimbursement depends on various factors, including compliance with applicable administrative protocols, date(s) of services rendered and benefit plan terms and conditions.

2 Notify us in accordance with the Standard Notification Requirements list.

3 Prepare complete and accurate claims (see “Complete Claims” below).

4 Submit claims online at UnitedHealthcareOnline.com or use another electronic option.

a) Connectivity Director is a free direct connection for those who can create a claim file in the HIPAA 837
format. This Web-based application enables real-time and batch submissions direct to UnitedHealthcare.
Connectivity Director provides immediate response back to all transaction submissions (claims, eligibility, and
more). Additional information can be found at UnitedHealthcareCD. com, including a comprehensive User Guide and information on how to get started.

b) UnitedHealthcare Online All-Payer Gateway™ is a Web-based connectivity solution which links
UnitedHealthcare Online users to a leading clearinghouse vendor (Ingenix) that offers multi-payer health
transactions and services at preferred pricing. Using your current UnitedHealthcare Online User ID and
password, you can register with Ingenix to submit batch claims to many of your governmental and commercial
payers. For more information: UnitedHealthcareOnline.com  Claims and Payments  Electronic Claims
Submission  EDI Options.

c) EDI Gateway and Clearinghouse Connections – UnitedHealthcare’s preferred clearinghouse is Ingenix, but you can use any clearinghouse you prefer to submit claims to UnitedHealthcare. Both participating and nonparticipating physician, health care professional, facility and ancillary provider claims are accepted electronically using UnitedHealthcare’s payer ID 87726. Other UnitedHealthcare and affiliate payer ID s can be found on UnitedHealthCareOnline.com.


UnitedHealthcare contracts generally require you to conduct business with us electronically and contain requirements regarding electronic claim submission specifically. Please review your agreement with us and abide by its requirements. While some claims may require supporting information for initial review, UnitedHealthcare has reduced the need for paper attachments for referrals/notifications, progress notes, ER visits and more. We will request additional information when needed.

5 Receive Electronic Payments and Statements (EPS)


If you are enrolled with us for EPS, payments are electronically deposited into one or more checking
accounts which you designate. Take the next step by auto-posting the electronic 835/Electronic Remittance
Advice (ERA) that you receive from your clearinghouse, or obtain one free of charge from our Web site at
UnitedHealthcareOnline.com.

Explanations of Benefits (EOBs) that match each daily/weekly consolidated deposit are available on
UnitedHealthcareOnline.com, where you can review, store and print hard copies to use for manual posting.


EPS is UnitedHealthcare’s preferred method for receiving payments and statements and results in faster and easier payment to you. If you have not yet enrolled in this standard operating process, start receiving electronic payments and statements now by enrolling online at UnitedHealthcareOnline.com or by contacting us at (866) 842-3278, Option 5. Please note EPS is not available in all markets for our Medicare Advantage plans.

End Stage Renal Disease/ Dialysis Services CPT code and revenue code list

Services for the treatment of End Stage Renal Disease (ESRD), including outpatient dialysis
services (as defined by, but not limited to, the revenue and CPT codes below), require
notification.

No notification is required for end stage renal disease when a Medicare member travels outside
of the service area.

Dialysis:
90935, 90937, 4052F, 4054F – hemodialysis
90945, 90947, 4055F – peritoneal
90963 – 90970 – ESRD
90989 – patient training, completed course
90993 – patient training, per session
90999 – unlisted dialysis procedure, inpatient or outpatient

Revenue Codes:
304 – Nonroutine Dialysis
800 – 804, 809 – Renal Dialysis
820 – 825, 829 – Hemo/op or home
830 – 835, 839 – Other outpatient/peritoneal dialysis
840 – 845, 849 – Capd/op or home
850 – 855, 859 – Ccpd/op or home
880 – 882, 889 – Dialysis / misc

For the most current listing of UnitedHealthcare contracted dialysis facilities, please refer to our
online provider directory at UnitedHealthcareOnline.com or call us at (877) 842-3210. In an
effort to maximize member benefit coverage and lifetime maximum limits, we ask that you refer to
UnitedHealthcare contracted dialysis facilities whenever possible. Note that your agreement with
us may include restrictions on referring members outside the UnitedHealthcare network.

LIST AND DEFINITION OF DUAL ELIGIBLES - Medicare and Medicaid

Dual Eligibles - The following describes the various categories of individuals who, collectively, are known as dual eligibles. Medicare has two basic coverages: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services. Dual eligibles are individuals who are entitled to Medicare Part A and/or
Part B and are eligible for some form of Medicaid benefit.

1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services provided by Medicare providers. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).

2. QMBs with full Medicaid (QMB Plus) - These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and
coinsurance, and provides full Medicaid benefits. FFP equals FMAP.

3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.

Medicaid pays their Medicare Part B premiums only. FFP equals FMAP.

4. SLMBs with full Medicaid (SLMB Plus) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits. FFP equals FMAP.

5. Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. FFP equals FMAP.

6. Qualifying Individuals (1) (QI-1s) - This group is effective 1/1/98 - 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 120% FPL, but less than 135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.

Medicaid pays their Medicare Part B premiums only. FFP equals FMAP at 100%.


7. Qualifying Individuals (2) (QI-2s) - This group is effective 1/1/98 - 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 135% FPL, but less than 175% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays only a portion of their part B premiums ($2.23 in 1999). FFP equals FMAP at 100%.

8. Medicaid Only Dual Eligibles (Non QMB, SLMB, QDWI, QI-1, or QI-2) -  These individuals are entitled to Medicare Part A and/or Part B and are eligible for full Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI, QI-1, or QI-2. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid eligibility poverty group that exceeds the limits listed above. Medicaid provides full Medicaid benefits and pays for Medicaid services provided by Medicaid
providers, but Medicaid will only pay for services also covered by Medicare if the Medicaid payment rate is higher than the amount paid by Medicare, and, within this limit, will only pay to the extent necessary to pay the beneficiary's Medicare costsharing liability. Payment by Medicaid of Medicare Part B premiums is a State option; however, States may not receive FFP for Medicaid services also covered by Medicare
Part B for certain individuals who could have been covered under Medicare Part B had they been enrolled. FFP equals FMAP.

Improve Medical Billing Collections - Billing Tips

Any medical billing company would like to have on-time collections, of course.  Although, it cannot be denied that there are issues that may hinder this from happening.  To make sure that every billing is paid successfully, you have to work hard and to be organized.  First, do not let a claim sit around for a long time.  Once you have received it, process it immediately and inform the insurance company.  If you take long in processing it, it would also take longer for the payment to arrive.  Follow it up with the insurance company and get a specific answer about when payment will be sent so you could easily inform the patient in case they call or drop by. 
Make good use of the available technology we have nowadays.  Invest on electronic modes of payment and claims.  This is not only convenient, it is also faster.  This method is also more reliable because an electronic machine would easily detect entry errors and missed fields.  It would immediately inform the patient or the insurance company about it so that it would be corrected right away. 

It is necessary to follow-up with insurance companies in a timely manner.  If a payment is expected today and it has not yet arrived, call them up.  If they give another date, follow it up again on that particular date.  If they do not reply at all, try calling them weekly.  Regular follow-ups give the insurance company an impression that you are serious about collecting.  Most insurance companies would do anything to avoid a payment.  Make sure you point out to them that you will keep calling until the collection is sent.

As with other types of businesses, medical billing should document and record all conversations between them and the patient and between them and the insurance company.  This way, when something fails and gets neglect, you can easily reference it.  If an insurance company refuses to pay, you can inform them about certain conversations you have had or any promise they might have said.  This will show them that there is no use for alibis as everything that went on between you is properly documented.

If none of this makes the insurance company pay, involve the patient.  You will be surprised to know that patients are very willing to call their insurance companies and demand for payment.  This is because if their insurance does not cover it, the bill might be charged to the patient.  No patient would ever agree to this.  If the patient is very busy or cannot able to contact their insurance company, ask them if you could write a letter or request on their behalf.

Update on Evaluation Management CPT codes - HighMark insurance

Highmark Announces Adjustments to UCR and Premier Blue sm

Shield Reimbursement

 As noted in the April 2011 issue of PRN, Highmark filed with, and has now received approval from, the Pennsylvania Insurance Department to implement a broad range of UCR Level II and Premier Blue Shield reimbursement adjustments.

The adjustments impact anesthesia, select surgical, diagnostic and evaluative services, including, but not limited to, musculoskeletal, eye, behavioral health, allergen immunotherapy and routine electroencephalography procedures.

• Increases in allowance will be implemented for dates of service beginning July 1, 2011.

• A minimum number of allowances will be decreased for dates of service on/after Sept. 26, 2011.

Highmark will also implement changes to its payment differential for evaluation and management procedure codes 99201 through 99215 when performed in the facility, compared to services performed in a non-facility setting. Effective Sept 26, 2011, Highmark will calculate payment for the facility service using Medicare's site-of-service differential, or at a predetermined cap, not to exceed a certain designated percentage. Currently, Highmark applies a 15 percent differential.

In addition, the allowances for CT studies of the abdomen and pelvis combined, procedure codes 74176, 74177 and 74178,will be increasing with this update. The allowances will be based upon additional data collection and analysis and have yet to be finalized.

Fees Available Via NaviNet

You may access the reimbursement adjustment information online in four convenient ways.

1. Visit our Provider Resource Center via NaviNet. Simply hover on Administrative Reference Materials, and click on Fee Updates to view the complete list of fee adjustments. (Fees are not published on the public 

Provider Resource Center.)

When the adjustments are in effect (see effective dates above), you can also use the following online tools.

2. On NaviNet, hover on Allowance and then select Allowance Inquiry to determine pricing for specific procedure codes-by planrproduct type.

3. Also on NaviNet, you can hover on Allowance, and select Frequently Billed Codes. This function initiates a report request that provides you with a quicker means of retrieving the most frequently billed codes/procedure codes based on the specialty represented by the selected billing provider and plan.

4. Via NaviNet's Resource Center, you can download the full Premier Blue Shield fee schedule. Simply click on

Administrative Reference Materials.

Understanding CPT Code 28510 – Billing for Fracture Care Follow-Ups

With regards to Standard Fracture Care, a patient’s fracture follow-up can be billed by the doctor.  The doctor must make sure, however, that the appropriate procedure codes as well as the ICD-9 code is used.  This pertains to the site of the fracture.  The follow-up care for closed fracture sites are covered by the CPT code 28510.  All, except those that involve the big toe.  Due to the details enclosed in this code, the need to perform site manipulations is no longer required if you plan to bill a patient’s follow-up care.  Because of the code 28510, it is immediately expected that a doctor will earn a hundred dollars for each patient.

A patient who comes in for a follow-up with regards to an injury such as a fracture is expected to spend time in a doctor’s clinic.  There is also a big possibility for them to inform you about certain medical issues they might have that would not be related to their fracture.  Doctors would not have to worry when this type of situation arises especially if they did not provide the fracture care initially.  As long as you document the visit correctly, you would be able to bill for the fracture follow-up and the additional concerns separately.  This is justified by the fact that the other concerns are not in any way related to the fracture.  The doctor just has to be very detailed about the consultation with regards to the proper procedure codes and the injuries addressed.

If ever the situation involves a patient who has multiple fractures comes for a follow-up, you can bill for each type of fracture.  For example, a patient has a fracture in his ribs, legs, and arms.  You can bill each site separately.  It is, however, crucial to document each fracture addressed and how long it took you to address it. 

Most fractures are billed to insurance companies of patients.  There are cases, however, wherein their fracture is work-related.  With this situation, Worker’s Compensation and the Personal Injury Protection Policy are applied.  The guidelines with this type of insurance may vary from state to state so it is important for a doctor to know about them before applying codes for the follow-up and any procedures done on the patient.  The important thing here is that the doctor gets paid for the care he has provided for the patient even if the initial check was done by another doctor.

How to Buy Good Medical Billing Books

There are an overwhelming number of medical billing books available in the market today.  The electronic types, popularly known as eBooks are gaining more attention because it can easily be downloaded through the internet.  No matter how interesting the title is or how cheap the book is, do not rely on these factors in purchasing medical billing books.  There are things you must consider when choosing which one to purchase.
Do not just look at the title and the summary of a medical billing book.  Though the text is smaller, the author is also an important factor to consider.  If you really want to buy a good book about medical billing, research on the author.  Look at their credentials as well as their accomplishments.  Do not rely on their statements.  Their record should speak for itself.

Not all medical books are the same.  In fact, there are books that only tackle one specific part within the medical billing career.  If you really want to learn all you need to learn, you could buy several books.  This is, of course, not a practical thing to do.  It is expensive and unnecessary.  Research on each book with regards to the topics it tackles and the information it provides.  The important topics that should be part of a really good medical billing book are: Claim Processing, Insurance (Primary, Secondary, Tertiary), Forms that are commonly used, Medicare, Medicaid, HMO, PPO, Explanation of Benefits (EOB), Patient Billing, Aging Reports, Account Receivables, Commonly used Terms, HIPAA, Training, ICD diagnosis and CPT procedure codes and their uses.

If you are planning on starting a medical billing business company or a home-based medical billing career, look for books written by authors who have experienced starting one up.  First-hand experience is very important.  Getting information from someone who has that experience would truly be beneficial.  Some of the things you need to see in a book for medical billing business start-up books are: About medical billing contracts, expected income, what is needed when starting a medical billing business, rates and prices, medical billing software, electronic file claiming, and, of course, the business plan of medical billing.

You should also find a book that would help you market your medical billing business.  Find a book that would help you on how to get a client, techniques on effective marketing, tips on how to talk to potential clients, and how to stand out in the growing world of medical businesses.

Service covered under Newborn Care

Newborn Care

Provide the highest level of care for the newborn beginning immediately after birth. Such level of care shall include, but not be limited to, the following:

(1) Instilling of prophylactic eye medications into each eye of the newborn;
(2) When the mother is Rh negative, securing a cord blood sample for type Rh determination and direct Coombs test;
(3) Weighing and measuring of the newborn;
(4) Inspecting the newborn for abnormalities and/or complications;
(5) Administering one half (.5) milligram of vitamin K;
(6) APGAR scoring;
(7) Any other necessary and immediate need for referral in consultation from a specialty physician, such as the Healthy Start (postnatal) infant screen; and
(8) Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant to Chapter 468, F.S., a licensed M.D. or D.O., or an individual who has completed documented training specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed physician or a licensed audiologist).

Postpartum Care
(1) Provide a postpartum examination for the enrollee within six (6) weeks after delivery;
(2) Provide for voluntary family planning, including a discussion of all methods of contraception,
as appropriate;
(3) Refer the newborn to a pediatrician for completion of CHCUP (Child Health Check Up)
screenings

Pregnancy service - prior authorization information

Pregnancy

PCP’s or obstetricians are required to notify SHP of the first prenatal visit and/or positive pregnancy test within two (2) working days by completing the Pregnancy Notification Form (refer to the Forms Section), whether the pregnancy was identified through medical history, examination, testing or otherwise.

SHP will allow pregnant enrollees to choose in-network obstetricians as PCP’s if the obstetrician is willing to participate as a PCP.

If a pregnant member has not selected a PCP for her unborn child, SHP will assign a pediatrician for the care of their newborn babies no later than the beginning of the last trimester of gestation. If a provider treating a pregnant member for prenatal care decides to terminate the contract with the Plan, SHP will allow the  member to continue care with that provider until completion of the postpartum care.

If the provider knows the recipient is pregnant and that her unborn child does not have a Medicaid ID  number, the provider may have the newborn assigned a number by sending a CF-ES 2039, Medical  Assistance Referral Form to the Department of Children and Families (DCF) regional office. The forms may be downloaded at http://www.dcf.state.fl.us/publications/eforms/es2039.pdf. Or the member may call the  DCF to notify them of her pregnancy and obtain the Unborn ID Number and later call SHP Member Services with the number.

Finding Good Medical Billing Software - Question need to Ask yourself

A medical billing business requires efficient software to be able to perform tasks related to medical insurance and benefits.  There are several billing software available in the internet today, finding the right one, however, can be challenging.  Below are some questions you can ask yourself to help you come up with a decision on which medical billing software to purchase. 

Is it cost-effective?  Our usual perception is that cheaper means less effective.  This is not always true.  Most expensive types come with a lot of extra features but you do not really need them.  Purchase software that has all the things you need, nothing more.

Is it user-friendly?  This question is asked not for computer illiterate employees.  Most medical billers are tech savvy but the software should be easy enough to use so they could spend the extra effort in dealing with complex software in dealing with other important tasks instead.

Has the software been around for a long time?  If it has, it is more likely to have encountered every bug and issues possible and a fix has already been applied.  New software says that it is bug-free.  It may be bug-free for now but it would surely encounter one in the future.

Is the medical billing software company experienced?  A company that has been around for a long time is more reliable especially if they have a lot of employees.  This ensures that there are experienced people to help you out in times of software trouble.

Is software training programs available?  An online training should be available because it is more convenient and less costly.  Vendors that require you to attend training seminars do not only save money, they do it at the expense of their customers. 

Is there are technical support desk?  A technical hotline should be available and reliable enough to help you out.  Do not rely on companies that only offer email and fax contact numbers. 

Is it integrated with Electronic Health Records software?  This helps medical billers save time by entering data into only one system: the Electronic Health Records software integrated with the medical billing software.

Is it appropriate for your company’s type of practice?  Purchasing software with tools that you do not really need is not only a waste of computer memory, but also a waste of your hard-earned money.

Can the software be tested before a purchase?  A test run is necessary for you to be able to try out if the software is indeed easy to use and reliable.  If possible, ask them for an online demonstration.  If they have trial versions, that would be better.

Can the vendor provide you a list of their clients?  Ask them for lists of offices that make use of the software you are interested.  You can then approach each one and ask them about their experiences with the software.  If the vendor is unable to provide you with references, find another one who could.

What is Second Medical Opinion service

Requests for a Second Medical Opinion

Second Opinion is a consultation by a physician other than the member’s Primary Care Physician, whose specialty is appropriate to the need, and whose services are obtained when the member disputes the appropriateness or necessity of a surgical procedure, is subject to a serious injury or illness, including failure to respond to the current treatment plan.

The member will be advised to contact the Primary Care Physician (PCP) and request a consultation with the necessary specialty provider. The member may select a contracted provider listed in the provider directory supplied by SHP or a non-contracted provider in the Plan’s geographic area. The UM Coordinator will contact the member’s PCP, or admitting physician if the member is in the hospital if necessary to assist in the second opinion process.

SHP shall pay the amount of all charges which are usual, reasonable and customary in the community for second opinion services performed by a physician not under contract with SHP, but the member may be responsible for part of the bill. SHP’s physician’s professional judgment concerning the treatment of a member derived after review of a second medical/surgical opinion shall be controlling as to the treatment obligations of
SHP.

Treatment not authorized by SHP is at the member’s expense.

Any tests/procedures deemed necessary by a second opinion consultant, and/or non-contract physician, are to be performed by an SHP-contracted provider. The UM Department will coordinate the care between the provider and the member to ensure continuity of care. The Medical Director may choose to deny reimbursement rights granted as above in the event the member seeks in excess of three (3) such referrals per year if such subsequent referrals costs are deemed by SHP to be evidence that the member has unreasonably over-utilized the second opinion privilege. A member thus denied reimbursement under this section should have recourse to grievance procedures

Does Emergency Services require Authorization ?

Emergency Services

Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably
expect that the absence of immediate medical attention could reasonably be expect to result in any of the following:

*  Serious jeopardy to the health of the member, including a pregnant woman or fetus
*  Serious impairment to bodily functions
*  Serious dysfunction of any bodily organ or part
*  A pregnant woman having contractions

SHP shall not:
*  Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;
*  Deny payment for treatment obtained when a representative of the SHP instructs the enrollee to seek emergency services.
*  Specify or imply that emergency services and care are covered by the Plan only if secured within a certain period of time;
*  Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or
*  Deny payment based on a failure by the enrollee or the hospital to notify SHP before, or within a certain period of time after, emergency services and care were given.
*  Deny claims for emergency services and care received at a hospital due to lack of parental consent.

Pre-hospital and hospital-based trauma services and emergency services and care will be authorized.

SHP shall cover all screenings, evaluations, and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member has an emergency medical condition. If the provider determines that an emergency medical condition does not exist, SHP is not required to cover services rendered subsequent to the provider's determination unless
authorized by the Plan.

If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of SHP, the hospital must make a reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan has previously requested in writing that it be notified directly of the
existence of the emergency medical condition

If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must notify SHP as soon as possible before discharging the enrollee from the emergency care area; or notify the Plan within twenty four (24) hours or on the next business day after the enrollee’s inpatient admission.

If the hospital is unable to notify SHP, the hospital must document its attempts to notify the Plan, or the circumstances that precluded the hospital's attempts to notify the Plan. SHP shall not deny coverage for emergency services and care based on a hospital's failure to comply with the notification requirements of this section.

SHP shall cover any medically necessary duration of stay in a non-contracted facility, which results from a medical emergency, until the Plan can safely transport the member to a participating facility. SHP may transfer the member, in accordance with state and federal law, to a
participating hospital that has the capability to treat the member’s emergency medical condition. The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer, and that determination is binding.