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PROVIDER GUIDE 2008

ECN PROVIDER RELATIONS 700 Central Parkway Stuart, Florida 34994 1-800-431-2221 Ext 4488 Fax: 772-287-1387

ECN PROVIDER GUIDE 2008

EMI PROVIDER CONTACT DIRECTORY

Contracting/Provider Relations: ECN EPO/PPO NETWORK ECN PPO DENTAL Provider Relations Coordinator ECN Phone Number ECN Fax Number Provider Relations e-mail address WEB-TPA Customer Service: Veronica Bates Ext. 4488 1(800) 431-2221 (772) 287-1387 [email protected]

Customer Service 1(877) 283-2432 MMHS Members only 1(800) 365-2432 _____________________________________________________________________________________ WEB-TPA Benefits: Plan Specific Customer Service MMHS Members only See member ID Card 1(877) 283-2432 1(800) 365-2432 See member ID Card 1(877) 283-2432 1(800) 365-2432 See member ID Card 1(800) 697-9757 1(772) 403-6279 1(772) 403-6249

WEB-TPA Eligibility & Verification: Plan Specific Customer Service MMHS Members only WEB-TPA Authorizations: Plan Specific Toll Free Phone: Local Phone: Fax: WEB-TPA Claims:

Customer Service 1(877) 283-2432 MMHS Employees only 1(800) 365-2432 _____________________________________________________________________________________

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WEB-TPA Medical & Dental Claims Address:

PO Box 99906 Grapevine, TX 76099 ___________________________________________________________________________________ WEB-TPA Electronic Claims: Payor ID 75261

Electronic Claim Issues: www.webtpa.com _____________________________________________________________________________________ WEB-TPA Appeals: Appeals Department

Send Appeals to:

1(877) 283-2432 Attn: Appeals Coordinator

WEB-TPA PO Box 1808 Grapevine, TX 76099

_____________________________________________________________________________________

WEB-TPA Correspondence, Return Address/Checks WEB-TPA PO Box 1808 Grapevine, TX 76099

Mental Health Provider

UniPsych 1-800-272-3626 Member Services ___________________________________________________________________________________ Website Directory: www.emi-tpa.com _____________________________________________________________________________________ EMI Corporate Address: Employers Mutual, Inc. 700 Central Parkway Stuart, Fl 34994 1(800) 431-2221 772-287-7650 Fax: (772) 287-1387

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ECN NETWORK PLAN PRODUCTS PPO/EPO

The ECN Preferred Provider Network is a local specialty care network providing a full range of provider services designed to support the operations of benefit plans for medium to large selffunded employer groups. The following describes our product lines. Self-Funded Employer Groups: ECN manages and supports a Network for local employer health benefit programs. Under a selffunded arrangement, the employer retains the responsibility to fund the claims and hires a Third Party Administrator (TPA) to process and manage the health/dental plan. The employer and the employee may contribute toward the cost of the self-funded plan. PRODUCT REVIEW ECN EPO PLAN: Exclusive Provider Organization (EPO) Coverage: PLAN SPECIFIC Referrals: NONE REQUIRED AT THIS TIME The ECN EPO plan operates like a PPO but with no out-of-network benefits. Insured employees must use a preferred contracted hospital or provider to receive benefits. The EPO benefit plans require the insured to receive all services within a defined network of providers. Authorization is required for all inpatient services and may be required in order to obtain certain specialty services such as DME or Diagnostics, including radiology and laboratory. ECN PPO PLAN: Preferred Provider Organization (PPO) Coverage: PLAN SPECIFIC Referrals: NONE REQUIRED ECN contracts directly with independent providers at a discounted amount for medical services. These providers will accept the ECN allowed amount as payment in full. Insured members may choose any provider for their health services, but pay less out of pocket costs (i.e. deductible, coinsurance) when a preferred provider is utilized. ECN PPO DENTAL PLAN Coverage: PLAN SPECIFIC Referrals: NONE REQUIRED The benefit program may have applicable co-insurance and deductible amounts. Please verify coverage and eligibility to determine member responsibility. SERVICE AREA: The ECN Service Area includes: Treasure Coast, South Florida, and Brevard County.

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PROVIDER SERVICES CUSTOMER AND MEMBER SERVICES

CUSTOMER SERVICE: Contact the WEB-TPA Customer Service Department for any questions regarding member eligibility, benefit verification and claims status related issues: Toll Free Number 1(877) 283-2432 WEB-TPA

Office Hours: Monday through Friday 8:00 A.M. through 5:00 P.M.

MEMBER ID CARDS: The WEB-TPA ID Card will assist you in identifying the type of benefit plan, copay amounts, and deductible if any, Customer Services telephone number, Pre-certification telephone number, and address where to file claims. MEMBER ELIGIBILITY & BENEFIT VERIFICATION Coverage and Benefit information may be obtained by calling the WEB-TPA Customer Service Department as per the member's ID Card. The Customer Service Department number is 1 (877) 283-2432; for Martin Memorial Health Systems member's please contact 1(800) 365-2432. You may also verify coverage through the WEB-TPA website www.webtpa.com. Before providing services to a WEB-TPA Member, please obtain the following. 1. 2. 3. 4. Request a Member ID Card from the member. Verify patient eligibility and benefits. Verify primary insurance if any. Obtain patient's signature as required.

The following will also assist you with proper documentation of service: 1. 2. 3. 4. 5. 6. Make a copy of the member's ID Card. Call the number on ID Card to obtain the most up to date eligibility information. Collect co-payment as indicated on the member ID card. Send provider claims to the address on the member ID Card. Contact Customer Service for any questions and billing issues. Bill the member for any deductible or co-insurance amount as per the EOB.

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WEB-TPA PROVIDER SERVICES

CHECK OUT THE WEB-TPA WEBSITE! www. webtpa.com You may access member eligibility and obtain the status of claims by using the WEB-TPA website. Accessing this information is simple and easy to follow. Eligibility Verification and Claims Status Provider Directory

SELECT "LOGIN AS A PROVIDER"

Verification: Confirm eligibility status and coverage on up to 5 members at a time. Enter the Member ID Number located on the front of the member's Identification Card. Enter all dashes and numbers as they appear on the Identification Card to ensure the correct information is displayed. Claims: Select "Claims" to review claims. Enter your Provider Tax ID number and the Patient Account Number, as stated in Box #26 on the HCFA form or Box # 3 on the UB-92 Form. Verify and track claim status information including the claim number, date received, claim status, billed charges, discounts, member responsibility, payment amount, check number, check date and date of service. WEB-TPA Employer Services offers provider and member online services 24 hours a day, 7 days a week. VERIFICATION OF PROVIDER PARTICIPATION FOR REFERRALS: ECN recommends that prior to referring patients to other providers you verify that the provider participates in the ECN Network. You may access this information on our website www.emitpa.com or contact our Provider Relations Department at 1-800-431-2221 Ext. 4488. CLAIMS AND BILLING All Claims for Covered Services need to be submitted to WEB-TPA within thirty (30) days after the date services were rendered. Claims may be submitted electronically or on a HCFA-1500 billing for Physicians services or a on a UB92 billing form for Facility services. If you should require assistance with a claim issue, please contact the WEB-TPA Customer Services Department.

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Claim Requirements: All claims submitted must contain the following information: Policy and/or group number Name of the Employer Insured's name, social security number and address Patient's Name and date of birth Hospital claims must include; ICD9 codes DRG codes (applicable to in-patient claims) WHERE TO SEND PAPER CLAIMS: Please see member ID card or send to:

MEDICAL/DENTAL CLAIMS

WEB-TPA PO Box 99906 Grapevine, TX 76099

ELECTRONIC CLAIMS:

WORKERS COMP EMI Workers Comp 700 Central Parkway Stuart, Florida 34994

WEB-TPA can accept electronic claims; contact your vendor for set-up. WEB-TPA is a participating Payor with WebMD. For assistance with electronic billing, please contact the WEB-TPA Customer Services Department. For assistance with WebMD, please contact 1 (800) 845-6592. STUART: MEDICAL/DENTAL WEB-TPA PAYOR # 75261 CLAIMS PROCESSING Claim Submission Deadline: Provider shall arrange for all Claims for Covered Services to be submitted to Plan Administrator within Thirty (30) days from the date services were rendered, and no more than 12 months from the date of service. Promptness of Payment. Clean claims received by WEB-TPA will be processed and paid within thirty (30) days. If additional information is needed, the claim will be denied and communicated via mail to the provider. WEB-TPA will pay all valid claims within (30) days of receipt of a paper claim or electronic claim.

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Clean Claim. A clean claim will have appropriate and accurate member and provider information as required for adjudication and the enabling of claims processing without errors, edits, or additional documentation requirements. Elements of a clean claim include: See HCFA Form.

· · · · · Insured's ID Number Patient Name Patient Date of Birth Insured's Name Referring Doctor Name · · · · Date of Service CPT Procedure Code Service Charge Diagnosis

Patient Billing: At the time of service, provider may collect from covered individual any applicable co-payments, coinsurance, deductibles, non-covered services, or non-covered out-of-network services as defined by the member's Benefit Plan. Contact the Customer Service Department to determine the actual member out of pocket amounts prior to billing the member. Provider Reimbursement: The total amount payable to a provider will be based upon the provider's agreement with ECN, less any applicable co-payments, co-insurance, deductibles, non-covered services, or non-covered out-ofnetwork services as defined in member's Benefit Plan. The Provider will accept this amount as payment in full and should not balance bill the patient for any difference between actual charges and the ECN allowable. Fee Schedules: If Provider Reimbursement is based on a Medicare fee schedule, claims will be processed according to the most current Medicare Fee Schedule. New fee schedules take effect no later than March 1st of each year and remain in effect until a new Medicare Fee Schedule has been received and programmed by WEB-TPA on or before March 1st of the next year. Usual, Customary & Reasonable (UCR) Charge: If Provider Reimbursement is to be paid according to a UCR fee, the UCR allowable for a procedure will be determined by industry standards to be no greater than the average and prevailing charge for the same service in the same geographic area. The UCR allowable will be determined by standard fee schedules in the industry. Coordination of Benefits: Please verify primary coverage and submit the claim to the member's primary carrier. If WEB-TPA is deemed "primary" in accordance with applicable industry coordination of benefits ("COB") standards, WEB-TPA shall reimburse Provider with no delay, reduction, or offset. If WEB-TPA is deemed "secondary", WEB-TPA will reimburse provider according to Benefit Plan and in accordance with applicable industry coordination of benefits ("COB") standards. Claim Denials: The WEB-TPA Explanation of Benefits (EOB) document will provide explanation of claim payment. This document will include a statement on denials or reduction of claim payments. Please contact the WEB-TPA Customer Service Department to review any claim issues or, should there be a claim dispute, the patient and provider have the right to appeal a payment decision within 45 days from the date the claim was processed.

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Claim Appeals: The Provider may submit an appeal for reconsideration to the Plan Administrator within 60 days of the date the claim was processed. To appeal a claim decision, the written appeal should be sent to: WEB-TPA PO Box 1808 Grapevine, TX 76099 Attn: Appeals Coordinator WEB-TPA will conduct a review and render determination on an appeal within 60 days from the date the Provider's request is received. The claim appeals process is plan specific; each Benefit Plan determines the evaluation process for an appeal. The following is a standard procedure for an appeal. · · · Upon receipt of an appeal, the appeal is logged by the WEB-TPA Appeals Coordinator. The appeal and background claim information is reviewed by the WEB-TPA Appeals Coordinator in accordance with the applicable Benefit Plan. WEB-TPA will respond to the Provider by mail with the appeal determination. If an appeal is granted, the denial is reversed and the claim is processed.

Erroneous Payments, Overpayments & Refunds: The Provider is to notify WEB-TPA of any overpayments or payment errors within 60 days of the date the claim is processed. If a refund is requested by WEB-TPA, the Provider is required to refund WEB-TPA immediately and no more than 45 days from the date of request. Overpayment requests made by the Plan Administrator will not be assessed to future claims if received within the required time. Claim Disputes: Any and all Provider payment disputes need to be received by WEB-TPA within twelve (12) months following Provider receipt of payment. Thereafter, payments shall be deemed final with no further recourse. UR/Peer Reviews: For claims denied based on medical determination, a medical review or a peer-review will be completed upon an appeal request. The appeal process will offer a final reconsideration of a claim based on an independent and unbiased professional opinion.

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FORMS

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AUTHORIZATION REQUEST/APPROVAL FORM

Please verify benefits with customer service prior to faxing.

Routine Request PATIENT INFORMATION:

Fax to (772) 403-6249

Urgent Request (Same day/next day)

Full name ___________________________________ DOB Member ID No. REQUESTING PHYSICIAN: Name Phone ( ) Fax ( ) Employer Group

SERVICES REQUESTED: Diagnosis/ICD 9 ______________________ # of visits Procedure/CPT _________________________________ DOS Facility/Provider Name _________________________________________________________________________ Phone (_____) ________________________________ Complete Address Business Office Representative_______________________________________________________________ Clinicals attached: Fax ( ) _____________________________________

No Yes: # of pages ____________

FOR EMI USE ONLY Authorization # __________________ Authorization Date # of visits authorized ____________________ Initials Authorization Start Date _______________ Expiration Date

A Precertification/Authorization is not a guarantee of payment. All claims will be paid in accordance with policy guidelines subject to deductibles, coinsurance and eligibility at the time services are rendered.

WEB-TPA UR

ECN PROVIDER GUIDE 2008

1-800-697-9757/ 772-403-6279

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PRACTICE CHANGE NOTIFICATION FORM ECN PROVIDER RELATIONS FAX 772-287-1387

Provider Name: _______________________________________________________________ Contact: ________________________________________ Phone: _______________________

Adding New Provider to group practice:

Name of Provider: ___________________ Title: ____ Effective: ______________________

Specialty: __________________________ Tax ID: ____________________________ Deleting Provider from group practice:

Name of Provider: ____________________ Title: ____ Effective: ________________________

Specialty: ___________________________

Reason: __________________________________________________________________________

Change of Tax ID: Attach copy of W-9

Old Tax ID: _________________ New Tax ID:_____________________________

Effective: ________________________ (Fax copy of W-9)

Change of Address:

Old Address: ____________________________________ ____________________________________ New Phone Number: __________________ New Fax Number: ____________________

Adding new Address:

New Address: ____________________________________ ____________________________________

Other: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _____________________________________________________________________________________

Contact Name/Title: _______________________________________ ECN PROVIDER RELATIONS 1-800-431-2221 Ext. 4488 Fax: 772-287-1387

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PROVIDER NON-MEDICARE PROCEDURE FEE SCHEDULE UCR REQUEST FORM Date of Request: _______ ECN/EMI Provider Relations Fax: (772) 287-1387 1-800-431-2221 Ext. 4488 Provider Name: __________________________ Phone/Fax: _______________________________ Contact: _________________________________

Specialty: ______________________________

Tax Id: __________________________

FOR PROCEDURES NOT LISTED WITH MEDICARE REIMBURSEMENT WILL BE: 70% OF PLAN'S UCR. COMPLETE BELOW FOR PROCEDURES NOT LISTED WITH MEDICARE. CPT CODE 1 2 3 4 5 6 7 8 9 10 YOUR FEES $ ECN FEES

PLEASE FAX THIS INFORMATION TO: PROVIDER RELATIONS

EMPLOYERS COMMUNITY NETWORK

Date returned: _______________

File Date: ____________________ FAX: 772-287-1387

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