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1 HOME | TABLE OF CONTENTS | APPENDICES1199 SEIU Benefit Funds Provider Manual | 11199 SEIUPROVIDER MANUAL||National Benefit Fund Health Care Employees Pension FundGreater New York Benefit Fund Greater New York Pension FundHome Care Employees Benefit and Pension Funds Home Health Aide Benefit Fund330 WEST 42ND STREET | NEW YORK, NY 10036-6977 | BENEFIT AND PENSION FUNDS (646) 473-9200 | FOR RETIREES (646) 473-8666 | FOR PROVIDERS (646) 473-7160 BENEFITS ARE SUBJECT TO EACH FUND S SUMMARY PLAN DESCRIPTION (SPD) AND THE DISCRETION OF THAT FUNDO ctober 2013 Dear 1199 SEIU Provider:Welcome to the 1199 SEIU Benefit Funds Provider Manual. Inside you ll find a helpful overview of our members covered health services. We understand that the 1199 SEIU Benefit Funds extensive network of talented providers is integral to the quality of service we re able to provide.

2 We re delighted that you are part of our network, and we are committed to working with you to ensure our members receive quality advantages that you will enjoy while participating in the 1199 SEIU Benefit Funds network include: Participation in a provider network of 80 hospitals and over 30,000 providers; A dedicated Provider Relations Department to handle your questions or concerns; Lower administrative costs with electronic claims processing; No deductibles and no co-payments for participants in the 1199 SEIU National Benefit Fund for Health and Human Service Employees, and minimal co-payments for participants in the 1199 SEIU Greater New York Benefit Fund and the 1199 SEIU National Benefit Fund for Home Care Employees; Automated eligibility verification and claims status 24 hours a day, seven days a week, through our Interactive Voice Response (IVR) system, and through our online provider portal, NaviNet, at ; Speedy credentialing and re-credentialing; and Regular updates, notices and alerts via our Provider Connections we regularly update our list of services requiring prior authorization, please check our website at regularly for the most current information and read our Provider Connections newsletters, specially created to serve your look forward to working with you and your staff.

3 Our Provider Relations staff is always here to answer any of your questions just call (646) 473-7160 or email BehrooziExecutive Director1199 SEIU Benefit Funds|TABLE OF CONTENTSI ntroduction ..81199 SEIU Provider Quick Reference Guide ..9 Section I: Provider Resources .. Provider Manual .. Provider Relations Department .. Provider Connections Newsletter and Notices .. 1199 SEIU Benefit Funds II: Summary of Covered and Non-Covered Services .. Covered Services .. Hospital and Facility Services .. Medical Services .. Medical Services Co-Payments .. Ancillary Services .. Dental Services .. Prescription Drug Services .. Non-Covered General Services .. Non-Covered Medical Services .. Non-Covered Dental Services .. Non-Covered Prescription Drug Services ..19 Section III: Member Eligibility .. Identifying an 1199 SEIU Benefit Funds Member.

4 Automatic Eligibility Verification Interactive Voice Response (IVR) System and NaviNet .. Eligibility Verification for Emergency Services .. Retroactive Eligibility .. Coordination of Benefits .. When the 1199 SEIU Benefit Funds Are Primary or Secondary .. Spouse and Dependent Coverage .. HMO, Paid-in-Full or Prepaid Plan Coverage .. Medicare Eligibility .. Member Choice ..24|Section IV Participating Providers and Networks .. Credentialing Process .. Credentialing Criteria .. Application Process .. Incomplete Applications .. Re-Credentialing .. Delegated Credentialing .. Facility and Ancillary Provider Credentialing ..31 Section V: Participating Provider Roles and Responsibilities .. Participating Provider Requirements .. Member Choice Primary Care Provider .. Member Choice Specialists .. Provider Changes ..34 Section VI: Preferred Providers.

5 Laboratory Services .. Approved In-Office Tests .. Pharmacy Services .. radiology Services .. Durable Medical Equipment (DME) Services ..38 Section VII: Care Management Programs .. Utilization Management Overview .. Outpatient and Home Care Services That Require Prior Authorization .. Prescription Drugs Requiring Medical Management of Hospital Services .. Selected Outpatient and Ambulatory Surgical Procedures that Require Pre-Certification .. Hospital Discharge Notifications .. Utilization Review Procedural Guidelines .. Hospital Appeal and Dispute Resolution Program .. First-Level Hospital Appeals Inpatient/Outpatient/Ambulatory Surgery .. Second-Level Hospital Appeals Inpatient Services Only .. External Third-Level Hospital Appeals Inpatient Services Only .. Focus Diagnosis Related Groups (DRG) Validation Program and the Related Appeals Process.

6 Re-Admission Review Program .. Care Management Programs .. Dental Services that Require Prior Authorization ..54|Section VIII: Clinical Wellness Programs and Member Assistance Programs .. Wellness Programs .. Member Assistance Program (MAP) .. Prenatal Program ..57 Section IX: Claims and Reimbursement .. Timeframe for Claims Submission .. Claims Payer Identification Number .. Plan Provider ID Number .. National Provider Identifier .. Paper Claims Submission .. Coding Standards .. Provider Remittance .. Claims Status .. Claims Reviews .. Overpayment Recovery Program ..62 Section X: Healthcare Fraud and Abuse .. What Is Healthcare Fraud? .. What Is Healthcare Abuse? .. Preventing Fraud and Abuse .. If Fraud or Abuse of Benefits Is Suspected ..66 Section XI: Confidentiality ..66|Appendices ..67 Appendix A General Provider Forms and Information: Provider Recruitment Form.

7 69 Provider Demographic Information Change Request Form ..70 W-9 Form: Individual/Sole Proprietor ..72 W-9 Form: Corporation or Partnership ..76 Appendix B In-Office Laboratory Guidelines ..80 Appendix C radiology Privileging by Specialty ..81 Appendix D The 1199 SEIU Benefit Funds Prior Authorization Guidelines and Request Forms Pre-Certification Listing: Pre-Certification List ..83 Quick Reference Contact Sheet ..84 Pre-Authorization Request for Outpatient/Home Care Services/Rx ..85 Request Forms: Service/Equipment Request ..86 PT, OT and ST Benefit Extension ..88 Service/Equipment Request for O2 Authorization ..90 Cardiac, Pulmonary Rehabilitation ..92 Provenge Pre-Certification Request ..95 CareAllies Initial Pre-Certification Request ..97 Appendix E Medical Management Programs: Quick Reference Contact Sheet.

8 99 Inpatient Hospital Services ..102 Outpatient/Ambulatory Surgical Procedure Certification ..103 Chiropractic Services ..104 Focus DRG Validation Program ..105 1199 SEIU Benefit Funds' radiology Review Program ..106 Appendix F Prescription Drug Benefit: Preferred Drug List: Specialty Drug List ..107 Benefit Funds Rx Request for Authorization ..121 Express Scripts/Medco by Mail Order Form ..123 Express Scripts Prior Authorization List ..125 Express Scripts Prior Authorization for Step Therapy ..131 Express Scripts Prior Authorization for Quantity Duration ..136 Dose Optimization ..140 Prior Authorization Drug List Administered by the 1199 SEIU Benefit Funds ..151 Express Scripts/1199 SEIU Contact Information ..152 Appendix G Preferred Durable Medical Equipment Network ..154|HOME | TABLE OF CONTENTS | APPENDICES1199 SEIU Benefit Funds Provider Manual | 8 INTRODUCTIONThe 1199 SEIU Benefit Funds are among the largest self-administered, joint labor-management funds in the country.

9 We are not an insurance company. We are a not-for-profit organization providing health and other benefits to 1199 SEIU healthcare workers, retirees and their eligible dependents covered by the 1199 SEIU Benefit Funds nearly 450,000 lives in total. While the 1199 SEIU Benefit Funds are jointly administered, it s important to note that benefits and coverage vary between the 1199 SEIU Benefit Funds. Employer contributions to the 1199 SEIU Benefit Funds pay for the cost of benefits. The 1199 SEIU Benefit Funds goal is to provide members with access to quality, cost-effective healthcare with few, if any, out-of-pocket costs. This manual covers the benefits and services available to 1199 SEIU members in the 1199 SEIU National Benefit Fund for Health and Human Service Employees, the 1199 SEIU Greater New York Benefit Fund and the 1199 SEIU National Benefit Fund for Home Care Employees.

10 These Funds contract directly with you as a Member Choice or a Panel Provider. For more information, please visit our website at 1199 SEIU Home Health Aide Benefit Fund covers 1199 SEIU members working as home health aides, who access care through the HIP, an EmblemHealth company. We encourage you to join this network if you do not participate already. To join HIP s network, call (866) 447-9717, or visit their website at |HOME | TABLE OF CONTENTS | APPENDICES1199 SEIU Benefit Funds Provider Manual | 91199 SEIU PROVIDER QUICK REFERENCE GUIDEFor all provider inquiries (including provider participation status): 1199 SEIU Benefit Funds Provider Relations Department 330 West 42nd StreetNew York, NY 10036-6977(646) 473-7160 | Interactive Voice Response (IVR) System is available to you 24 hours a day to check claim status and member eligibility. Just call (888) 819-1199, or check online at Request a Provider Application PackageComplete the Provider Recruitment Form on our website at and fax to (646) 473-7213, or call (646) Submit Provider Demographic Information ChangesComplete the Provider Demographic Information Change Form on our website at and fax it to (646) 473-7229.