MERIDIAN HEALTH PLAN

1 MERIDIAN HEALTH PLAN333 South Wabash AvenueSuite 2900 Chicago, IL 60604 Phone: 312-705-2900 Fax: UsHEDIS Bonus ProgramMember EngagementClaimsPayments, Status & BillingClaims Appeal ProcessEDI SubmissionClaim Billing RequirementsMeridian MembersNo Co-PaysPharmacy BenefitsMeridian Service AreaProduct DescriptionsReferral GuideFraud, Waste & AbuseTo Report Potential Fraud, Waste & AbuseAnnual Training ProgramQuick Reference/Contact Information2336666677891011-1617-1818192 0 CONTENTS12 PHONECall 866-606-3700 or contact your Provider Network Development Representative are assigned a local Provider Representative to handle any questions or MERIDIAN HEALTH plan s website to access these features.

2 Provider Manual & Orientation Provider Directory Formulary Bulletins/Updates Important Forms Live Chat ServicesPROVIDER Provider Portal gives contracted providers exclusive access to these features: Member Eligibility Verification Authorizations Claims Status and Submission/Correction MERIDIAN Member Information & Reports Enrollment Lists HEDIS Bonus Information HEDIS Self-Reporting Member Utilization/ HEALTH History Contact MERIDIAN departments directlyA MERIDIAN -supplied user name is required for access to the Provider Portal. To sign up, please visit Questions?

3 Please contact your Provider Network Development continuously improve the quality of care in a low resource be the premier service organization in be the #1 HEALTH organization based on quality, innovative technology and service to our US3 HEDIS BONUS PROGRAMAs part of the enrollment process, MERIDIAN utilizes claims data and various risk assessments to automatically enroll members in outreach programs that meet their level of need. Providers can refer members to the Disease Management, Care Coordination or Complex Case Management programs as needed through the by: Clicking the Notify HEALTH plan button on our Provider Portal Calling MERIDIAN at 866-606-3700 Faxing in the Care Coordination/Complex Case Management Referral Form to MERIDIAN .

4 This form can be found online at , in the Documents and Forms sectionMEMBER ENGAGEMENTC ommitted to ensuring quality care for our members, MERIDIAN offers a HEDIS Bonus Program for all contracted providers. The program includes generous incentives ranging between $20 and $200 per HIGHLIGHTS Paid over $18 million to participating providers (2012)Bonus structure varies by line of business. For more details, please reference the MERIDIAN Provider Incentive Program Overview online at you have any questions about the HEDIS bonus program, or what bonuses you may qualify for, visit our website at or call your Provider Network Development Representative. 4 PROGRAM DESCRIPTIONSLow Intervention LevelPeriodic outreach, as applicable, to remind members of important preventive services such as well visits and important Intervention Level + Self- Management NeedsAvailable to all eligible members.

5 Includes education for the following conditions: Asthma Cardiovascular Disease Diabetes Emphysema/COPDH ealth OutreachProgramDisease Management ProgramCare CoordinationProgramComplex Case Management ProgramHealth OutreachProgramDisease Management ProgramCare CoordinationProgramComplex Case Management ProgramHighPreventive Care Reminders (phone, community and mail based)Condition-Speci c EducationPersonal Care CoordinatorTransition ManagementPerson-Centered plan of CareInterdisciplinary Care TeamCare CoordinationProgramPreventive Care Reminders (phone and mail based)Condition-Speci c EducationComplex Case ManagerIntensive Case ManagementTransition ManagementPerson-Centered plan of CareInterdisciplinary Care TeamComplex Case Management ProgramMember Welcome CallRisk AssessmentsClaims DataMedium LowStrati cationHealth OutreachProgramPreventive Care Reminders (phone and mail based)Preventive Care Reminders (phone and mail based) and Condition-Speci c EducationDisease Management Program (included at all strati cations)THE CARE COORDINATOR IS THE MEMBER S SINGLE POINT OF CONTACT.

6 5 INTEGRATED CARE TEAMCARE COORDINATOR(clinical & non-clinical)MEMBER& FAMILYH ealth OutreachProgramDisease Management ProgramCare CoordinationProgramComplex Case Management ProgramMedium Intervention LevelMeridian s Care Coordination program uses interdisciplinary approaches to focus on members (and their families) that have special HEALTH care, community support, facility service, and behavioral HEALTH efforts links members with needed services and resources to achieve: Better access Skilled navigation through the complex HEALTH care and community supports system Increased self-management and self-advocacy skillsA member s personal Care Coordinator works with clinical and non-clinical consultants to arrange the right care at the right time for all services, including home and community based, nursing and other facility services.

7 The Care Coordinator collaborates with the member, their family and the member s care team to create a tailored person-centered plan of care. This plan of care includes: A personal HEALTH record Problems, life goals and outcomes HCBS service plan summary authorization (if applicable)The plan of care is developed by tailoring to the member s specific preferences and needs, delivering service with transparency, individualization, respect, linguistic and cultural competence, quality care, quality of life and OutreachProgramDisease Management ProgramCare CoordinationProgramComplex Case Management ProgramDepending upon member population, specialized subprograms may include: Adults and Children with Special Needs Behavioral HEALTH High ER Utilizers Home and community-based waiver programs, nursing and other facility care Integrated Care Program (all members) Maternity (all members) Medicare MERIDIAN Advantage Dual Eligible Special Needs (all members) Complete/MMAI (all members) Smoking Cessation Weight ManagementLong Term Service & Support (LTSS) ProgramA more specialized form of Care Coordination, the MERIDIAN Long Term Services and Supports (LTSS) Program is for members who are eligible for Home and Community Based Service (HCBS) waiver programs or the Nursing Facility strategies to improving the well-being of members in this program include.

8 Avoiding hospital re-admissions Assisting members in returning to or remaining in the residence of their choice (including home and community) Increasing quality of lifeHigh Intervention LevelUsing the same consultant resources as Care Coordinators, case managers provide more intensive counseling and management to high-risk members. These members often have multiple, serious comorbidities. Members have the option to accept or decline Complex Case Management for their care; it is not a requirement. Providers may refer members to Care Coordination by clicking the Notify HEALTH plan button within our Provider Portal, or by calling MERIDIAN at OutreachProgramDisease Management ProgramCare CoordinationProgramComplex Case Management Program7 PAYMENTS, STATUS & BILLINGM eridian is dedicated to processing your claims in under 10 days.

9 You may status your claims several ways: MERIDIAN s secure Provider Portal at Call or fax our Claims departmentTel: 800-203-8206 Fax: 313-324-3642 By Mail MERIDIAN HEALTH PlanClaims Department1001 Woodward AvenueSuite 520 Detroit, MI 48226 CLAIMS APPEALS PROCESSIn cases where a claim has been denied, providers may submit an appeal in writing within 30 days of the denial. Please include the following: Patient name and ID# Reason for appeal Any relevant clinical information to support your appealThe MERIDIAN Appeals Committee meets regularly to review these appeals. You will receive a written response within 30 SUBMISSIONM eridian currently accepts EDI from all of our providers through the following vendors:Payer ID#: 13189 Special instructions: PROFESSIONAL PIN must be the NPI #.

10 FACILITY Use the NPI # for provider ID (locator 51), attending physician ID (Locator 82) and the other physician ID (Locator 83).CLAIM BILLING REQUIREMENTS Facility - UB04 Professional - CMS 1500 or *IL HFS 2360 **Laboratory - CMS 1500 or *IL HFS 2360* MERIDIAN accepts claims billed on both a CMS 1500 and IL HFS 2360, but prefers the submission of the CMS 1500** All laboratory charges should be submitted to MERIDIAN on a CMS 1500 or IL HFS 2360 CLAIMSFAST CLAIMS PROCESSINGA verage claims processing time - 3 daysSSI Group: 800-880-3032 Availity: 800-282-4548 PayerPath: 877-623-5706 Relay HEALTH : 800-527-8133 WebMD (Emdeon): 800-845-6592 Netwerkes: 866-521-8547 MEDICAID (TANF/SPD): MERIDIAN HEALTH plan is a Medicaid managed care organization (MCO) with subsidiary operations in Michigan, Illinois and Iowa.