Meritage Medical NetworkProvider ManualHours: Monday-Friday 8:30 am -5:00 pmPhone: (415) 884-1840 or (800) 874-0840TDD/TTY for the hearing impaired: (415) e:

Table of Contents1.0 Introduction . 11.1. Care Management Overview . 11.2. Meritage Medical Network’s - Current HMO Health Plan Partners . 21.3 Network Territory . 31.4 Role of Primary Care Physician . 31.5. Role of Specialist Physician. 41.7. Meritage Medical Network Provider Directory . 51.8. Medical Group Contacts . 52.0 Claims and Billing . 62.1. Claims Processing MMN complies with federal and state regulatory requirements standards forthe receipt, acknowledgement, payment and denial of claims. . 62.2. Requests for Medical Records. 62.3. Claim Denial and Payment . 62.4. Misdirected Claims . 62.5. Third Party Liability . 62.6. Coordination of Benefits (COB) . 62.6.1. Coordination with another Group Health Plan (Order of BenefitDetermination Prime Carrier Rules). . 62.6.2. Medicare Secondary Payer. 82.6.3. Duplicate MMN Coverage . 93.0 Member Services . 103.1. Language Assistance Phone Interpretation . 103.1.2. Translation Services. Provider Responsibilities for Language Assistance. 114.0 Provider Services . 124.1. Provider Information . 124.2. Provider Directories . 12

4.3. Provider Appeals . 124.4. Contract Termination . 134.4.1. Individual Practitioner Termination . 134.4.2. Termination for Cause by MMN. 134.5. Concierge Practices . 144.6. Access and Availability Standards . 145.0 UM Denial Process. 165.1. UM Decision Timelines . 165.2. UM Communication Services . 185.3. Provider Appeals . 186.0 Privacy and Security of Information . 186.1. Use and Disclosure of PHI. 186.2. Incident and Breach Reporting . 196.3. Fraud and Abuse . Claims Laws . 21Whistleblower Protections . 21You Suspect Fraud . 21APPENDIX . 23

1.0 IntroductionMeritage Medical Network (MMN) is a professional corporation representing theinterests of its physician members. MMN’s efforts to represent physicians’ interests arereflected in several key objectives:-To respond to the ever-changing face of managed care by forming acohesive integrated health care delivery systemTo manage HMO payor relations to ensure continuedpatient/membership acquisition at maximum HMO reimbursementTo develop physician-directed Utilization Management and Quality AssuranceprogramsTo provide financial and medical management services in keeping withmanaged care market demandsIn addition to strategic health care planning, the MMN is committed to providingday-to-day support to MMN physicians and staff in the dynamic and competitivehealth care environment.MMN Staff Provides Assistance:The MMN staff provides assistance with:1. Physician office traininga. Risk adjustment and proper codingb. Staying up to date with Medicare rules and regulations2. Provider network contracting3. Credentialing and compliance with state and federal regulators4. Case management support5. Inpatient concurrent review6. Coordination of pre-authorization system7. Explanation of claims payments8. Confirmation of eligibility9. Explanation of HMO benefits/co-payments10. Resolving member problems1.1. Care Management OverviewCare Transitions—Hospital to Home Manage transitions from inpatient to outpatient and/or skilled nursing facility sitesof care. Prevent avoidable readmissions, improve patient safety through medicationreconciliation, and improve patient satisfaction by providing better communicationand coordination. Review discharge instructions, medication reconciliation, safety, life planning. Care Transitions Coaching follows the Coleman Model 1

Complex Care Management Help members regain optimum health and improved functional capability, in theproper setting, in a cost-effective manner. Comprehensive assessment of the member’s condition, determination of available benefits and resources, and development and implementation of a caremanagement plan with patient centered goals, monitoring, and follow up Includes telephonic Care management and in-home visits and assessmentsEmergency Department (ED) Follow up Follow-up with members after ED visits– Review dischargeinstructions/medications Provide information on nurse lines and available After-Hours Clinics and UrgentCare locations and hoursBehavioral Health Provides seamless, efficient professional support to PCPs and specialists inmanaging assessment, triage and referral for patients with co-morbid behavioralhealth issues that require intervention.Care Coordination Providing patient support by connecting patient to community resources Help physician offices with DME orders and referralsLife Planning Ensure that patients’ end of life wishes are honored. Discussion of life planning goals includes any life planning activities such as thepresence of wills, living wills or advance directives, POLST forms and health carepowers of attorney documents. 1.2. Meritage Medical Network’s - Current HMO Health Plan PartnersCommercial Plans:-Aetna (2021)Blue Shield (HMO, PPO)Blue Cross (Anthem)Canopy Health NetCanopy UHCCignaHealthNetUnitedWestern Health AdvantageMedicare Advantage:-Alignment Medicare AdvantageAetna Medicare Advantage (2021)Health Net Medicare AdvantageUnited Medicare AdvantageWestern Health AdvantageMedicare Advantage (2021)2

1.3 Network TerritoryGeography Map slides from Tom1.4 Role of Primary Care PhysicianThe Primary Care Physician (PCP) is the primary caregiver for most medical problemsand is the care manager/adviser for those problems which may require the services of aphysician specialist or other allied or ancillary providers.Physicians participating with the MMN as PCPs are: General and family practitionersInternistsPediatriciansDoctor of Osteopathic MedicineFind a complete list of all physicians by clicking here.MMN and its contracted Health Plans promote the relationship between members and3

their PCPs, as we believe this relationship is the foundation of effective, high qualityhealth care.The following are some responsibilities managed by the PCP in a managed careprogram: Coordinate all medical services required for assigned patients by specialists andor allied/ancillary providersBe available or have a covering MMN physician available to provide access tomedical services or to advise patients with urgent needs 24 hours a day, 7 daysa weekMaintain medical records for MMN patients with appropriate clinical detail andattention to confidentialityRefer MMN patients to other MMN contracting providers and coordinate referralsand prior authorization as appropriateConsider MMN Primary Care Health Management Guidelines when managingthe care of MMN patients (see PCP guidelines)1.5. Role of Specialist PhysicianMMN specialists perform a key role in medical management and ensuring that MMNpatients have access to a full spectrum of medical care.In coordination with the MMN UM/QA Department staff, the Specialist outlines theextent of services required based on the nature of the medical problem and the type ofassistance requested by the PCP.Examples include: Simple diagnoses and recommendations for a PCP-managedtreatment plan; requests for procedures and care management on an ongoing basis fora particular problem. A primary responsibility for all specialists is keeping the PCPinformed regarding his or her patient via consultation and written reports.Specialist physicians should only perform those services requested. Specialists mayinitiate requests for Prior Authorization from the MMN Managed Care Department as putforth in the1.6. Role of OB/GYNPer HMO and MMN rules, all members are required to choose a PCP, who is either aGP, FP, PED or Internist. PCPs coordinate all patient care and are available to provideall necessary care directly or, under IPA policy, will refer patients for any specialty care.Female members may request to see their OB/GYN for gynecological conditions or formaternity management and no referral is needed. However, the PCP may provide theseservices if they so choose and if the PCP/patient relationship supports this.4

OB/GYNs may initiate requests to other specialist providers from MMN’s Managed CareDepartment.1.7. Meritage Medical Network Provider Directory Provider Directory /Roster is posted online on MIPAnet and the Meritage WebsiteReview Roster prior to referring to a MMN Provider to determine if accepting newpatients.Notify MMN Provider Relations Department of ANY changes or corrections inwriting.Prior notification of 30 days required if opening/closing to new patients (requiredto continue to accept new patients during that time).Prior notification of 90 days required if retiring from practice or resigning fromMMN.Prior notification of 60 days required if changing office location(s).Prior notification of 60 days of TIN and/or billing office address change.MMN patients should be referred only to participating providers listed. Anyservices provided by non-participating providers (“out- of-plan referrals”) must beapproved by the MMN Managed Care Department prior to services beingrendered.New physicians will be announced in MMN Office manager Bulletins.1.8. Medical Group ContactsBilling Address/ Physical Address: (use for paper claims)MERITAGE MEDICAL NETWORKHangar No. 44 Hamilton Landing, Suite 100Novato, CA 94949Network Relations:Claims and Authorizations InquiriesMicky Fleetwood, Network LiaisonManager – MarinPhone: (415) 884-1840 x423Email: [email protected] Medical Network Call CenterPhone: (415) 884-1840Email: [email protected] Liaison – Sonoma and Napa(415) 884-1840 x2545

2.0 Claims and Billing2.1. Claims ProcessingMMN complies with federal and state regulatory requirements standards for the receipt,acknowledgement, payment and denial of claims.2.2. Requests for Medical RecordsMMN will send notification via a remittance advice if medical records are needed toadjudicate a claim.2.3. Claim Denial and PaymentIf a claim is denied, MMN will issue a denial notice via remittance advice which willinclude your rights to appeal a denial.MMN will acknowledge receipt of claims pursuant to AB 1455 Regulations For ClaimsSettlement Practices and Provider Disputes2.4. Misdirected ClaimsWill be forwarded to the correct payor within ten (10) business days of receipt.2.5. Third Party LiabilityMMN is required to comply with applicable state and federal laws pertaining to claimsprocessing for health maintenance organizations.In the case of personal injuries caused by an act or omission of a third party, MMN hasa contractual right to recovery from its members who obtain a monetary settlement orjudgement as the result of such injuries.2.6. Coordination of Benefits (COB)2.6.1. Coordination with another Group Health Plan (Order of BenefitDetermination Prime Carrier Rules).These rules should be applied in the order in which they are listed in determining whichplan is primary and which is secondary: Rule 1 – Plan Without COB Provision is Primary PlanIf one contract contains a COB provision and the other does not, the insurer withoutthe provision is the prime carrier. The following rules apply when there are two (ormore) plans and both contracts contain a COB provision: Rule 2 – Plan Covering Patient as an Active or Retired Employee is the Primary6

Plan When the patient is the employee with one insurer and the dependent withanother, the insurer that covers the patient as the employee is the primary plan. Rule 3 – When the Patient is a Dependent Child With Both Insurers, the BirthdayRule AppliesThe plan of the subscriber whose birthday occurs earlier in the calendar year is theprimary plan for the dependents covered under that subscriber’s group health plan.The plan of the subscriber whose birthday occurs later in the calendar year is thesecondary carrier for dependents covered under that subscriber’s group health plan.This rule also applies to the dependent children whose parents are living together buthave never married. It does not apply to dependent children whose parents have beendivorced or legally separated. (This revision has been recommended by the NationalAssociation of Insurance Commissioners (NAIC). Although the NAIC model is not law, itis used by many states as a basis for their COB policies. Please be aware, however,that all states may not follow this recommendation.) Rule 4 – How Primary Plan for Divorced or Legally Separated Spouses isDeterminedIf spouses are legally separated or divorced and a court decree directs oneparent to be financially responsible for the child’s medical, dental, and/or otherhealth care expenses, the plan of the parent who is financially responsible willbe the primary plan.If there is no court decree regarding health care responsibility, the insurer of theparent with custody is the primary plan. Rule 5 – Unmarried Spouses With Legal CustodyWhen there has been a divorce and the court has not assigned financialresponsibility for the child’s medical, dental, and/or other health care expenses,and the parent with legal custody of the child has not remarried, the plan ofthe parent with legal custody of the child is the primary plan for the child, andthe plan of the parent who does not have legal custody is the secondaryplan. Rule 6 – Remarried SpousesIn the case of a divorced parent, when the court has not assigned financialresponsibility for the child’s medical, dental, and/or other health care expenses,and the parent has remarried, the plan that covers the child as the dependentof the parent with custody is the primary plan, and the stepparent’s plan is thesecondary plan. The plan of the parent without custody is tertiary. If the parentwith custody does not have his or her own health coverage, the stepparent’splan is then the primary plan and the insurer of the parent without custodybecomes secondary. Rule 7 – When the Court Orders Joint CustodyWhen the court has awarded joint custody of dependent children to divorced orlegally separated parents, MMN applies the birthday rule.7

Rule 8 – Retired and Laid-off EmployeesWhen a retired or laid-off employee has more than one coverage, the plan thatprovides coverage to the member as an active employee is primary; the planproviding coverage as a retirement benefit is secondary. But see the rulesregarding Medicare coverage below.When rules one through eight do not establish an order of benefit determinationthe plan that has covered the patient the longest is the primary plan.2.6.2. Medicare Secondary PayerMMN would be considered the primary insurer for members meeting the followingcriteria: Working Aged:A Medicare working aged individual is defined as a person who meets one of thefollowing criteria:-An age 65 or over working individual who: Works for an employer that employs twenty (20) or more employees,and is covered under that employer’s health plan and entitled to Parts A& B; Age 65 or over and a spouse of a worker employed by an employer oftwenty (20) or more employees who is covered under anemployer’s health plan and entitled to Parts A & B; or A self-employed worker or spouse age 65 who is: Covered by the employer’s health plan throughassociation with a firm which employs twenty (20) or moreemployees, and Entitled to Parts A & B.If Member is retired, over age 65, and part of an Employer Group Health Plan (EGHP),Medicare is primary regardless of group size. If Member is age 65 or over and coveredby Medicare and COBRA, Medicare is always primary to the COBRA plan. End Stage Renal Disease/Permanent Kidney Failure:-A MMN commercial plan is primary to Medicare during a thirty (30)month coordination period for beneficiaries who have Medicarecoverage due to permanent kidney failure. This rule applies to boththose with permanent kidney failure who have their own coverageunder MMN and to those covered under MMN as dependents.Additionally, this rule applies without regard to the number of8

employees or to the enrollee’s employment status .e.g., Member canbe on COBRA. The period for which MMN would be the primary payerbegins with the earlier of:The first month of the enrollee’s entitlement to Medicare Part A on the basis ofpermanent kidney failure, or the first month in which the enrollee would have beenentitled to Medicare Part A if he or she had filed an application for Medicare on thebasis of permanent kidney failure. Disability:-A MMN commercial plan is the primary payer for claims forbeneficiaries under the age of 65 who have Medicare because of adisability and who are covered under a Large Group HealthPlan(LGHP) through their current employment or through the currentemployment of any family member. A LGHP is defined as anemployer who normally employs at least 100 employees on a typicalbusiness day during the previous calendar year.-Note: This does not apply to disabled retirees. Medicare is alwaysprimary for retirees with a disability. Medicare is also primary todisabled members who are on COBRA.2.6.3. Duplicate MMN CoverageIf a member is covered by more than one MMN commercial plan, MMN will applyRules 1 through 8 of Section above. Members covered by more than one MMN planwho are not enrolled with the same PCP for both plans will not benefit from lower costsharing that would otherwise occur as a result of being enrolled in multiple plans.In addition, when a benefit stipulates a maximum number of visits, the member isentitled to the number of visits in the plan with the greater benefit. For example, if oneplan covers 20 visits and the other 50 visits, the member is limited to a total of 50 visits.Lower cost-sharing: Deductible plan primary, Copay plan secondary: Secondary’s copay applies untilthe secondary OOP MAX is satisfied, then covered in full. Copay plan primary, Deductible plan secondary: Secondary’s deductible applies.Once secondary deductible satisfied, then covered in full. Copay plan primary, Copay plan secondary: Covered in full, copayments waived.Deductible plan primary, Deductible plan secondary: Both deductibles apply. Once bothdeductibles are satisfied, then covered in full.9

3.0 Member ServicesMMN strives to provide exceptional customer service via its dedicated call center.Members and providers can also submit general inquiries via email and a MMNrepresentative will respond within one (1) business day. To submit an email inquiryplease visit MMN’s website and click on “Contact Us.”3.1. Language Assistance Phone InterpretationMMN complies with all laws and standards for cultural and linguistic services, includingbut not limited to the Americans with Disabilities Act (ADA), the Affordable Care Act andits implementing regulations, the California Health and Safety Code, regulationspromulgated by the California Department of Managed Health Care (DMHC), otherapplicable federal and State requirements, and the accreditation standards of theNCQA. Interpretation is the act of listening to something spoken or reading somethingwritten in one language and expressing it in another language orally, accurately andwith appropriate cultural relevance. Providers can utilize their bilingual staff, or servicesprovided by the members health plan. If those services are unavailable or insufficient,Meritage contracted plans offer interpretation services. Please refer to our website forthe full policy numbers-plan/3.1.2. Translation ServicesTranslation is the replacement of written text from one language to the equivalent text inanother language. All standardized and enrollee-specific written materials falling underthe category of vital or significant documents must be translated and made available inthe Plan’s threshold language(s). Vital and significant documents include but are notlimited to: ApplicationsConsent formsLetters containing eligibility information and participation criteriaPrior authorization noticesGrievance and appeal rights and forms to fileNotices about the availability of and how to access free language assistance andExplanation of benefits or other claim processing information.Based on census data for the MMN service area and a survey of members, Spanish isthe Plan’s threshold language. MMN sends standard vital documents in Spanish tomembers who have indicated it as their preferred written language. Non-standard lettersand information that contain vital enrollee-specific information that are sent to MMNmembers in English must include the Notice of Language Assistance (NOLA) asrequired by federal and State law.The procedures for requesting translation of an English document are as follows:10

Member Requestsa. Members should contact their health plan directly. The plan will coordinate alltranslation requests and maintain a log for audit purposes.b. The members health plan will offer to interpret the document over the phone,using the language services vendor or qualified in-house interpreters, asappropriate. If the member prefers to receive a written translation of thedocument, the health plan will obtain a copy and initiate the translation process. Provider Responsibilities for Language AssistanceIn addition to the above, providers are responsible for the following:a. Member Informing/SignageProviders must inform members of the availability of language assistance services. Thismay be accomplished by posting a multilingual sign in areas likely to be seen bymembers or providing the Notice of Language Assistance (NOLA) to MMN members.Use of Appropriate Interpreters Interpreter services, including TTY lines services, must be offered at thetime of appointment scheduling and for scheduled appointments. ASLmust be provided for scheduled appointments. Providers must not require or suggest that members with limited Englishproficient (LEP), or who are deaf or hard of hearing, provide their owninterpreters or use family members, particularly minors, or friends asinterpreters. If a member insists upon using the family or friend as aninterpreter after beinginformed of the availability of language assistance services, the providershoulddocument this choice in a prominent place in themember’s medical record.b. After-Hours Linguistic AccessProviders are encouraged to accommodate members with limited English proficiency byhaving multilingual messages on answering machines and training their answeringservices and on-call personnel on how to access interpreter services after hours.c. Provider Directory UpdatesProviders must notify MMN of changes in the language capabilities of medical staff attheir offices so that this information is up-to-date on the MMN website11

4.0 Provider Services4.1. Provider InformationIt is the responsibility of each provider to notify MMN immediately when a practitionerhas been added, terminated or updated as a MMN participating provider. In the case ofa newly contracted practitioner, the provider must initially submit a CV to start the MMNmembership process. The practitioner must be Board certified in their practicingspecialty, see patients a minimum of 20 hours per week, work in the MMN service area,accept Medicare patients, and utilize a contracted Hospital. Please note that all boardcertifications must include the precise name of the board certification from the ABMS (orother) board, as well as the effective and expiration dates.In the case of a provider termination, the Practitioner or representative must informMMN within 90 days by contacting MMN’s Provider Relations Department.MMN mails a New Provider Orientation Packet within ten (10) days of the effective dateof a new direct provider contract. The packet includes a Welcome Letter, key policiesand procedures, a copy of the most current provider materials. MMN is responsible foreducating their contracted practitioners/providers regarding the medical group/IPApolicies and procedures related to providing care and services to MMN members.Information and resources for providers are also available on the MMN website.Providers may request a policy/procedure not available on the website or obtainclarification regarding a specific policy/procedure by calling Member Services at (415)884-1840.4.2. Provider DirectoriesThe Provider Directory is available online in the MIPANet portal and the results areprintable. The online directory is searchable by name, specialty, office location(s) andpractitioners that are accepting new patients, Hospitals are also searchable by facilityname and location.The directory is used as a reference to primary care physicians, specialists,laboratories, urgent care centers, hospitals, and pharmacies. Each practitioner orrepresentative must inform MMN how its participating providers are to be listed in thedirectory, including subcontracted facilities, specialists, etc. Listing information will betaken from the provider profile (see discussion above).MMN takes great care in preparing the Provider Directory, but the accuracy isdependent on the information received from the participating practitioners. Onlinesearch results may be exported and printed. Additional information can be obtained bycalling Member Services at (415) 884-1840.4.3. Provider Appeals12

Providers have the right to appeal directly to the health plan when dissatisfied with theinitial adverse determination of MMN for all issues related to denial of service or medicalnecessity.4.4. Contract Termination4.4.1. Individual Practitioner TerminationIf an individual participating practitioner terminates their contract with Meritage MedicalNetwork, they must notify MMN (90) days prior so that MMN may notify all membersassigned to the terminating practitioner

Meritage Medical Network . Provider Manual . Hours: Monday-Friday 8:30 am -5:00 pm . Phone: (415) 884-1840 or (800) 874-0840 . TDD/TTY for the hearing impaired: (415) 884-1801