Dear Participating Provider

Provider Networks of America, Inc.

Provider Manual

4100 InternationalPlaza, Suite 400

Fort Worth, TX76109

Revised 02/03/2004

Table of Contents

Member Rights and Responsibilities

Member Rights4

Member Responsibilities5

Member Office Visits

Member Access5

Member Identification Cards6

Co-Payments and Deductibles6

Referral Procedures6

Laboratory Services7

Claims Requirements

Assignment of Benefits7

Submitting Claims 7

Electronic Billing8

Quality Claims Practices8

Claims Appeals8

Provider Information9

Contact Information11

Claims Review Form12

Provider Update Form13

Dear Participating Provider:

Welcome to ProNet’s PPO managed care programs. We are proud to include you in our network of quality providers.

The purpose of this manual is to provide you with information on administrative procedures that will serve as a reference throughout your tenure as a ProNet participating provider. The answers to some of the more frequently asked questions are found in the following sections:

Member Rights and Responsibilities

Member Office Visits

Claims Requirements

Quality Claim Practices

Claims Appeal Process

Provider Information

Contact Information

ProNet understands you may experience changes in your office during the course of our relationship. If these changes affect your ability to work with respect to any aspect of the program, please contact our Provider Relations department.

ProNet will be securing many types of benefit plans for the PPO program. Be sure to check each benefit card for specific benefit information.

Please review the manual at your earliest convenience and feel free to contact our Customer Service or Provider Relations departments if you have further questions.

Thank you for your continued support of ProNet managed care programs.

Sincerely,

The ProNet Team

I.Member Rights and Responsibilities: ProNet adopts as its policy, that all patients deserve quality care and that certain rights and responsibilities shall be extended to each and every member.

AMembers have a right to:

Receive medically necessary and appropriate care and services as defined in the member’s benefit plan.
Receive considerate, respectful care and services at all times from all network providers under all circumstances with recognition of their dignity and need for privacy.
Be provided with information necessary to enable him/ her to make treatment decisions that reflect their wishes including the consideration of a second medical opinion from another provider.
Accept medical care or refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal.
Have information kept confidential (released only on written consent from the member) except when and to the extent permitted by law and to be informed of the medical consequences if request is refused.
Formulate advance directives and appoint a surrogate to make health care decisions on their behalf to the extent permitted by law and to be informed of the medical consequences of such decisions.
Obtain information about the network’s services, practitioners providing care, and member’s rights and responsibilities policy.
File complaints and grievances when dissatisfied with the care and treatment rendered by network providers and the quality of services provided by the managed care organization.
Receive a review by a grievance panel.

BMembers have a responsibility to:

Provide, to the extent possible, information the provider needs in order to care for the member
Follow instructions and guidelines given by those providing health care services.
Present their identification card to the person in charge of billing at the network provider’s office.
Show consideration and respect to providers and their staffs.
Make required co-payments and deductibles for health care received.

II.Member Office Visits

AMember Access

One of the responsibilities of the network provider is to provide members with access to care in a timely manner. Access includes the availability of the physician for consultations and, as appropriate, availability of office visits to members. The member’s benefits, network management, or the provider’s contract could further clarify access. Should you have any questions, call your Provider Relations Representative.

BMember Identification Card

Possession of an insurance card does not guarantee eligibility for coverage. It is important to remember that benefits will vary by employer. Call the number on the insurance identification card to verify eligibility and benefits.
Identification cards will contain:

a)Logo (Indicated to the right. It may be tailored for the client)

b)Eligibility, UM and referral phone number

c)Claims address

d)PCP and OB (if applicable)

e)Co-pay amount

f)Referral requirement (if applicable)

CCo-Payment/ Deductibles

Collect all co-payments and /or deductibles from the member at the time of service. Co-payment/ deductibles will vary by client. Call the phone number on the insurance identification to verify eligibility and benefits.

DReferral Procedures

Participating physicians should make every effort to admit/ refer ProNet members to a contracted network facility as long as patient care is not compromised.

ELaboratory Services

For laboratory services, please note the following options:

Use In-office lab
Use a ProNet hospital lab
Use ancillary lab i.e. Laboratory Corporation of America (Consult ProNet’s website for in-network ancillary labs).

III.Claims Requirements

Always bill usual and customary charges on HCFA 1500, UB92, or equivalent billing form. Also, you must obtain a valid assignment of benefits. Mail claims to the address printed on the identification card.

AAssignment of benefits

It is extremely important that the member or authorized person complete a form that assigns the member’s group health plan benefits. The assignment of benefits directs the Payor to pay plan benefits directly to the physician. Payor will honor message “signature on file” as an assignment of benefits once the member or authorized person has signed one assignment authorization

BSubmitting claims primary

The provider of services is responsible for submitting charges to the claims office indicated on the patient’s identification card. Incomplete or missing information on claims submitted for payment may delay payment of plan benefits.

CSubmitting claims secondary

When the ProNet plan is the secondary Payor, claims should be submitted to the primary plan first. After receiving a statement from the primary plan of what it will pay, send a copy of that statement along with the appropriate billing form to the claim office listed on patient’s identification card.

DElectronic billing

For electronic submissions of claims, ProNet uses WebMD and THIN. The Payor identification number for both is 51032.

IV.Quality claim practices:

Providers are expected to fulfill their contractual obligations in billing their services:

No balance billing patients for amounts in excess of negotiated fees or requesting the patient pay any amount up front other than the applicable deductible or co-payment.
Billing in a timely manner and in the necessary format.
No upcoding, inappropriate or inadequate coding, or unbundling charges that results in a higher payment for services.
Appropriate coding for diagnosis and treatment.

V.Claims Appeal

AClaim appeals regarding payments and/or medical necessity should be directed to the insurance company indicated on the patient’s identification card or on EOB/ EPP. Claim appeals regarding discount disputes must be sent in to ProNet on the attached ProNet Claims Review Form. To properly research the claim, ProNet must have the HCFA 1500, UB92, EOB and/ or EPP along with the claim review form. Fax or mail the information to:

ProNet

Provider Relations Department

PO Box 101385

Fort Worth, TX76185

817-735-1487 Fax

BAll claims must contain group ID, insurer’s name, and employer name for the proper payment.

CDo not list ProNet as the insurer as we do not pay claims.

VI.Provider Information

AIn order to load provider information into ProNet’s system, it is necessary to submit all of the following data:

Provider Name
Social security number
Federal tax identification number (Number that claims are filed under)
Date of birth
Degree
Office information

a)Each physical address must indicate a billing address and tax identification number

b)Each physical address must have a phone number.

c)The office hours for each physical address.

d)Indicate if provider is accepting new patients at each physical address.

e)Indicate if provider has handicap facilities at each physical address.

Specialty to be listed in the directory.

a)It must be indicated if specialty practiced is different according to location.

b)Indicate if provider is board certified and year of certification.

c)Indicate if provider wants to be a primary care provider if provider practices family practice, internal medicine, or pediatrics.

Hospital that provider maintains privileges at for MD’s, DO’s, and DPM’s.
Medical school and year of graduation.
Medical license and expiration date.
Federal DEA number and expiration date.

BPlease be advised, it is imperative that the required elements listed above are sent with any updates or changes to the system. If all data elements are not received this could result in delays in claims payment, claims being paid incorrectly, or may cause your status to be terminated.

CProviders participating in ProNet through a contracted entity, i.e. an IPA or PHO, must submit updates to that contracted entity and not directly to ProNet.

DProviders with direct contracts with ProNet can complete and submit the attached ProNet Provider Update Form (page 13) for any demographic or TIN changes that may occur in your practice. Please notify ProNet of these changes immediately so that claim issues can be avoided.

Updates received by ProNet on or before the 10th of the month will be made effective the 1st day of the next respective month. Example: Updates received on January 3rd will be made effective February 1st.
Updates received after the 10th of the month will be made effective the 1st day of second respective month. Updates received January 15th will be made effective March 1st.

EYou can FAX the information to ProNet at 817-735-1487 or mail your information to the Provider Relations department at:

ProNet

Provider Relations Department

PO Box 101385

Fort Worth, TX76185

VII.Contact Information

Provider Networks of America, Inc. (ProNet)

4100 InternationalPlaza, Suite 400

Fort Worth, TX76109

800-462-7554

817-735-8293

817-735-1487-Fax

Email –

ProNet Provider Claims Review Form

Date: ______

Provider Information:

Contact:______

Provider Name: ______Phone Number: ______

Address: ______Fax Number: ______

City/ State/ Zip: ______Tax Identification Number: ______

Contracted Entity (Physician Group, IPA, PHO, etc.): ______

Patient Information:

Patient Name: ______ID or Insured’s SS#: ______

Payor: ______Date of Service: ______

Employer Group: ______Employer Group #: ______

Please check the appropriate box in reference to the claims issue:

Processed as in-network or out-of-network in correctly (circle one)

Claim sent to ProNet but not processed by Payor

Incorrect discount

Processed incorrectly by Payor (Must complete comment section)

Other (Must complete comment section)

Note: A copy of the claim must be submitted along with the EOB and/or EPP

Comments: ______

Please fax or mail information to:ProNet

P.O. Box 101385

Fort Worth, Texas76185

Fax: 817-735-1487

Attention: Provider Relations

Completed by ProNet:

Provider Relations Service Representative:______

Date Received: ______

CONFIDENTIALITY NOTICE: The material in this facsimile transmission is either private, confidential, privileged or constitutes work product, and is intended only for the use of the individual(s) listed above. If you are not the intended recipient be advised that unauthorized use, disclosure, copying, distribution, or the taking of any action if reliance on this information is strictly prohibited. If you have received this transmission in error, please immediately notify us by telephone to arrange for the return of this material to us.

ProNet Provider Update Form

To:Provider RelationsFrom:

Re: Provider UpdateDate:

Fax #:(817) 735-1487Phone:

Please list all applicable tax identification, service and billing locations for indicated provider. Please notify me immediately if all pages are not received at phone or fax number listed above.

Old Information:New Information:

Provider Name: / Provider Name:
Physical Address: / Physical Address:
City, State, Zip: / City, State, Zip:
Phone #: / Phone #:
Fax #: / Fax #:
TIN: / TIN:
Billing Address: / Billing Address:
City, State, Zip: / City, State, Zip:
Phone #: / Phone #:
Fax #: / Fax #:
TIN: / TIN:

PLEASE CIRCLE WHETHER THIS IS A(N): CHANGE ADD DELETE

REQUESTED EFFECTIVE DATE OF THIS UPDATE: ______

Signature: Date:

Note: All updates for providers with direct agreements with ProNet must bear the signature of the provider to be implemented.

PLEASE FAX BACK TO PROVIDER RELATIONS AT 817-735-1487!