EMHS EMPLOYEE HEALTH PLAN PROVIDER ORIENTATION

1. EMHS EMPLOYEE HEALTH PLANPROVIDER ORIENTATION May 2013 Geisinger Health Options is administered by Geisinger Indemnity Insurance Company, an affiliate of Geisinger Health Plan.

2. The EMHS Difference an accountable system of care … providers, hospitals, and others working together to coordinate patient care, ensure access, reduce costs, and help people learn how to live as healthy a life as possible.

3. Primary Care Through innovative primary care and health information technology, EMHS can reduce healthcare costs while improving quality and outcomes.

4. Care Coordination Close gaps in care Better communication Frequent patient/family interaction Daily provider/team interaction

5. EMHS Progress to an Accountable System of Care

6. The Difference Starts at HomeEMHS medical plan: 11,000 employees/dependents • Wellness Coaching • Elimination of pre-existing condition rule • Zero copay for certain generic drugs • Zero copay for supplies for coronary artery disease, depression, diabetes, and hypertension

7. GEISINGER TEAM The Geisinger Team Duane Davis, M.D. Chief Exec. Officer & Exec. Vice President of Insurance Operations Ray Roth, D.O. Chief Medical Officer, GIO Janet Tomcavage Chief Administrative Officer, GIO Jason Renne Vice President, Network Innovations Leigh Brock-Webster Director, New Market Development Christy Spurlock Manager, Business Operations Jan Goodeluinas Team Lead Kimberly Fullmer Sr. Provider Network Development Associate

8. PARTNERSHIP FOR SUCCESS EMHS/Geisinger Partnership- why? • EMHS: Quality- focused clinically integrated network • Geisinger Health Plan: Proven track record for quality and innovation • Bring physician partnership in the delivery of quality care Why did the partnership come together? • Advancement of quality initiatives • Partner with country’s leading not for profit health plan • Geisinger seeking strategic partnership outside PA with innovative partners to implement models of care in collaboration with physicians.

9. PARTNERSHIP FOR SUCCESS EMHS/GeisingerPartnership for success Shared strengths: Geisinger dedicated to physician led quality of care • Like-minded, not-for-profit, mission focused • Geisinger – “PASSIONATE” about improving quality of care; earned national reputation for redesigning care and value. Compatible Interests: • Build a clinically integrated delivery system • Deploy Geisinger care delivery model

10. Geisinger Health System - An Integrated Health Service Organization Provider Facilities $1,564M Managed Care Companies $1,465M Physician Practice Group $702M • Geisinger Medical Center • Hospital for Advanced Medicine, Janet Weis Children’s Hospital, Women’s Health Pavilion, Level I Trauma Center, Ambulatory Surgery Center • Geisinger Shamokin Community Hospital • Geisinger Northeast (3 campuses) • Geisinger Wyoming Valley Medical Center with Heart Hospital, Henry Cancer Center, Level II Trauma Center • South Wilkes-Barre Adult & Pediatric Urgent Care, Ambulatory Surgery Center, inpatient rehab, pain mgmt., sleep center • Geisinger Community Medical Center • Marworth Alcohol & Chemical Dependency Treatment Center • Mountain View Care Center • > 69K admissions/OBS & SORUs • 1,372 licensed inpatient beds • ~298,000 members (including ~63,000 Medicare Advantage members) • Diversified products • ~30,000 contracted providers/facilities • 43 PA counties • Multispecialty group • ~900 physician FTEs • ~520 advanced practitioner FTEs • 65 primary & specialty clinic sites (37 community practice sites) • 1 outpatient surgery center • > 2.1 million clinic outpatient visits • ~360 resident & fellow FTEs Note: Numerical references based on fiscal 2012 budget plus impact of GSACH and GCMC acquisitions.

11. Our system is a model for health care reform “…We need to build on the examples of outstanding medicine at places like…Geisinger Health System in rural Pennsylvania…islands of excellence that we need to make the standard in our health care system.” Remarks by President Barack Obama, American Medical Association Annual Conference, June 15, 2009

12. Geisinger Health Plan carries on the tradition of quality Top-ranked Medicare and commercial health plan in Pennsylvania #12 private and #6 ranked Medicare plan in the nation Ranked 4.5 out of 5 stars by CMS five years in a row. “Excellent” Accreditation from NCQA (since 1994) Named 2008 “Outstanding Health Plan” by DMAA: The Care Continuum Alliance * According to the National Committee for Quality Assurance (NCQA) Health Insurance Plan Rankings 2010-11–Private and Medicare lists.

13. And our mission is to be the best Best in the state for: • Breast cancer screenings* • Ensuring recommended medications are taken after a heart attack* • Glaucoma Screening • Monitoring of persistent medications • Diabetes monitoring

14. DISCLAIMER This presentation is not intended to be all inclusive. All information is fully delineated in the Provider Guide (Rev 08/11), which may be amended from time to time by written correspondence and can be found at www.thehealthplan.com. 14

15. WEBSITE www.thehealthplan.com

16. WEBSITEwww.thehealthplan.com 16

17. PROVIDER INFORMATION CENTERPROVIDER/PHARMACY SEARCH 17

18. WEBSITESECURED/UNSECURED Secured (required log-in) Unsecured Service Center Provider/facility search -Member benefit -Claim/authorization data Physician Quality Reports Medical Policies Member Health Alerts Drug formulary Health Plan Communications Electronic Transaction Provider Guide 18

19. SERVICE CENTER ONLINE ACCESS: • Service Center • Providers have the ability to verify Member Eligibility, Benefits, Authorizations, Referrals and Claim Status • Registration is necessary. Complete the Service Center Registration form called the “Super User Registration Form.” 19

20. SUPER USER REGISTRATION FORM 20

21. SECURED MESSAGES SERVICE CENTER 21

22. COMMUNICATION

23. COMMUNICATION TOOLS Forms and Publications Located at www.thehealthplan.com within the Provider Information Center The Provider Guide • An important part of the contract between the Health Plan and the provider Operations Bulletins • Health Plan’s method to communicate important time sensitive information Briefly • Quarterly newsletter providing useful Health Plan news and information about changes which affect Participating Providers These Forms and Publications are mailed to the participating providers and accessible online.

24. WHO TO CALL • GHP has developed a user friendly handout to help you identify your key contacts at the Health Plan, such as: • Claims/Customer Service Department – (855) 863-2429 • Medical Management – (800) 544-3907 • PNM Number – (800) 876-5357 • The Who To Call Card is included in your packet and will be located on the website. 24

25. MEMBERS

26. IDENTIFICATION CARDS Each member is issued an ID card similar to this example. Contact Customer Service using the toll free number of the back of the ID card to confirm eligibility and/or benefits prior to rendering services. DRAFT

27. MEDICAL MANAGEMENT

28. REQUIRES PRECERTIFICATION The following require precertification by the Health Plan: • Planned inpatient admission, including rehabilitation admissions; • Skilled level of care admissions; • Outpatient rehabilitative services (PT/OT/ST); • Outpatient radiology services (NIA-To be discussed later in presentation) • Home Health/Hospice Services by Home Health Provider 28

29. PRECERTIFICATION REQUIREMENTS Admitting or ordering physician is responsible for obtaining pre-certifications All requests for prior authorization/pre-certification by the Health Plan should be submitted by the admitting/ordering participating provider. Requests may be telephonic, faxed, or submitted via US Mail to: • Geisinger Health Plan Medical Management Department. 30-20 100 North Academy Ave Danville PA 17822 (800) 544-3907 or (570) 271-6497 Mon. - Fri., 8:00 am to 5:00 pm Please refer to the Prior Authorization/Pre-certification list available on our websiteat: http://www.thehealthplan.com/providers_us/prior_auth_list.pdf

30. PRECERTIFICATION REQUIREMENTS Planned admission require pre-certification no less than two (2) business days prior to date of admission. Observation Services expected to exceed 23 hours require the Participating Provider to initiate a request for pre-certification Non-Emergent ambulance transportation with a non-participating provider requires pre-certification prior to service being rendered.

31. CONCURRENT REVIEW PROCESS • Subsequent Concurrent Review: • Reviews will continue during the member’s entire stay. • Please have member information readily available during the Concurrent Review. • Nursing or therapy updates; and • Plan of care with anticipated disposition and estimated length of stay. Initial Concurrent Review: Facilities are required to initiate with the MM Department within one (1) business day of the admission. Please have member information readily available during the Concurrent Review. • Verification of admission date and attending physician; • Current inpatient needs; • Plan of care; and • Overall goals and anticipated length of stay.

32. REQUIRES PRECERTIFICATION Contact the Medical Management Department to initiate a request for precertification at (800) 544-3907 or (570) 271-6497, option 1, Mon. – Fri. 8:00 am – 5:00 pm. Skilled level of care admissions (Facilities accepting skilled admissions are responsible for precertification) • Precertification is required prior to the admission. • A three (3) day prior hospital stay is not required. • Precertification is also required when the Health Plan is not the member’s primary insurance coverage.

33. REQUIRES PRECERTIFICATION Contact the Outpatient Rehabilitative Therapy Network to initiate a request for precertification at (800) 270-9981 or (570) 271-5301 Mon. – Fri. 8:30am to 5:00pm. Outpatient Rehabilitative Therapy • Facility Outpatient Rehabilitative Therapy Services Providers (Outpatient Rehab. Providers) are required to initiate the request for precertification through the Outpatient Rehabilitative Therapy Network. • Such requests must be initiated within seven (7) calendar days of the initial rehabilitative evaluation. • Precertification is also applicable to members in an intermediate care setting.

34. OUTPATIENT REHAB FORM

35. REQUIRES COORDINATION Hospice Election • Facilities are required to notify the Health Plan’s Home Health/Hospice Network immediately upon a member’s decision to invoke their hospice benefit. Infusion Therapy Services • Facilities are encouraged to refer to their agreement for specific information regarding the inclusion/exclusion of infusion therapy services. Personal Care Facility (PCF) • Medicare/Health Plan standards do not consider a PCF an institutionalized facility. Therefore, members residing in a PCF should have all services coordinated by their PCP, as applicable.

36. NIA NATIONAL IMAGING ASSOCIATES, INC.

37. Geisinger Health Plan Provider Training Program

38. Agenda • Welcome and Opening Remarks • About National Imaging Associates, Inc. • Provider Partnership • Program Components • How the Program Works: • Authorization Process • Authorization Appeals Process • Claims Process • Claims Appeals Process • Provider Self-Service Tools (RadMD and IVR) • RadMD Demonstration • NIA Provider Relations and Contact Information • Questions and Answers

39. NIA is accredited by NCQA and URAC certified • National Imaging Associates (NIA) - chosen by national and regional health plans, serving more than 17 million members, and offering: • Distinctive clinical focus • National Committee for Quality Assurance accreditation and Utilization Review Accreditation Commission certification • Stability reinforced by parent company, Magellan Health Services • Enhanced operational competencies • Strong IT capabilities • Comprehensive patient support tools • Financial stability promoting growth and investment in innovative technology • Focus and Results - Maximizing quality diagnostic services and promoting patient safety through: • A clinically-driven process that safeguards appropriate diagnostic treatment for Geisinger Health Plan members. • Convenient access to a network of qualified providers About NIA

40. Overview of Program Components for Geisinger Health Plan

41. The Authorization Process

42. NIA Prior Authorization Is Required for: Non-emergent outpatient • CT/CTA Scan • CCTA • MRI/MRA • PET Scan • Diagnostic Nuclear Medicine • Nuclear Cardiology/MPI • Any code specifically cited in the Geisinger Health Plan /NIA Billable CPT® Code Claims Resolution Matrix. • ALL other procedures will be adjudicated and paid by Geisinger Health Plan per their guidelines. • Authorizations are valid for sixty (60) days from date of determination.

43. NIA Prior Authorization is NOT required: • When the following studies are performed in an emergency room, observation or inpatient setting, prior authorization is not required from NIA. • CT/CTA Scan • CCTA • MRI/MRA • PET Scan • Diagnostic Nuclear Medicine • Nuclear Cardiology/MPI • Providers should continue to follow Geisinger Health Plan authorization policies for emergency room, observation or inpatient procedures.

44. Clinical Record Validation • Sometimes NIA will require validation of clinical criteria within the patient’s medical records before an approval can be made. • We want to ensure that the clinical criteria that support the requested test are clearly documented in the medical records. • OTHER INFORMATION • Required based on algorithm • Methods of Submitting Clinical Records • Upload through RadMD – Preferred Method • Fax to NIA using the OCR Fax Coversheet

45. NIA’s Authorization Process • The ordering physician is responsible for obtaining prior authorization. • The rendering provider must ensure that prior authorization has been obtained. It is recommended that procedures are not scheduled without prior authorization. • Requests for CCTA and Nuclear Cardiology will be reviewed using cardiac specific algorithms, and when a physician is needed, a board certified cardiologist, who in some scenarios may suggest an alternate study. • Procedures performed without proper authorization will not be reimbursed. • If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, they should contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is 1-866-305-9729. • If an emergency clinical situation exists outside of a hospital emergency room, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is 1-866-305-9729. • Separate prior authorization numbers are not needed for CT-guided biopsy, CT-guided radiation therapy and some MR-guided procedures.

46. NIA Clinical UM Authorization Process System evaluates request based on physician entered information Physician’s office contacts NIA for prior authorization of study Initial Clinical Specialty Team Review Physician Review  Physician Approves Case Without Peer-to-Peer Additional clinical information complete –procedure approved  Clinical information complete – procedure approved  • RADMD.COM  Physician Approves Case With Peer-to-Peer Clinical information not complete – additional information needed  ? Additional clinical not complete or inconclusive Ordering Physician Withdraws Case W Request for specific clinical information needed ?  • Telephone Physician Denies Case

47. The Authorization Appeals Process • In the event of a denial or you are not satisfied with a medical decision from NIA, you may appeal the decision through Geisinger Health Plan . • You will receive appeal information in the denial letter that will be sent to you

48. The Claims and Claims Appeal Process How Claims Should be Submitted: • Rendering providers/imaging providers should continue to send their claims directly to Geisinger Health Plan as per the current process. • Providers are strongly encouraged to use EDI claims submission. Claims Appeal Process • In the event of a prior authorization or claims payment denial, you may appeal the decision through Geisinger Health Plan . • Follow the instructions on your non-authorization letter or Explanation of Benefits (EOB) notification.

49. Self-Service Tools and Usage

50. NIA Provider Tools “Make it Easy” for Providers to Partner with NIA Clinical algorithms apply sophisticated criteria to auto-approvemost requests and send others for additional review