Devon Health Hospital Manual
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Overview
Welcome to Devon Health Services, Inc., a national healthcare cost management
company that includes the Northeast’s largest Preferred Provider Organization
(PPO). Devon Health's network of healthcare providers includes more than
350,000 physicians, 27,000 ancillary providers, and 675 hospitals. Devon Health
prides itself on providing its members with the best possible healthcare, while
offering providers a user-friendly system that is unencumbered by excessive
paperwork.
This manual is designed to aid in your orientation as a new Devon Health network
provider. The following information will serve as a guide for office personnel
to follow when treating Devon Health patients.
Should you have any questions that are not answered in this manual, please call
Devon Health's Hospital Relations department at 800.431.2273 or email
hospital_relations@devonhealth.com.
Devon Health has been operational as a non-risk bearing PPO since 1991. Our
clients include Insurers (Insurance Companies), Third Party Administrators
(TPA), Self-Funded Employers and Union Trust Funds. Products include group
health, workers' compensation and motor vehicle accident plans.
At Devon Health, we realize that strong relationships with our participating
hospital providers are key to our success. That is why we have full-time
Hospital Relations Representatives specifically assigned by hospital. Please
consider your Hospital Relations Representative a resource for effective
problem resolution, staff education, or any other instance where partnership
can further both our efforts and goals. We welcome your comments because they
help us gauge our performance. Please contact your Hospital Relations
Representative to let us know when things are right or, just as importantly,
when we need to fix something.
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PPO at a Glance
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A PPO is a managed care arrangement consisting of hospitals, physicians and
ancillary healthcare providers contracted to provide medical services for an
agreed upon discounted fee.
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The PPO has minimal control, whereas an HMO has strict control.
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The PPO has NO gatekeeper function - specialty referrals are unnecessary.
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In a PPO, providers are compensated on a discounted, fee-for-service basis.
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The PPO's health benefit plans generally have deductibles, coinsurance and
copayment provisions.
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After the deductible is met, the plan administrator issues payment to the
provider based on an agreed discounted amount enclosed with an Explanation of
Benefits (EOB).
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Pre-certification is typically not required for most in-office procedures.
However, surgeries, non-emergency hospitalizations, and high cost diagnostics
generally do require pre-certification.
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A PPO affords benefits to members who seek medical care outside of the network
(out-of-network benefits). However, there are strong financial incentive for
patients to see in-network providers.
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The PPO assumes NO cost risk for treatment such as capitation, risk pools, etc.
Payment is issued by the insurance company, self-funded employer or third party
administrator.
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Devon Health's Clients
Devon Health's client contracts are with the claim payers. Once our client has
notified us of a new employer and has gone through our implementation process,
our Client Services unit defines the service area in use. Devon Health will be
the only PPO in that defined service area. The Devon Health logo will always be
displayed on the patient's ID card. The appropriate claims address will also be
displayed (please note: the claims address will vary from client to client).
Once the claim has been processed, you will receive payment along with an
Explanation Of Benefits (EOB) indicating that any discount applied was
according to your contract with Devon Health.
As a non-risk bearing PPO, we are never a payer. You can expect to receive
payment directly from the client (Third Party Administrator, Insurance Company,
Self-Funded Employer, or Union Trust Fund).
Self-Funded (or Self Insured) Employer - An employer or
organization that assumes responsibility for the healthcare losses of its
employees. This usually includes a fund which has been set up such that claim
payments can be drawn against it. Claims processing is usually managed through
an administrative services contract with an independent organization.
Self-Funded Employers normally purchase stop loss insurance to eliminate
catastrophic financial risk.
Insurance Company - An organization that assumes responsibility
for the healthcare losses of its clients or individuals who pay a premium for
such coverage. Insurance companies typically process and pay claims for the
covered individuals or groups.
Third Party Administrator (TPA) - Organizations with expertise
and capability to administer all or a portion of the claims process, but do not
assume financial responsibility for their client’s health plan.
Union Trust Fund - Unions may operate like a Self-Funded
Employer, or may contract with an Insurance Company or TPA to administer their
benefit program and process claims.
For a current client list, please contact your hospital relations
representative.
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Patient Registration
Patients should be registered according to the hospital's normal registration
process. Whenever possible - and dependent on your system's capability - the
registering of claims should include the patient's administrator and payer
information, with the Devon Health information as secondary. Please remember,
Devon Health is a network and never the payer. This helps to apply payments
more quickly and accurately. Additionally, having the patient's employer and
administrator names will enable your Hospital Relations Representative to
assist you more effectively with any problem resolution.
The hospital should verify benefit coverage and eligibility of the plan member
with the payer. The appropriate telephone number will be on the back of the
group medical ID card.
All plans have admission review requirements through their Medical Management
programs. Non-emergency admissions must be pre-certified at least two (2) days
prior to admission. Emergency, urgent, and maternity admissions must be
certified no later than the next business day following admission. The
telephone number to contact the medical management program will be listed on
the plan members' group medical ID cards. An emergency is defined as follows:
A sudden unexpected illness or injury which requires the immediate care
and attention of a qualified physician, and which, if not treated immediately,
would jeopardize or impair the health of the Member or represent a serious
threat to the life or limb of a Member.
If you have any difficulty locating Medical Mangement phone numbers, please
contact Devon Health's Customer Service Department, which should be able to
provide you with the appropriate number. This information is listed either by
administrator/insurer or by employer/union. The member group medical ID card is
the best reference for this information. You should have this information
available before calling Customer Service at 800.431.2273.
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Submitting and Processing Claims
All of our clients provide their members/employees with an ID card. The Devon
Health logo should be clearly displayed. Claims addresses will also be
displayed and will vary from client to client, so it is important that you
collect each Devon Health patient's information. Please refer to the sample ID
card in the Appendix.
Clean claims submitted on a UB-92 are typically processed and returned with
payment and/or EOB within 30-45 days. Clean claims are those submitted on a
universal insurance claim form that is complete, accurate and legible. HCFA
claims must be completed using the CPT-4 coding system as well as ICD-9
diagnosis coding. Please include both the administrator's (payer’s) and the
employer's information and any plan identification numbers on the claim. Our
clients are generally directed to pay providers within 30 days of receipt of
the repriced claim from Devon Health.
Along with the payment, you should receive an Explanation of Benefit (EOB) that
indicates how the claim was processed and states that the discount was taken
according to your Devon Health agreement. Any reasons for non-payment will
appear on the EOB.
Questions about payment should be directed primarily to the payer. The phone
numbers for the appropriate payer office typically appear on the EOB. However,
should you encounter any difficulties or require assistance or intervention
from Devon Health, you should contact your Hospital Relations Representative
immediately.
Clean claims are submitted, in most cases, directly to our client or their
administrator. This address will be on the patient's ID card. Once the client
or administrator has received the claim, they will first check the patient's
eligibility. Assuming the patient is eligible, the claim will then undergo a
short review to determine the medical necessity of the services provided and to
be sure that submitted charges follow Medicare guidelines for billing (typical
for professional charges). Repricing of the claim, according to the contract
rate, is done in conjunction with Devon Health. The client or administrator
then produces the EOB and check and forwards this to the hospital.
All claims addresses will appear on the patient's group medical ID card.
Hospital Appeal Process
If the hospital receives a payment or denial of benefits that they disagree
with, they should follow the normal channels to appeal the payment or denial.
The first step would be to contact the payer directly through their member
service call center (telephone number would be displayed on the member's ID
card). The hospital should express the reason they feel the claim was not
adjudicated properly and ask for a verbal response from the payer. If the claim
was partially or totally denied due to pre-certification reasons, the hospital
may need to also contact the Utilization Review Department/vendor directly.
This first level of appeal may satisfy the hospital and end the appeals process
for this claim. If the hospital still feels that the payment or denial is
unjustified, they should follow the second level appeals process and submit a
written letter directly to the payer's appeals/grievance department. They would
need to state the specific facts they are disputing, and indicate that they
have already filed a first level appeal. The hospital should expect that a
written appeal might take approximately thirty (30) days to receive a response.
Depending on the circumstances of the claim the hospital should allow the payer
adequate time to perform a full investigation of all the issues.
At any time during the appeals process, the hospital may contact its Hospital
Relations Representative. If the hospital is filling a second level appeal,
copies should also be sent to Devon Health.
Certain appeal processes may vary from time to time due to the specific line of
business and payer to which they are appealing.
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Medical Management Program
How Medical Management Is Performed In Each Group.
Devon Health's clients provide their own Medical Management programs. The
program may be proprietary to the client or contracted to a vendor. Programs
are not standardized, but the following represents the features that will be
encompassed. Devon Health anticipates that its contracted providers will
cooperate with our clients' Medical Management programs.
Typical Medical Management Programs
Medical Management will frequently include each of the following medical cost
management programs:
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A nurse call center available during normal business hours.
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Inpatient review encompassing medical, surgical, psychiatric, substance abuse
and rehabilitation care.
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Hospital pre-Admission review for non-emergencies.
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Post admission review for urgent and emergency admissions.
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Concurrent/continued stay review.
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Discharge planning, in cases where appropriate.
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Screening and referral to large case and disease management programs.
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Managed Second Surgical Opinion Program.
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Steerage to appropriate PPO and ancillary providers.
Inpatient Admission Review
All inpatient admissions must be reviewed for medical necessity. Scheduled
admissions should be reviewed at least seventy two (72) hours in advance of the
admission. Urgent or emergency admissions must be reviewed the next business
day following admission.
TThe admission review process should be initiated by the hospital or the
physician. Many programs will, however, involve the patient regarding the
options and alternatives available under the client's benefit plan. In many
instances the review nurse will assign an initial expected length of stay,
which will be determined from a clinical database.
A concurrent review process will be based on a schedule determined by the
initial assigned length of stay, or the judgement of the nurse reviewer as to
the appropriate follow-up intervals. Concurrent review will be conducted either
with the hospital UR department, the floor nurse, or the attending physician.
In all instances the nurse reviewer will need to determine the discharge day
and its appropriateness.
The Concurrent Review process is initiated by the nurse reviewer. The patient
may be too ill to be discharged and should not have the burden of notifying the
nurse reviewer as well. The nurse reviewer also works with hospital personnel
to assist in assessing the patient's condition, especially in those cases that
can change rapidly, such as a patient admitted for acute abdominal pain.
Contact with the floor nurse can offer the most up-to-date information
regarding the patient's condition without disrupting the physician. However, it
should be noted, in the majority of cases, the physician is the individual
contacted in reference to the patient's condition.
Clinical Review Criteria is derived from one of the following sources:
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The Interqual Intensity of Service/Severity of Illness Criteria.
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Miliman & Robertson Optimal Recovery Guidelines.
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Psychiatric and Substance Abuse admissions--DSM-IV criteria which is provided
by the American Psychiatric Association.
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The above criteria modified by the review organization, or proprietary clinical
criteria developed by a review organization, each of which may have been
modified for individual client applications in order to determine
appropriateness of admission for treatment.
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Length of stay for any admission determined through a data base such as Miliman
& Robertson, or the CPHA average length of stay guidelines.
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Workers compensation injury guidelines through Miliman & Robertson or
proprietary criteria developed by a review organization.
Large Case and Disease Management
Large Case and Disease Management encompass both catastrophic and chronic care
management. Each requires a different approach, but the common thread is that
each must have a case manager as the interventionist.
Large Case and Disease Management services are designed to maximize healthcare
dollars by seeking the most cost and care effective environment and services
for the patient. Programs will vary slightly by client. Case Managers seek to
affect quality of life, quality of care, and cost of care. Care is coordinated
across multiple providers, and special discharge arrangements may be made by
the Case Manager. Most importantly, the patient and family are involved in the
decision-making process from the onset, because patients with chronic or
catastrophic illnesses are not solely affected; the entire family is touched by
these circumstances.
Patients appropriate for case management are identified through the
Pre-Admission Review process, Concurrent Review process, and Medical
Information Helpline, as well as through claims processing or client
notification, for those patients who have either not come through the
utilization review process and/or who have expensive, chronic outpatient care.
The major triggers for Large Case Management screening are:
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Diagnosis that indicates a catastrophic and/or chronic disease process (i.e.,
AIDS, traumatic injury, certain cancers).
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Prolonged hospital stay or frequent hospitalization.
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Questionable adequacy of treatment plan.
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Treatment/Discharge plan in need of clarification/modification.
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Potential for case management to impact the level of care.
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Potential for high dollar cost savings.
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Urgency to facilitate discharge/treatment plan.
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Problems with coordination of care.
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Potential for long term high cost care.
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Plan of care not in keeping with clinical information/picture presented.
Ongoing monitoring is performed to ensure that quality and frequencies of
services are appropriate. The ongoing review will also provide information in
the event that revisions are required to the original recommendations regarding
items such as level of care or frequency of care. Case management may be
applied to any type of admission.
Case Managers are heavily involved from the date of authorization (this will
come from Devon Health's client or the administrator of the patient's benefit
plan), in the development of a treatment plan. They speak with the physician
and work in a cooperative manner with both the physician and family members
involved.
The Case Managers are both nurses and physician assistants who have expertise in
a multitude of specialties; all have extensive clinical experience in their
particular specialty. Case Managers are familiar with local resources and
utilize specialist Case Managers, such as Certified Rehabilitation Nurses for
spinal cord or head injury patients and Neonatal Practitioners for premature
babies. The patient and family are involved in the decision-making process from
the onset, because patients with chronic or catastrophic illnesses are not
solely affected; the entire family is touched by these circumstances.
Maternity Care Programs
Most programs include education and high risk screening components to accomplish
the following:
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Reduction in C-Section Rate.
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Fewer Pregnancy Related Complications.
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Avoidance of Unnecessary Testing.
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Decreased Occurrence of Premature/Low Birth Weight Infants.
Program components may include:
Ongoing Support for the expectant mother
Each expectant mother is provided access to a counselor. Counselors are
accessible to the mother via a toll free number in the event she has a question
or concern. Each Counselor has a clinical background (Registered Nurse or
Physician Assistant), and is trained to complement, not replace, the provider.
Ongoing education for the expectant mother.
Each expectant mother receives an educational package of information during the
first, second and third trimesters. The mailings are designed to provide the
mother with the type of information that will assist her through each
particular period of her pregnancy. Should the Counselor identify a mother
having additional problems or needs, specialized information is sent in
addition to those standard mailings provided in each trimester.
Regular screening for the expectant mother.
The Counselor contacts the mother each trimester to provide verbal education and
support, but, just as importantly, to ascertain the mother's status. If it is
determined that a mother is high risk, the case is referred to Case Management
for evaluation. If Case Management is judged to be appropriate, the Case
Manager works directly with the maternity counselor, patient, family and
physician to manage problems and propose and coordinate solutions. In some
cases, community services may be utilized, depending on the specific situation
involved and the expected outcome of such intervention.
Managed Second Surgical Opinion Program
Client medical plans will generally pay for a needed second surgical opinion. At
any time, a patient may obtain a voluntary second surgical opinion, and a third
surgical opinion in the case of a disagreement between the first and second
opinion.
In most instances the medical plan will contain a program to encourage use of
second surgical opinions. The majority of plans will have a managed second
surgical opinion program, which means that the need for a second surgical
opinion will be determined by the nurse reviewer at the time that the admission
review is done. If the nurse reviewer determines that a second surgical opinion
is needed, then the admission will not be certified until the opinion is
obtained.
Some plans will have a published list of procedures for which it is necessary to
obtain a second surgical opinion. The lists will vary from client to client,
and it would not be possible for a hospital to have all the lists. Information
regarding the second opinion is provided at the time that the admission is
certified. The patient must have presented evidence that a second surgical
opinion has been obtained.
Optional Outpatient Review Programs
Certain clients will elect to purchase outpatient review programs. Typically,
these programs will review ambulatory surgery performed in the same-day surgery
unit of the hospital or in a free-standing surgi-center. In addition, most
programs will review higher cost diagnostics procedures such as MRIs and CT
Scans. Some clients will have a defined list of procedures to be reviewed, and
others will review all outpatient procedures done in the hospital. As with
second surgical opinions, it will not be possible to provide a list of
procedures for each client.
Devon Health’s clients will expect notification at least 48 hours in advance of
a planned admission. Notification within 24 hours or the next working day
following an emergency admission is preferred. Pre-certification numbers are
available on the patients’ ID cards. For assistance in locating those numbers,
please contact Devon's Customer Service at 800.431.2273.
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Procedures for Denials
In instances where the Medical Management program cannot certify an
admission/service or a continuation of a stay, the nurse reviewer will involve
their medical director. The nurse reviewer and the medical director will
discuss the case with the attending physician, and, in the case of a continued
stay, the hospital UR Department. They will make recommendations for
alternative treatment. The goal is to come to a consensus on the most effective
method for treating the patient.
If all parties agree, then the initially proposed admission/service or continued
stay is avoided, and the other approved care is provided to the patient. If the
attending physician does not agree, then he/she can immediately institute an
appeal. Appeals are dealt with in two ways:
Expedited Appeals: This kind of appeal is done for cases that
have an urgency. The case may relate to a continued stay or the nature of the
medical care is more urgent. The Medical Review program will have the case
reviewed by a second physician. This review will be performed in a timely
fashion, and the results communicated to all parties. This appeal would be
considered final.
Non-expedited Appeals: This kind of appeal is done for cases
that do not have an urgency to resolve. The case may be an elective admission
or ambulatory surgery. The Medical Review program will also have these cases
reviewed by a second physician and the results will be communicated to all
parties. This appeal would be considered final.
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Conclusion and Contacts
This manual is provided to serve as a guideline for your encounters with
patients who access the Devon Health PPO. It is only a guide and may not cover
all circumstances you may encounter. For assistance, please contact your
Hospital Relations Representative. If you have not been assigned a Hospital
Relations Representative, call us at 800.431.2273.
In any instances where you require assistance referring a patient to an
in-network provider (for example, ancillary services, DME, labs, etc.), please
visit our online provider finder or contact Customer Service or your Hospital
Relations Representative.
Please be aware that some of our clients have specific rules regarding
laboratory services and may only cover lab work performed by specific
providers. This information is typically outlined on the patient's ID card. If
you need assistance in determining how to appropriately handle lab work, our
Customer Service Department should be able to refer you to the client's
benefits and eligibility office.
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Appendix - ID Card
Devon Health ID Card
Front of Card
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Devon Health Logo Identifying Network Participation
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Client Group Name: For Example, Local XXX
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Participant's Name
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Group Number (usually enrollee's Social Security Number)
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Applicable Co-pay for office visit, if any (can also be on the back)
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6. Address to mail claims to; each plan is design specific (can also be on the
back)
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Will identify who needs to be called concerning benefit, claim and eligibility
status
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