Provider Manual

A. INTRODUCTION
A1.1 Introduction
A2.1 How to Contact Physicians Plus Insurance

B. PRODUCTS AND BENEFIT PLANS
B1.1 Benefit Plans
B2.1 Exclusions and Limitations

C. MEMBERSHIP
C1.1 Membership
C2.1 Sample ID Card
C3.1 Member Rights & Responsibilities; Appeals Process

D. PHYSICIAN SERVICES/PLAN PROVIDERS
D1.1 Physician Services
D2.1 Role of the Primary Care Physician
D3.1 Role of the Specialist
D4.1 Privacy and Confidentiality of PHI

F. PRIOR AUTHORIZATION OF PROCEDURES
F1.1 Prior Authorization Definition
F2.1 Services Requiring Prior Authorization
F3.1 Prior Authorization Form Instructions (* downoad the form in the "Forms" section)
F4.1 Provider Responsibility
F6.1 Durable Medical Equipment

G. UTILIZATION MANAGEMENT
G1.1 Utilization Management
G2.1 Concurrent Review and Discharge Planning
G4.1 NursePlus & MobileNurse

H. EMERGENCY/OUT-OF-AREA
H1.1 Emergency Care
H2.1 Out-of-Area Services
H3.1 Urgent Care

I. BEHAVIORAL HEALTH/CHEMICAL DEPENDENCY (BH/CD)
I1.1 Prior Authorization Process

J. PHARMACY SERVICES
J1.1 Pharmacy Services Department
J2.1 Drug Formulary
J4.1 Tobacco Cessation

K. CLAIMS PROCEDURES
K1.1 Claim Form Requirements
K2.1 Payment of Claims
K2.2 PlusLink
K3.1 Coordination of Benefits (COB)
K4.1 Subrogation
K5.1 Worker's Compensation
K6.1 Surgical Assistant Reimbursement Schedule

L. QUALITY IMPROVEMENT
L1.1 Quality Management
L2.1 Case Management
L3.1 Access to Care
L4.1 Credentialing and Recredentialing of Practitioners
L6.1 Facility Review Policy

M. PROVIDER CONTRACT PROVISIONS
M1.1 Provider Contract Provisions
M2.1 Provider Appeals Process

N. PROVIDER NETWORK MANAGEMENT
N1.1 Provider Network Management