CLARENDON KIDS CHIP PLANv Pages 21 –36 Scope of Benefits Outlines benefit coverage through the Clarendon Kids CHIP Plan. v Page 37 Referral Sheet Since there is no benefit for out-of-network

CLARENDON KIDS CHIP PLAN

EPO PROVIDER MANUAL

clarendon insurance group

Dear CHIP Provider:

USA Managed Care Organization (USA) and Clarendon Insurance Company are pleased to welcome youto the Clarendon Kids CHIP Plan Network. In an effort to assist you in becoming familiar with ourprocedures, the following is enclosed:

~ TABLE OF CONTENTS ~

v Page 4 Clarendon Kids CHIP Plan OverviewIncludes basic company and program information.

v Pages 5-6 Frequently Asked QuestionsIncludes answers to commonly asked questions.

v Page 7 Key ContactsProvides helpful phone numbers and contact information for all aspects of the program.

v Page 8 Sample ID Card

v Pages 9-10 Cost Sharing InformationProvides information on applicable co-pays.

v Page 11 Rx InformationHelpful information relating to prescription coverage.

v Page 12 List of EPO CountiesAlthough our insureds are from this list of 170 counties, our CHIP Provider Network isstate-wide in order to ensure continuity of care, undisturbed referral patterns, and thebest medical treatment available.

v Pages 13-15 Medical Management/Pre-CertificationOverview of medical management team and procedures.

v Pages 16-18 Pre-certification RequirementsProvides a summary of precertification requirements.

v Page 19 Psych - Outpatient Review Documentation Guide– New Form

v Page 20 Scope of Benefits –Quick ReferenceProvides a quick reference guide for basic scope of benefits.

v Pages 21 –36 Scope of BenefitsOutlines benefit coverage through the Clarendon Kids CHIP Plan.

v Page 37 Referral Sheet

Since there is no benefit for out-of-network services (except for Emergency andUrgent Care) and because we believe it is important that your standard referralpatterns are not disturbed, please indicate those providers you normally refer patients toand we will contact them regarding participation.

v Page 38 CHIP Identification ToolQuestionnaire for Children with Complex Special Health Care Needs.

v Pages 39-43 Texas Vaccines for Children Program (TVFC)Information regarding vaccine program through Texas Department of Health (includesenrollment forms).

v Pages 44-45 Provider HotlineInstructions for provider to verify CHIP member enrollment status.

v Pages 46-49 Requirements by which Providers are GovernedStandards by which providers shall be governed.

v Pages 50-51 CHIP Healthcare Provider Marketing PolicyProvides TDI Guidelines for marketing of the CHIP program to your patients.

v Pages 52-54 Sample TexCare Partnership ApplicationPlease call USA MCO for additional applications and other Outreach Materials.

v Pages 55-56 GlossaryProvides definitions of Plan terms.

We appreciate your participation and look forward to a long and mutually beneficial relationship. Shouldyou have any questions or require assistance, please contact USA’s Provider Relations Representatives at(800) USA-3860 ext. 4889 from 8:00 to 4:30 CST.

Thank you,

Provider RelationsAustin Corporate Office

4

Clarendon National Insurance Company

The Clarendon Kids CHIP Plan EPO Health Insurance Model

• EPO stands for Exclusive Provider Organization. An EPO does not require members to choose aprimary care physician. However, the Clarendon Kids CHIP Plan does encourage members toselect a primary care physician to direct the care required by members.

• Members may change primary care physicians whenever they wish.

• The EPO also does not require a referral from a primary care physician before members can see aspecialist. However, while no referral authorization is required from primary care physicians inorder for members to access a specialist, members and physicians are encouraged to utilize theservices of physicians and other providers that are part of the Clarendon Kids CHIP Planparticipating provider network.

• If services are obtained from a physician or other provider that is not an in network, participatingprovider then those services are generally not going to be covered services unless there is amedical emergency or unless the services are prior authorized by us.

• The Clarendon Kids CHIP Plan is an indemnity model plan that uses the Medicaid Fee Scheduleas the reimbursement benchmark.

• Many services do require pre-certification. You will want to refer to the Pre-CertificationRequirements section of this information for more details.

5

Clarendon Kids CHIP PlanFrequently Asked Questions

_____________________________________________________________Q A

How will I recognize CHIP insureds who are subjectto my Agreement with USA Managed CareOrganization (USA MCO)/Clarendon KIDS CHIPPlan?

CHIP insureds will have I.D. cards with the nameClarendon KIDS CHIP Plan as well as the USA MCOlogo.

Who do I call to verify eligibility and benefits? Clarendon KIDS CHIP Plan at (800) 971-0480. Thisinformation is also on the insured’s I.D. card.

Who do I call if I am told pre-certification isrequired?

National Health Services, Inc. at (877) 868-9621. Thisinformation is also on the insured’s I.D. card.

Who do I call for dental eligibility/benefits? United Concordia at (800) 332-0366.

Who do I call if an insured needs to be referred to aspecialist or another provider?

Your contract requires you to refer to a USAMCO/Clarendon KIDS CHIP Plan participating provider.Call (800) 872-3860 to obtain names of participatingproviders in your area.

Why is it so important to refer to USA MCO/Clarendon KIDS CHIP Plan participating providers?

When non-participating providers are utilized, the insuredsreceive no benefit. Therefore, the use of participatingproviders greatly reduces out-of-pocket expenses to theinsured.

Am I required to refer lab work to a participating lab,or may I perform the lab work in my office?

If lab services are available in your office, billed underyour name and tax I.D. # and you have a valid CLIAcertificate on file with USAMCO then services may beperformed in your office.

Must I participate in the Texas Vaccine ForChildren’s Program?

Yes. Clarendon will reimburse for the administration ofthe vaccine, but the serum must be obtained from theTexas Vaccine for Children’s Program.

6

How do I bill for immunizations? Bill with the Medicaid THStep Codes or with CPT Codes90471 or 90472.

What are accepted forms for billing? HCFA-1500 for Physicians. UB92 for Hospitals.

Physician claims may be submitted through THIN utilizingPayor ID:EPOTX

How do I bill for services rendered to CHIP insureds? Bill with your Usual and Customary charges.

Where do I mail claims? Clarendon Kids CHIP PlanPO Box 160300, Dept. 9200Austin, TX 78716

Who do I call if I have claim status questions? Clarendon KIDS CHIP Plan at (800) 971-0480 option 3.

Who do I call if I have a question about my networkcontract ?

USAMCO at (800) 872-0820.

Please visit our website at www.usamco.com for the following options:

¶ Print current copy of our CHIP Provider Directory.¶ Locate a CHIP provider near you with our easy Provider Search Program.¶ Get additional information about the CHIP program.¶ Refer a doctor to the CHIP Program with our easy Provider Referral Form.¶ Find links to other helpful websites.

7

Clarendon Kids CHIP PlanKey Resources

Helpful Telephone Resources

Resource Needed Who to Call Telephone Number

Eligibility and Benefits Customer Service (800) 971-0480

Claims Customer Service (800) 971-0480

Electronic Claims Submission (ECS) Participation

§ ECS – Claims Status

THIN

Provider Services

(972) 766-5480

(800) 872-0020

Pre-Certification Medical Services (877) 868-9621

Case Management Medical Services (877) 868-9621

Nurse Hot Line Nurse Line (877) 868-3822

Participating Providers Provider Services (800) 872-0020

Provider Contracting and Credentialing Provider Services (800) 872-0020

Verification of Provider Participation Provider Services (800) 872-0020

Information Updates and General Assistance Provider Services (800) 971-0480

All Dental Provider Questions and Information United Concordia (800) 332-0366

Prescription Drug Program General Information TexCare Partnership (800) 647-6558

Prescription Drug Program Provider Assistance Vendor Drug Help Desk (800) 435-4165

Helpful Billing Information

Paper Claims Submission Electronic Claims Submission

Clarendon Kids CHIP Plan

P.O. Box 160300; Dept 9200Austin, TX 78716-0300

THIN Provider Automation

Receiver ID: XCLR45Payor ID: EPOTX

Claims Information phone: (800) 971-0480 THIN Information phone: (972) 766-5480

8

Sample ID Card

9

CHIP Member Cost-Share Changes

Effective March 1, 2002 all CHIP members may have new cost share, or co-pay amounts (the amounts the memberpays) for medications, emergency room visits, and other health care services. The cost sharing payment limits mayhave changed.

CHIP Copayment Schedule for Certain Medical Services

Plan de copagos de CHIP para ciertos servicios médicos

Niveles depobrezafederales

Citas alconsultorio

Visitas a lasala deemergencias

Hospitalizacióncomo pacienteinterno

Medicamentosgenéricos dereceta

Medicamentosde receta demarca

Límite anualde gastos

Indiosamericanos

$0 $0 $0 $0 $0 $0

100% omenos

$0 $3 $0 $0 $3 $100

Entre 101%y 150%

$2 $5 $25 $0 $5 $100

Entre 151%y 185%

$5 $50 $50 $5 $20

5% de losingresos

netos anualesde la familia

Entre 186%y 200%

$10 $50 $100 $5 $20

5% de losingresos

netos anualesde la familia

FederalPoverty Levels

OfficeVisits

EmergencyRoomVisits

InpatientHospitalizations

PrescriptionGenericDrugs

PrescriptionBrand Drugs

AnnualReporting

CapsNative

Americans$0 $0

$0$0 $0

$0At or Below

100%$0 $3

$0$0 $3

$100

101%-150% $2 $5$25

$0 $5$100

151%-185% $5 $50 $50 $5 $205% cap of

family annualnet income

186%-200% $10 $50 $100 $5 $205% cap of

family annualnet income

10

CHIP cost-sharing amounts are based upon the budget group’s percentage of Federal Poverty Level.

At or below 100% Current Policy ChangeEnrollment Fee $0 No ChangeMonthly Premium $0 No ChangeOffice Visit $0 No ChangeER $0 $3Generic Drug $0 No ChangeBrand Drug $0 $3Co-pay Cap n/a $100Deductible, non-institutional $0 No ChangeDeductible, institutional $0 No ChangeFacility Co-pay, Inpatient $0 No ChangeFacility Co-pay, Outpatient $0 No Change

101% to 150% Current Policy ChangeEnrollment Fee $15 per yr./per family No ChangeMonthly Premium $0 No ChangeOffice Visit $2 No ChangeER $5 No ChangeGeneric Drug $1-2 based on cost $0Brand Drug $1-2 based on cost $5Co-pay Cap $100 No changeDeductible, non-institutional $0 No ChangeDeductible, institutional $0 No ChangeFacility Co-pay, Inpatient(per admission)

$0 $25

Facility Co-pay, Outpatient $0 No Change

151% to 185% Current Policy ChangeEnrollment Fee $15 (1st mo's premium) No ChangeMonthly Premium $15 per mo./per family No ChangeOffice Visit $5 No ChangeER $25 $50Generic Drug $5 No ChangeBrand Drug $10 $20Deductible, non-institutional $0 No ChangeDeductible, institutional $0 No ChangeFacility Co-pay, Inpatient(per admission)

$0 $50


186% to 200% Current Policy ChangeEnrollment Fee $18 (1st mo's premium) No ChangeMonthly Premium $18 per mo./per family No ChangeOffice Visit $10 No ChangeER $35 $50Generic Drug $5 No ChangeBrand Drug $10 $20Deductible, non-institutional $50/family/outpatient $0Deductible, institutional $200/family/inpatient $0Facility Co-pay, Inpatient(per admission)

$0 $100


11

Prescription Drug Benefit

The CHIP prescription drug benefit, currently administered by the CHIP health plans, will be transferredto the Texas Vendor Drug Program (VDP), who will be responsible for administering the prescriptiondrug program for CHIP1. This transition will occur effective March 1, 2002 for Clarendon Kids CHIPPlan members.

The CHIP Prescription Drug Benefit (PDB) is not covered by this health plan. The Medicaid VendorDrug Program (VDP) administers the CHIP PDB on behalf of CHIP. The VDP makes payment forprescriptions of covered outpatient drugs only to pharmacy providers contracted to provide the CHIPPDB. The CHIP PBD is an open formulary that includes drugs prescribed for medical treatment of illnessor injuries.

The CHIP PDB does not reimburse claims for the following:

§ Over the counter drugs

§ Contraceptive medications prescribed only for the purpose of primary and preventive reproductivehealth care

§ Nutritional products

§ Medical supplies or equipment (Exception: insulin syringes are covered)

§ Products unsuitable for use outside of physician offices or health care facilities.

The VDP operates a Vendor Drug Help Desk to assist CHIP contracted providers with informationpertaining to the online status of paid and rejected claims, eligibility, and general information regardingthe CHIP PDB’s policies and procedures. The hotline is open weekdays from 8:30 a.m. to 5:15 p.m.(Central Standard Time) for providers only, at 1-800-435-4165.

Providers may contact Clarendon Kids CHIP at 1-800-971-0480 with questions about potential healthplan coverage and reimbursement of nutritional products, medical supplies and equipment.

12

COUNTY

AndersonAndrewsAngelinaArcherArmstrongBaileyBaylorBellBlancoBordenBosqueBowieBrazosBrewsterBriscoeBrownBurlesonCallahanCameronCampCassCastroCherokeeChildressClayCochranCokeColemanCollingsworthColoradoComancheConchoCookeCoryellCottleCraneCrockettCulbersonDallamDawsonDeltaDeWittDickensDimmitDonleyEastlandEctorEdwardsErath

FallsFanninFisherFoardFranklinFreestoneFrioGainesGillespieGlasscockGonzalesGrayGraysonGreggGrimesHallHamiltonHansfordHardemanHarrisonHartleyHaskellHemphillHendersonHidalgoHillHopkinsHoustonHowardIrionJackJacksonJeff DavisJonesKentKerrKimbleKingKinneyKnoxLamarLampasasLa SalleLavacaLeonLimestoneLipscombLlanoLovingMadisonMarion

MartinMasonMaverickMcCullochMcLennanMcMullenMenardMidlandMilamMillsMitchellMontagueMooreMorrisMotleyNacogdochesNolanOchiltreeOldhamPalo PintoPanolaParmerPecosPresidioRainsReaganRealRed RiverReevesRobertsRobertsonRunnelsRuskSabineSan AugustineSan SabaSchleicherScurryShackelfordShelbyShermanSmithSomervellStarrStephensSterlingStonewallSuttonTaylorTerrellThrockmorton

TitusTom GreenTrinityUpshurUptonUvaldeVal VerdeVan ZandtWardWashingtonWheelerWichitaWilbargerWillacyWinklerWoodYoakumYoungZavalaTotal: 170

13

Medical Management

The Medical Management Team

Clarendon Kids CHIP Plan is very proud of its Medical Management team. The service-focused clinical staffthat makes up this team is a valuable resource to the health plan, participating providers and members. Beassured that all records and other information relating to CHIP members which are shared with the MedicalManagement team will be held confidential in accordance with applicable federal and state laws, rules, andregulations concerning the confidentiality of medical information.

The Medical Management team offers services and resources as listed below:

Nurse Line

Clarendon Kids CHIP Plan, through the Medical Management team, offers a 24 hour 7 day a week nurse hotline.This value-added service is provided to members at no cost. It allows parents of members to speak directly witha registered nurse regarding health care questions, issues or problems.

This telephone resource is staffed by Registered Nurses (RNs) trained in triage, health information andcare coordination. AT&T language interpreter system is available through the Nurse Line allowing thenurses to translate in 94 different languages. Nurse Line RNs utilize nationally recognized protocols andphysician-customized instructions to guide assessment of a caller’s condition and offer information onappropriate care level, setting and time. These protocols include information specific to pediatric andbehavioral health needs. Calls handled by Nurse Line RNs range from 911 emergencies to instructionsfor self care at home.

Although primarily a source of information for appropriate setting and type of care, Nurse Line is also asource of general medical information for CHIP kids and their parents. In addition, these calls are alsothe source of early identification for possible care coordination, which facilitates early intervention ofservice that is so important in overall care management.

Each Nurse Line caller receives a follow up call to ensure that the outcome of the initial call is accuratelyrecorded. If a caller is referred to a physician or other provider the RN can fax a copy of informationgathered via the Nurse Line assessment to the physician.

Members can access the Nurse Line by calling 1 (877) 868-9622.

Care Coordination

Care Coordination is an enhanced, collaborative process that has been developed to work with membersand providers to enable the best use of clinical resources available to members. Care Coordination is usedto assist when members have a chronic or complex health condition that requires thorough assessmentand careful coordination, monitoring and communication.

Care Coordination works with families and providers to identify individuals that meet specific criteria forcase management intervention and acts as a liaison between the member and available clinical resourcesto assist in promoting quality, cost-effective outcomes and improved quality of life. Children withComplex or Special Health Care Needs (CCSHCN) are a good example of the types of individuals thatmay benefit from care coordination.

14

The program uses a variety of data and referral information for analysis to screen and identify childrenwith special needs. Cases are also initially screened using criteria developed by the State of Texas. IfCCSHCN are met, the child is designated as CCSHCN and placed in special care coordination for aminimum of twelve months. If the child does not meet the specific CCSHCN criteria, but would benefitfrom care coordination, he/she receives care coordination services until no longer necessary

To speak with Care Coordination call: 1 (877) 868-9621.

Prior Notification and Pre-Certification

Medical Management works with members and providers to facilitate required prior notification and pre-certification. To obtain pre-certification, call the toll free telephone number, as found on the member’s IDcard: 1 (877) 868-9621.

The pre-certification process is designed to be as simple and as straightforward as possible. Withappropriate clinical information available, most calls will result in immediate authorization. Moreover,the Medical Management team has been trained to expedite the information-gathering process so thatminimal time is spent on the phone.

Forty eight (48) hours or two (2) business days is required prior to all scheduled prior admissions orservices. For all emergent, urgent admissions or services notification is required within 48 hours or twobusiness days after admission or initiation of treatment.

Medical necessity determinations will be made within 48 hours or 2 business days of receipt of all pertinentclinical information.

Following is a list of services requiring pre-certification:

• Scheduled inpatient admissions• Inpatient rehabilitation and skilled nursing facility admissions• Inpatient mental health services• Inpatient residential and outpatient substance abuse services• Outpatient mental health services (including day treatment)• Outpatient rehab services (hospital, clinic, health center and ambulatory care services• PT, OT ST• Professional (physician extender) services• DME,prosthetics & medical supplies over $500• Home and community services• Case management services for Children with Complex Special Health Care Needs• Hospice care services – also requires physician prescription• Transplants

The criteria used for pre-certification are internally developed and maintained and have been validated byMedicaid programs in New York, Kentucky, and Ohio as well as the South Carolina and MississippiMedical Associations and validated nationally by HCFA and the Utilization Review and AccreditationCommission (URAC). Since these are proprietary criteria, they can be modified as necessary to respondto new technologies and area-specific practice patterns.

15

At the request of Behavioral Health providers, we have developed a form to be used in faxingprecertification requests. A copy of the form is included in this manual. (Please note that this is forBehavioral Health providers only.)

16

Clarendon’s Precertification RequirementsTexas CHIP Program

I. NOTIFICATION REQUIREMENTS

A. Scheduled admissions/services

Notification is required within 48 hours or 2 business days prior to admission or initiationof services.

B. Emergency/Urgent admissions/services:

Notification is required within 48 hours or 2 business days prior to admission or initiationof treatment.

C. Medical necessity determinations will be made within 48 hours or 2 business days uponreceipt of all pertinent clinical information; immediately if physician referral is notnecessary.

II. PRE-CERTIFICATION/PRIOR AUTHORIZATION REQUIREMENTS BY BENEFIT

A. INPATIENT GENERAL ACUTE INPATIENT REHABILITATION HOSPITALSERVICES

• All inpatient hospital and rehabilitation stays must be precertified.

B. OUTPATIENT HOSPITAL, COMPREHENSIVE OUTPATIENT REHABILITATIONHOSPITAL, CLINIC (INCLUDING HEALTH CENTER) AND AMBULATORYHEALTH CARE SERVICES

• All physical therapy, occupational therapy, and speech therapy services must beprecertified.

C. PROFESSIONAL (PHYSICIAN/PHYSICIAN EXTENDER) SERVICES

• None

D. PRESCRIPTION DRUGS

• Over $500.00

E. INPATIENT MENTAL HEALTH SERVICES

• All inpatient mental health services/admissions must be precertified.

F. OUTPATIENT MENTAL HEALTH SERVICES

• All outpatient mental health services, including day treatment programs must beprecertified.

17

G. DURABLE MEDICAL EQUIPMENT (DME), PROSTHETIC DEVICES ANDDISPOSABLE MEDICAL SUPPLIES

• All DME totaling over $500 per service date must be precertified.

H. HOME AND COMMUNITY SERVICES

• All home and community services must be precertified.

I. INPATIENT/RESIDENTIAL AND OUTPATIENT SUBSTANCE ABUSETREATMENT SERVICES

• All inpatient/residential and outpatient substance abuse treatment services must beprecertified.

J. CASE MANAGEMENT SERVICES FOR CHILDREN WITH COMPLEX SPECIALHEALTH CARE NEEDS

• As required by other benefits, must be precertified.

K. HOSPICE CARE SERVICES

• Requires prior authorization and Physician prescription

L. SKILLED NURSING FACILITIES (INCLUDES REHABILITATION HOSPITALS)

• All admissions to skilled nursing facilities and rehabilitation hospitals must beprecertified.

M. SERVICES INCLUDING EMERGENCY HOSPITALS, PHYSICIANS, ANDAMBULANCE SERVICES

• None

N. PROFESSIONAL VISION SERVICES

• None

O. TRANSPLANTS

• All transplants must be precertified (may require referral to a transplant center ofexcellence within the state of Texas)

P. CHIROPRACTIC SERVICES

• None

Q. NON-EMERGENCY TRANSPORTATION

18

III. APPEALS PROCESS

A. EXPEDITED APPEALS

A board certified, peer matched Physician Advisor (PA) who has not previously reviewedthe case is available by telephone within 24 hours or 1 business day of the request forappeal of a non-certification determination when the patient is receiving ongoing,imminent healthcare services.

B. STANDARD APPEALS

For a minimum of 14 days following a non-certification for medical necessity, thepatient, attending physician and/or other ordering provider, or place of service is affordedthe opportunity to have written documentation of the case re-evaluated by a boardcertified, peer matched Physician Advisor (PA) who has not previously reviewed thecase. Standard appeals are completed and written notification of the determination willbe given to the patient, attending physician or other provider, and place of service as soonas practical but within 30 days after receiving the necessary information to conduct theappeal.

19

OUTPATIENT REVIEW DOCUMENTATION GUIDEReview Date: ______________________________________ Review Contact Person: ___________________________________Facility: __________________________________________ Phone Number: ___________________________________________Patient Name: _____________________________________ ID Number: ______________________________________________DOB: _____________Immunizations current (circle one): Yes No Unknown Custody (circle one): Family or StateCLINICAL INFORMATIONAxis I Diagnoses:____________________________________________________________________________________________Axis II Diagnoses:_ __________________________________________________________________________________________Axis III Conditions: __________________________________________________________________________________________Axis IV Severity Rating (circle severity rating): Mild Moderate SevereCheck Affected Domains:

_____Primary Support Group _____Social Environment _____Educational Problems_____Occupational Problems _____Housing Problems _____Economic Problems

_____Healthcare Service Problems _____Legal/Criminal Problems _____Other ProblemsAxis V Scores: GAF_______________ Rationale: _________________________________________________________________Narrative Description of Patient’s Presenting Problems: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient’s Progress: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current Medications (type, dosage, frequency): ______________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________PATIENT HISTORYPlease circle all that apply: � Child abuse/neglect � Parent mental illness � Parent domestic violence

� Parent substance abuse € not applicablePrevious Treatment:Inpatient: Yes No Dates: _______________________Provider: ________________________________________________Outpatient: Yes No Dates: _______________________Provider: ________________________________________________TREATMENT PLANDate of Initial Evaluation: ___________________________ Performed by: ___________________________________________TREATMENT GOALS:1. __________________________________________________________________________________________________________2. __________________________________________________________________________________________________________3. __________________________________________________________________________________________________________

Service Planned(Y/N)

Clinical Focus(problem/symptom)

Frequency(times/month)

Clinician(name/educational

degree)

Location(office/home/school)

StartDate

EndDate

IndividualTherapy

Family TherapyGroup TherapySkills Training

(CircleApplicable)

� ½ hr / � 1 hr�Grp �Family

� IndividualMedication

ManagementDISCHARGE PLANCriteria to be met for discharge from treatment:______________________________________________________________________________________________________________________________________________________________________________Aftercare Plan:_________________________________________________________________________________________________________________________________________________________________________________________________________

20


Scope of BenefitsEffective 3-1-02

The Plan provides medically necessary health services for the following:

INPATIENT General Acute andINPATIENT Rehabilitation Hospital Services

• Applicable levels of co-pays apply to eachinpatient admission. $25 for families withincomes between 101% - 150%. $50 forincomes between 151% - 185%. $100 forincomes between 186% - 200%.

OUTPATIENT Hospital, OUTPATIENTRehabilitation Hospital, Clinic (includingHealth Center) and Ambulatory Health CareServices

• Co-pays and deductibles do not apply to theseservices

Physician and Physician Extender ProfessionalServices

• Applicable levels of co-pay apply to officevisits

• No co-pay for preventative visits

INPATIENT and OUTPATIENT MentalHealth Services

• Applicable levels of co-pay apply to officevisits and inpatient admissions

INPATIENT/Residential and OUTPATIENTSubstance Abuse Treatment Services

• Applicable levels of co-pay apply to officevisits and inpatient admissions

Durable Medical Equipment, ProstheticDevices and Disposable Medical Supplies

• Co-pays and deductibles do not apply to theseservices

Home and Community Health Services • Co-pays and deductibles do not apply to theseservices

Emergency Services • Applicable co-pays apply to emergency roomvisits (facility only)

Vision Benefits • Applicable level of co-pay applies to officevisits for refraction exam

Chiropractic Services • Applicable level of co-pay applies toChiropractic office visits

For complete benefit provisions, limitations and exclusions please call CustomerService at 1-800-971-0480.

21

CHIP Scope of Benefits

Covered CHIP services must meet the CHIP definition of "medically necessary." "Medically necessary" health services are:

A. Physical:

• Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that causesuffering or pain, cause physical malformation or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a Member, orendanger life;

• provided at appropriate facilities and at the appropriate levels of care for the treatment of Members' medical conditions;• consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental

agencies;• consistent with the diagnoses of the conditions; and• no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency.

B. Behavioral:

• reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder or to improve or to maintain or to preventdeterioration of function resulting from the disorder; and

• provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care.

These "medically necessary" health services:

• must be furnished in the most appropriate and least restrictive setting in which services can be safely provided;• must be provided at the most appropriate level or supply of service which can safely be provided; and• could not be omitted without adversely affecting the Member's mental and/or physical health or the quality of care rendered.

Emergency care is a covered CHIP service. “Emergency” and “emergency condition” means a medical condition of recent onset and severity, including, but notlimited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the child’s condition,sickness, or injury is of such a nature that failure to get immediate care could result in:

• placing the child’s health in serious jeopardy;• serious impairment to bodily functions;• serious dysfunction of any bodily organ or part;• serious disfigurement; or• in the case of a pregnant woman, serious jeopardy to the health of the fetus.

“Emergency services” and “emergency care” means health care services provided in an in-network or out-of-network hospital emergency department or othercomparable facility by in-network or out-of network physicians, providers, or facility staff to evaluate and stabilize medical conditions. Emergency servicesalso include, but are not limited to any medical screening examination or other evaluation required by state or federal law that is necessary to determine whetheran emergency condition exists.

There is no lifetime maximum on benefits; however, annual (a 12-month period) or lifetime limitations do apply to certain services, as specified in thefollowing chart. Deductibles and copays apply until a family reaches its specific cost-sharing maximum.

22

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or DeductibleInpatient General

Acute and InpatientRehabilitation

Hospital Services

Medically necessary services include, but are notlimited to, the following:• Semi-private room and board (or private if

medically necessary as certified by attending)• General nursing care• ICU and services• Patient meals and special diets• Operating, recovery and other treatment

rooms• Anesthesia and administration (facility

technical component)• Surgical dressings, trays, casts, splints• Drugs, medications and biologicals• Blood or blood products not provided free-of-

charge to the patient and their administration• X-rays, imaging and other radiological tests

(facility technical component)• Laboratory and pathology services (facility

technical component)• Machine diagnostic tests (EEGs, EKGs, etc)• Oxygen services and inhalation therapy• Radiation and chemotherapy• Access to TDH-designated Level III perinatal

centers or hospitals meeting equivalent levelsof care

• Hospital-provided physician services (facilitytechnical component)

• In-network or out-of-network facility andphysician services for a mother and hernewborn(s) for a minimum of 48 hoursfollowing an uncomplicated vaginal deliveryand 96 hours following an uncomplicateddelivery by caesarian section

• May require prior authorization fornon-emergency care and followingstabilization of an emergencycondition

• May require prior authorization forin-network or out-of-network facilityand physician services for a motherand her newborn(s) after 48 hoursfollowing an uncomplicated vaginaldelivery and after 96 hours followingan uncomplicated delivery bycaesarian section

Does not cover:• Infertility treatments or reproductive

services other than prenatal care,labor and delivery, and care related todisease, illnesses, or abnormalitiesrelated to the reproductive system

• Personal comfort items including butnot limited to personal care kitsprovided on inpatient admission,telephone, television, newborn infantphotographs, meals for guests ofpatient, and other articles which arenot required for the specific treatmentof sickness or injury

• Experimental and/or investigationalmedical, surgical or other health careprocedures or services which are notgenerally employed or recognizedwithin the medical community

• Treatment or evaluations required bythird parties including, but not limitedto, those for schools, employment,flight clearance, camps, insurance orcourt

• $200 annual deductible forfamilies with incomes between186% - 200% of FPL

23

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible• Custodial care• Mechanical organ replacement

devices including, but not limited toartificial heart

• Private duty nursing services whenperformed on an inpatient basis

• Hospital services and supplies whenconfinement is solely for diagnostictesting purposes, unless otherwisepre-authorized by Health Plan

Outpatient Hospital,ComprehensiveOutpatientRehabilitationHospital, Clinic(Including HealthCenter) andAmbulatory HealthCare Services

Medically necessary services include, but are notlimited to, the following services provided in ahospital clinic, a clinic or health center, or anambulatory health care setting:• X-ray, imaging, and radiological tests

(technical component)• Laboratory and pathology services (technical

component)• Machine diagnostic tests• Ambulatory surgical facility services• Drugs, medications and biologicals• Casts, splints, dressings• Preventive health services• Physical occupational and speech therapy• Renal dialysis• Respiratory Services• Radiation and chemotherapyBlood or blood products not provided free-of-charge to the patient and the administration ofthese products

• May require prior authorization andphysician prescription

• $50 annual deductible forfamilies with incomesbetween 186% - 200% ofFPL - This deductible doesnot apply to services with acopay

• Applicable level of copayapplies to prescription drugservices

• Copays and/or deductibles donot apply to preventive services

24

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or DeductiblePhysician/PhysicianExtenderProfessionalServices

Medically necessary services include, but are notlimited to, the following:• American Academy of Pediatrics

recommended well-child exams andpreventive health services (including but notlimited to vision and hearing screening andimmunizations)

• Physician office visits, inpatient andoutpatient services

• Laboratory, x-rays, imaging and pathologyservices and professional interpretation

• Medications, biologicals and materialsadministered in physician’s office

• Allergy testing• Professional component (in/outpatient) of

surgical services, including:- Surgeons and assistant surgeons for surgicalprocedures including appropriate follow-upcare- Administration of anesthesia by physician

(other than surgeon) or CRNA- Second surgical opinions- Same-day surgery performed in a hospital

without an over-night stay -Invasive diagnostic procedures such as

endoscopic examination• Hospital-based physician services

(including physician-performed technical andinterpretative components)

• In-network and out-of-network physicianservices for a mother and her newborn(s) for aminimum of 48 hours following anuncomplicated vaginal delivery and 96 hoursfollowing an uncomplicated delivery bycaesarian section

• May require prior authorization forspecialty services

Does not cover:• Infertility treatments, prostate and

mammography screening• Reproductive services other than

prenatal care, labor and delivery, andcare related to diseases, illnesses, orabnormalities related to thereproductive system

• Elective surgery to correct vision• Gastric procedures for weight loss• Cosmetic surgery/services solely for

cosmetic purposes• Out-of-network services not

authorized by the Health Plan exceptfor emergency care and physicianservices for a mother and hernewborn(s) for a minimum of 48hours following an uncomplicatedvaginal delivery and 96 hoursfollowing an uncomplicated deliveryby caesarian section

• Services, supplies, meal replacementsor supplements provided for weightcontrol or the treatment of obesity,except for the services associated withthe treatment for morbid obesity aspart of a treatment plan approved bythe Health Plan

• Acupuncture services, naturopathyand hypnotherapy

• Immunizations solely for foreigntravel

• Routine foot care such as hygieniccare

• Applicable level of copayapplies to office visits

• Copays do not apply topreventive visits or to prenatalvisits after the first visit

• Deductibles do not apply

25

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible• Diagnosis and treatment of weak,

strained, or flat feet and the cutting orremoval of corns, calluses andtoenails (this does not apply to theremoval of nail roots or surgicaltreatment of conditions underlyingcorns, calluses or ingrown toenails)

Prescription Drugs Medically necessary prescriptions include non-experimental, FDA-approved physician-prescribed drugs that are prescribed for themedical treatment of illness or injuries

• May require prior authorization forselected drugs

• If the HMO uses a closed formulary,it must provide a process forconsideration of drugs outside theformulary when medically necessary

• Excludes contraceptive medicationsprescribed only for the purpose ofprimary and preventive reproductivehealth care

• Excludes medications for weight lossor gain

• Does not cover over-the-countermedications

• Applicable level of copayapplies to a maximum 30-daysupply


Inpatient MentalHealth Services

Medically necessary services are furnished in afree-standing psychiatric hospital, psychiatricunits of general acute care hospitals and state-operated mental hospitals

• May require prior authorization fornon-emergency services

• Inpatient mental health services arelimited to:*45 days annual inpatient limit per 12month period*25 days of the inpatient benefit canbe converted to residential treatment,therapeutic foster care or other24-hour therapeutically planned andstructured services or subacuteoutpatient (partial hospitalization orrehabilitative day treatment) mentalhealth services on the basis offinancial equivalence against theinpatient per diem cost

• Copays and deductibles do notapply

26

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible*20 of the inpatient days must be heldin reserve for inpatient use only

Outpatient MentalHealth Services

Medically necessary services include, but are notlimited to:• Mental health services provided on an

outpatient basis• Medication management visits do not count

against the outpatient visit limit.

• May require prior authorization butdoes not require PCP referral

• 60 day annual limit per 12 monthperiod for rehabilitative day treatment

• 60 outpatient visits annual limit per12 month period for crisisstabilization, evaluation andtreatment, including school, home-based and outpatient hospital services(includes but not limited to seriousmental illness)

• 60 rehabilitative day treatment dayscan be converted to outpatient visitson the basis of financial equivalenceagainst the day treatment per diemcost



Durable MedicalEquipment (DME),Prosthetic DevicesandDisposable MedicalSupplies

Covered services include DME (equipment whichcan withstand repeated use, and is primarily andcustomarily used to serve a medical purpose,generally is not useful to a person in the absenceof illness , injury or disability, and is appropriatefor use in the home), devices and supplies that aremedically necessary and necessary for one ormore activities of daily living, and appropriate toassist in the treatment of a medical condition,including, but not limited to:• Orthotic braces and orthotics• Prosthetic devices such as artificial eyes,

limbs and braces• Contact lenses, when no other option is

available to correct the diagnosed visualdefect, such as keratoconus

• May require prior authorization andphysician prescription

• $20,000 per 12 month period limit forDME, prosthetics, devices anddisposable medical supplies (diabeticsupplies and equipment are notcounted against this cap)

• Authorization for more than one pairof eyeglasses (the first pair does notcount under the $20,000 cap) per 12month period and or for contactlenses when medically necessary forthe treatment of aphakia, or for headsize or prescription changes

• Health plan may reasonably limit thecost of the frames/lenses

• Co-pays and deductibles do notapply

27

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible• Hearing aides, prosthetic eyeglasses and

contact lenses• Other artificial aides including surgical

implants• Diagnosis-specific disposable medical

supplies, including diagnosis-specificprescribed specialty formulas and dietarysupplements (Refer to Attachment A)

Does not cover:• Replacement or repair of prosthetic

devices and durable medicalequipment due to misuse, abuse orloss when confirmed by the Memberor the vendor

• Corrective orthopedic shoes• Convenience items• Diagnosis and treatment of flat feet• Orthotics primarily used for athletic

or recreational purposesHome andCommunity HealthServices

Medically necessary services are provided in thehome and community and include, but are notlimited to:• Speech, physical and occupational therapy• Home infusion• Respiratory therapy• Visits for private duty nursing (R.N., L.V.N.,

block of time)• Skilled nursing visits as defined for home

health purposes (may include R.N. or L.V.N.).Skilled nursing visits are provided onintermittent level and not intended to provide24-hour skilled nursing services.

• Home health aide (under the supervision of aR.N.) when included as part of a plan of careduring a period that skilled visits have beenapproved

• May require authorization andphysician prescription

• Does not include custodial care (carethat assists a child with the activitiesof daily living, such as assistance inwalking, getting in and out of bed,bathing, dressing, feeding, toileting,special diet preparation, andmedication supervision that is usuallyself-administered or provided by aparent. This care does not require thecontinuing attention of trainedmedical or paramedical personnel.)

• Services are not intended to replacethe child's caretaker or to providerelief for the caretaker

• Skilled nursing visits are provided onintermittent level and not intended toprovide 24-hour skilled nursingservices

• Services are for blocks of time andare not intended to replace 24-hourinpatient or skilled nursing facilityservices

• Housekeeping


28

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible• Public facility services and care for

conditions that federal, state, or locallaw requires be provided in a publicfacility or care provided while in thecustody of legal authorities

• Services or supplies received from anurse, which do not require the skilland training of a nurse

Inpatient/Residential andOutpatientSubstance AbuseTreatment Services

Medically necessary services include residentialrehabilitation and outpatient substance abusetreatment services. These services do not require aprimary care provider referral, however theservices may require prior authorization by thehealth plan and include, but are not limited to:• Prevention and intervention services that are

provided by physician and non-physicianproviders, such as screening, assessment andreferral for chemical dependency disorders,hospital inpatient/residential services

Screening, assessment, and referral refers toa package of services provided by an independentQualified Credentialed Counselor (QCC) or afacility/STP (e.g., councils on alcoholism anddrug abuse or mental health clinics).

Screening: A brief informational processconsisting of an interview and application of avalidated and reliable instrument which providesinformation needed to determine if a potentialchemical dependency problem exists andchemical dependency assessment is warranted.Screening must be conducted by a QCC or alicensed health professional.

• May require authorization ofnonemergency services

• 14 days annual limit detox/crisisstabilization

• 24-hour residential rehabilitationprogram up to 60 days per episode.[30 days must be held in reserve but30 days (in addition to benefitsbelow) may be converted to 60 dayspartial hospitalization, 90 daysintensive outpatient rehabilitation or90 days of outpatient services]

• Maximum of three inpatient and/orresidential episodes per plan lifetime(please define and inform the planshow to track)

• Intensive outpatient program (up to12 weeks per episode)

• Outpatient services (up to six months perepisode)

• Maximum of three outpatientepisodes per plan lifetime

Aftercare for chemical dependencyservices such as, but not limited to,AA/NA, non-QCC support or educationgroups, and/or other services thatprimarily focus on relapse prevention tothe Member who completed treatmentand/or their family members



29

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible

Assessment: The clinical process of obtaining andevaluating information to determine if anindividual meets the DSM-IV criteria forsubstance abuse or dependence and is need oftreatment. The assessment also determines thelevel of treatment most appropriate for theindividual. Assessment must be conducted by aQCC.

Referral: The process of identifying appropriateservices and providing the information, assistance,and follow-up needed to access them.

Prevention/ Intervention (Selective andIndicated Prevention) Services refer toPrograms or counseling designed to preclude orinterrupt the use of alcohol and other drugs byenhancing protective factors and reducing riskfactors.

An “episode” of treatment is a planned,structured, and organized set of servicesdesigned to help individuals achievechemical-free status and significantimprovements in psychological, familial,and social functioning. An episode of carenormally includes multiple providers,programs, and/or levels of care in thebenefit plan. It is considered completewhen:1) The client achieves treatment goals, isdischarged in accordance with therecommendation of a physician and/orQCC without a referral for continuingcare, and maintains abstinence for aperiod of 90 days; OR2) A physician or QCC determines thatthe client will not benefit from furthertreatment and discharges the clientwithout a referral for continuing care;OR3) A client leaves treatment againstprofessional advice and does not seekfurther treatment (from that provider oranother behavioral health servicesprovider); OR4) A client fails to enter the next level oftreatment recommended by the Physicianor QCC when capacity is available.A set of services of less than one month induration is not counted against theMember’s three-episode limit per planlifetime, however, the maximum 24-hourresidential rehabilitation program planlifetime benefit shall not exceed 180 daysunder any circumstance

30

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or DeductibleCase ManagementServices forChildren withComplex SpecialHealth Care Needs(CCSHCN)

Medically necessary above and beyond thosenormally provided to all members including, butnot limited to:• Outreach and informing – Includes discussion

of covered services (including specialtyservices) with the family, the possibility of thefamily's right to select a in-network specialistas a primary care provider, out-of-networkservices applicable to the child's condition ifnot available in network, the availability ofenhanced care coordination and communityreferrals

• Enhanced care coordination – Includesresponding to a family’s request forcoordination activities or suggesting thisservice to the family where appropriate.Services are delivered at an administrativelevel and to facilitate overall care

• Intensive case management - Trained casemanagers (nurses or social workers) providecase management activities such as intake,assessment of services needed, and writtendocumentation of individual plan specifyingassistance with accessing services andperiodic reassessment. A PCP or specialistapproves a formal written plan of care

• Community Referrals - The HMO works toenlist and establish relationships withcommunity organizations to promoteimproved referrals and service delivery toincrease the health and wellbeing of Members.

Available to children meeting thefollowing established CCSHCN criteria,as determined by the Health Plan. Thechild must:• Have serious ongoing illness, a

complex chronic condition, or adisability that has lasted or isanticipated to last at least twelvecontinuous months or more;

• Have an illness, condition ordisability that results (or withouttreatment would be expected to result)in limitation of function, activities, orsocial roles in comparison withaccepted pediatric age-relatedmilestones in the general areas ofphysical, cognitive, emotional, and/orsocial growth and/or development;

• Require regular, ongoing therapeuticintervention and evaluation byappropriately trained health carepersonnel; and

• Have a need for health and/or relatedservices at a level significantly abovethe usual for the child’s age


RehabilitationServices

Medically necessary habilitation (the process ofsupplying a child with the means to reach age-appropriate developmental milestones throughtherapy or treatment) and rehabilitation servicesinclude, but are not limited to, the following:• Physical, occupational and speech therapy• Developmental assessment


• Reimbursement for school-basedservices are not covered except fortherapy services ordered by the PCP


31

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or DeductibleHospice CareServices

Medically necessary hospice services include, butare not limited to:• Palliative care, including medical and support

services, for those children who have sixmonths or less to live, to keep patientscomfortable during the last weeks and monthsbefore death

• Treatment for unrelated conditions isunaffected


• Services apply to the hospicediagnosis

• Up to a maximum of 120 days with a6 month life expectancy

• Patients electing hospice serviceswaive their rights to treatment relatedto their terminal illnesses; however,they may cancel this election atanytime


Skilled NursingFacilities(IncludesRehabilitationHospitals)

Medically necessary services include, but are notlimited to, the following:• Semi-private room and board• Regular nursing services• Rehabilitation services• Medical supplies and use of appliances and

equipment furnished by the facility

• 60 day annual limit per 12 monthperiod

• Private duty nurses, television andcustodial care are excluded



Tobacco CessationPrograms

• Covered up to a $100 limit for a plan-approved program per 12 month period

• Health Plan defines plan-approvedprogram

• May require authorization• Over the counter drugs are not

coveredMay be subject to formulary requirements


Emergency Services,includingEmergencyHospitals,Physicians, andAmbulance Services

Health plan cannot require authorization as acondition for payment for emergency conditionsor labor and delivery. Medically necessarycovered services include:

• Emergency services based on prudent layperson definition of emergency healthcondition

Hospital emergency department room andancillary services and physician services 24 hoursa day, 7 days a week, both by in-network and out-of-network providers

• May require authorization for post-stabilization services

• Applicable copays apply toemergency room visits(facility only)


32

Type of Benefit Description of Benefit Limitations and/or Exclusions Co-Pay and/or Deductible• Medical screening examination• Stabilization services• Access to TDH designated Level I and

Level II trauma centers or hospitalsmeeting equivalent levels of care foremergency services

• Emergency ground, air or watertransportation

Vision Benefit Medically necessary services include:• One examination of the eyes to determine the

need for and prescription for corrective lensesper 12 month period, without authorization

• One pair of nonprosthetic eyewear per 12month period

• The health plan may reasonably limitthe cost of the frames/lenses

• Vision training and vision therapy areexcluded

• Applicable level of copayapplies to office visits billed forrefractive exam


Transplants Medically necessary services include:Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplantsand all forms of non-experimental corneal, bonemarrow and peripheral stem cell transplants,including donor medical expenses

• Does not cover donor non-medicalexpenses

• May require authorization• Charges incurred as a donor of an

organ when the donee is not coveredunder this health plan


ChiropracticServices

Medically necessary services do not requirephysician prescription and are limited to spinalsubluxation

• Maximum of 12 visits per 12 monthperiod (regardless of number ofservices or modalities provided in onevisit)

• May require authorization foradditional visits

• Applicable level of copayapplies to chiropractic officevisits


33

CHIP DME/SUPPLIES

SUPPLIES COVERED EXCLUDED COMMENTS/ PROVISIONSAce Bandages X Exception: If provided by and billed through the clinic or home care agency it is

covered as an incidental supply.Alcohol, rubbing X Over-the-counter supply.Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing..Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies.Ana Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings.Arm Sling X Dispensed as part of office visit.Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and

used to provide care for a covered diagnosis as outlined in a treatment care planBandages XBasal Thermometer X Over-the-counter supply.Batteries – initial X For covered DME itemsBatteries – replacement X For covered DME when replacement is necessary due to normal use.Betadine X See IV therapy supplies.Books XClinitest X For monitoring of diabetes.Colostomy Bags See Ostomy Supplies.Communication Devices XContraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan.Cranial Head Mold XDiabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and

glucose strips.Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and

used to provide care for a covered diagnosis as outlined in a treatment care planDiaphragm X Contraceptives are not covered under the plan.Diastix X For monitoring diabetes.Diet, Special XDistilled Water X

Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Manytimes these items are dispensed in a kit when includes all necessary items for onedressing site change.

Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care.Dressing Supplies/Peripheral IVTherapy

X Eligible for coverage only if receiving home IV therapy.

Dressing Supplies/Other X

34

SUPPLIES COVERED EXCLUDED COMMENTS/ PROVISIONSDust Mask XEar Molds X Custom made, post inner or middle ear surgeryElectrodes X Eligible for coverage when used with a covered DME.Enema Supplies X Over-the-counter supply.Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for

coverage. Enteral nutrition products are not covered.Eye Patches X Covered for patients with amblyopia.Formula X Eligible for coverage only in certain chronic disorders (expected to last longer than 60

days when prescribed by the physician and authorized by plan. Physiciandocumentation to justify prescription of formula must include:

• Identification of a metabolic disorder requiring a medically necessarynutritional product or

• Indication that part or all nutritional intake is through a tube (for example,nasogastric or gastrostomy/jejunostomy) or

• Identification/explanation of the medical condition resulting in the requirementfor a formula

Does not include formula :• For members who could be sustained on an age-appropriate diet.• Traditionally used for infant feeding• In pudding form (except for clients with documented oropharyngeal motor

dysfunction who receive greater than 50 percent of their daily caloric intakefrom this product)

• For the primary diagnosis of failure to thrive, failure to gain weight, or lack ofgrowth or for infants less than twelve months of age unless medical necessity isdocumented and other criteria, listed above, are met.

Gloves X Exception: Central line dressings or wound care provided by home care agency.Hydrogen Peroxide X Over-the-counter supply.Hygiene Items XIncontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and

used to provide care for a covered diagnosis as outlined in a treatment care planInsulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for

coverage if the pump is a covered item.Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care.Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter.IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related

supplies necessary for home IV therapy.

35

SUPPLIES COVERED EXCLUDED COMMENTS/ PROVISIONSK-Y Jelly X Over-the-counter supply.Lancet Device X Limited to one device only.Lancets X Eligible for individuals with diabetes.Med Ejector XNeedles and Syringes/Diabetic See Diabetic SuppliesNeedles and Syringes/IV andCentral Line

See IV Therapy and Dressing Supplies/Central Line.

Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered athome.

Normal Saline See Saline, NormalNovopen XOstomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier,

filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesiveremover, and pouch deodorant.Items not eligible for coverage include: scissors, room deodorants, cleaners, rubbergloves, gauze, pouch covers, soaps, and lotions.

Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coveragewhen the parenteral nutrition has been authorized by the Health Plan.

Saline, Normal X Eligible for coverage:a) when used to dilute medications for nebulizer treatments;b) as part of covered home care for wound care;c) for indwelling urinary catheter irrigation.

Stump Sleeve XStump Socks XSuction Catheters XSyringes See Needles/Syringes.Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies.Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage.Under Pads See Diapers/Incontinent Briefs/Chux.Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge

when applied during office visit.Urinary, External Catheter &Supplies

X Exception: Covered when ordered by the PCP and approved by the plan

Urinary, Indwelling Catheter & X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal

36

SUPPLIES COVERED EXCLUDED COMMENTS/ PROVISIONSSupplies saline if needed.Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization.Urine Test Kit X When determined to be medically necessary.Urostomy supplies See Ostomy Supplies.

37

PROVIDER REFERRAL FORM

USA is committed to providing a seamless continuum of care network. To this end, we encourage you to fillout this provider referral form with those colleagues and facilities to which you refer cases.

Name and Address: Name and Address:__________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________________________________Phone:____________________________________ Phone:____________________________________Contact:___________________________________ Contact:___________________________________Specialty:__________________________________ Specialty:__________________________________





Facility name and Address: Facility name and Address:__________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________________________________Phone:____________________________________ Phone:____________________________________Contact:___________________________________ Contact:___________________________________

38

CHILDREN’S HEALTH INSURANCE PROGRAM

IDENTIFICATION TOOL

For Children with Complex Special Health Care Needs

Child’s Name: ________________________________

Child’s Address: ______________________________

Child’s Phone: _______________________________

Health Plan: _________________________________

PCP: _______________________________________

Child’s ID #: _________________________________

1 Is your child restricted or prevented in any way in his/her ability to do the thingsmost children of the same age can do?

YES(If YES, go to 1A)

NO(If NO, go to 2)

1A Is this because of ANY medical, behavioral or other health condition lasting orexpected to last for at least 12 months?

YES NO

2 Does your child currently need or use any of these (check all that apply):

(Note: a YES for ANY of the items listed below (a-d) will qualify as a YES response for question 2.)

YES(If YES to any (a-d) listed below go

to 2A)

NO(If NO, to all, go to 3)

a. Medicines prescribed by a doctor other than vitaminsb. Mental health treatment or counselingc. Physical, speech, or occupational therapyd. Special equipment (for example: to help moving, walking, talking,

hearing, breathing, feeding, personal care, etc.)2A Is this because of ANY medical, behavioral or other health condition lasting or

expected to last for at least 12 months?YES NO

3 Does your child currently have these (check all that apply):

(Note: a YES for ANY of the items listed below (a-d) will qualify as a YES response for question 2.)

YES(If YES to any (a-d) listed below go

to 3A)

NO(If NO, to all, go to 4)

a. Life-threatening allergic reactionsb. A special diet prescribed by a doctorc. A learning or behavioral difficulty for which he or she receives

professional treatment or counselingd. Early Childhood Intervention (ECI), Special Education or Rehabilitation

services3A Is this because of ANY medical, behavioral or other health condition lasting or

expected to last for at least 12 months?YES NO

4 Does your child need or use more medical care, mental health or educationservices than usual or routine for most children of the same age?

YES(If YES, go to 4A)

NO

4A Is this because of ANY medical, behavioral or other health condition lasting orexpected to last for at least 12 months?

YES NO

ADDITIONAL INFORMATION:Please provide diagnosis information, if available.

Primary: _____________________________________________________________

Secondary: ___________________________________________________________

TexCare Partnership

Children’s Health Insurance to Fit Your Budget

39

May 17, 2000

TO: All Clarendon KIDS CHIP Providers

As a provider in the Clarendon KIDS CHIP Plan you are eligible to receive free vaccines through theTexas Department of Health (TDH) Texas Vaccines for Children Program (TVFC). The ClarendonKIDS CHIP Plan will only reimburse providers for the administration of the vaccine since this program isavailable to you. If you choose not to participate you will be providing the vaccine at your own expense.

Vaccines for the Clarendon KIDS CHIP plan will be purchased through and distributed by the TDHTVFC. To take advantage of this free vaccine, all CHIP providers who provide vaccines must be enrolledin the TVFC.

If you are not enrolled and receiving vaccines from the TVFC, please enroll immediately. Attached arecopies of the following TVFC forms: Provider Enrollment, Provider Profile, Provider Listing, and PatientEligibility Screening Record. These forms must be filled out to enroll in the TVFC. All newly-enrollingCHIP providers who will be providing vaccine must return the completed enrollment forms to the TDHImmunization Division ASAP so that training may be provided for you. After you have submitted thecompleted enrollment forms, TDH regional staff or local health department/district staff will contact youto schedule training in your office. This training requires about 1 hour of your time. Return yourenrollment forms to:

Texas Department of HealthImmunization DivisionAttn: Cathy Gleasman

1100 W. 49th StAustin, Texas 78756-3199

OR FAX TO: (512) 458-7512Attn: Cathy Gleasman

For assistance in completing the enrollment forms, you may contact these Immunization Division staff:Mr. Jack Sims or Ms. Cathy Gleasman at (512) 458-7284 or toll-free at (800) 252-9152.

Sincerely,


Attachments

40

TEXAS VACCINES FOR CHILDREN PROGRAM: PROVIDER ENROLLMENT CHIP

This record is to be submitted to the Texas Department of Health and must be updated in accordance with State policy.

Name of Facility or Clinic: ___________________________________________________________________________________

Provider Name: _ (Last Name) (First Name) (MI) (Title)

Contact: __________________________________________________________________________________________________

(Last Name) (First Name) (MI) (Title)

Mailing Address: ___________________________________________________________________________________________

(P.O. Box or Street Address) (City) (Zip)

Address for Vaccine Delivery:_________________________________________________________________________________

(Street Address) (Suite Number) (City) (Zip)

Telephone Number: (_______)_________-___________ Fax Number: (________)________-_____________

Provider Identification Number (Medical License Number):

In order to participate in the Texas Vaccines for Children Program and/or to receive federally and state-supplied vaccines provided to me at no cost, I, on behalf of myself andany and all practitioners associated with this medical office, group practice, health department, community/migrant/rural health clinic, or other organization of which I am thephysician-in-chief or equivalent, agree to the following:

1. Before administering vaccines obtained through the Texas Vaccines for Children Program, my office will determine VFC eligibility. The PatientEligibility Screening Form will be provided to the parent or guardian to declare each child’s eligibility.

2. My office will maintain records of the parent/guardian/authorized representatives responses on the Patient Eligibility Screening Form for a periodof 3 years, unless State requirements call for a longer duration. If requested, my office will make such records available to the Texas Department of Health(TDH), the local health department/authority or the U.S. Department of Health and Human Services.

3. My office will comply with the appropriate immunization schedule, dosage, and contraindications, as established by the Advisory Committee onImmunization Practices, unless (a) in making a medical judgment in accordance with accepted medical practice, my office deems such compliance to bemedically inappropriate, or (b) the particular requirement is not in compliance with Texas Law, including laws relating to religious and medicalexemptions.

4. My office will provide Vaccine Information Statements to the responsible adult, parent, or guardian and maintain records in accordance with theNational Childhood Vaccine Injury Act. (Signatures are required for the Vaccine Information Statements for each vaccine type administered.)

5. My office will not charge for vaccines supplied by TDH and administered to a child who is eligible for the Texas Vaccines for Children Program.

6. My office may charge a vaccine administration fee. My office will not impose a charge for the administration of the vaccine in any amount higherthan the maximum fee established by TDH. Medicaid patients cannot be charged for the vaccine, administration of vaccine, or an office visit associatedwith Medicaid services.

7. My office will not deny administration of a Texas Vaccines for Children Program vaccine to a child because of the inability of the child’s parent orguardian/individual of record to pay an administrative fee.

8. My office will comply with the State=s requirements for ordering vaccine and other requirements as described by TDH.

9. My office will make certain that parents or guardians have the opportunity to approve or decline that their child’s immunization information beincluded in the statewide immunization registry.

10. My office or the State may terminate this agreement at any time for personal reasons or failure to comply with these requirements.

______________________________________________ ____________________________

(Provider Signature) (Date)

41

Please list all providers within the practice participating in the TVFC

CHIPLAST NAME FIRST

NAMEMIDDLEINITIAL

TITLE MEDICALLICENSENUMBER

MEDICAIDPROVIDERNUMBER

SPECIALTY

42

Public and private TVFC providers must complete the front and back of this form annually, and/or when the clinic typechanges (for example: a private provider becomes an agent of a Federally Qualified Health Center).Date: A. Name of Facility or Clinic:

B. Provider Name (Physician-in-Charge)

C. Vaccine Shipping Address:(Street Address) (City) (Zip) (County)

D. Phone Number ( ) -E. Is your facility a Federally Qualified Health Center (Migrant or Rural Health clinic)? (circle one) YES NOF. Type of Clinic: (ü check one)

o Public Health Department/District o Private Hospital

o Public Hospital o Private Practice (Individual or Group)

o Other Public Clinic o Other Private Clinic

G. PATIENT PROFILE:<1

year old1-6

years old7-18

years old19+

years oldTotal

TOTAL PATIENTS:Please enter the number of children, by age group whowill receive vaccinations at your clinic in Calendar Year2000.

H. Categories of Children Eligible for the Texas Vaccines for Children Program:Of the total numbers of children entered in Section G, please enter the number of children for each of the followingcategories by age group (the numbers below added together should equal the entries in Category G above):

NUMBER OF CHILDREN IN EACH CATEGORY <1year old

1-6 years old

7-18 years old

19+ years old

Total

a. Number Enrolled in Medicaid

b. Uninsured (Note: Children enrolled in Health MaintenanceOrganizations are considered insured.)c. Number of American Indiansd. Number of Alaskan Nativese. Underinsuredf. Children who do not meet any of the above criteria, but stillreceive immunizations at public health clinicsg. Children who receive benefits from the Childrens HealthInsurance Plan (CHIP)

43

TEXAS VACCINES FOR CHILDREN PROGRAMPATIENT ELIGIBILITY SCREENING RECORD CHIP

Purpose: To determine eligibility and the source of funds for the Texas Department of Health to be reimbursed forvaccines.

A record must be kept in the office of the health care provider that reflects the status of all children 18 years of age oryounger, who receive immunization through the Texas Vaccines for Children Program. The record may be completed bythe parent, guardian, or individual of record, or by the health care provider. This same record may be used for allsubsequent visits as long as the child’s eligibility status has not changed. While verification of responses is not required,it is necessary to retain this or a similar record for each child receiving vaccines.

Date of Screening: ______________________

Child’s Name: ______________________________________________________________________________ Last Name First Name MI

Child’s Date of Birth: / /

Parent/Guardian/Individual of Record: ________________________________________________________________________ Last Name First Name MIProvider’s Name: ___________________________________________________________________________

The above named child qualifies for vaccines through the Texas Vaccines for Children Program because he/she (check1st category that applies, check only one):

o (a) is a patient who receives benefits from the Children’s Health Insurance Plan (CHIP)

o (b) enrolled in Medicaid or

o (c) does not have health insurance or

o (d) is an American Indian or

o (e) is an Alaskan Native or

o (f) is underinsured (has health insurance that Does Not pay for vaccines) & routinely referred to a FederalQualified Health Center or Rural Health Clinic for immunizations or

o (g) is underinsured (has health insurance that Does Not pay for vaccines) & routinely referred to a facilitythat is not a Federally Qualified Health Center or Rural Health Clinic for immunizations or

o (h) is a patient who is served by any type of public health clinic and does not meet any of the abovecriteria

“I have been given a copy of the Vaccine Information Statement for each vaccine that will be received today. I have readthis information or someone has told me what it says. I know the benefits and risks of the vaccine. I also know the risksof the disease the vaccine prevents. I ask that the vaccine or vaccines checked be given to me or to the child for whom Ican consent. I agree that the information on this record may be given to school, officials, public health officials,authorized governmental agencies, and other health care staff.”

__________________________________________ (Parent/Guardian signature)

k:\vaccine\vfc\txscreen Revised 02-07-00

44

The TexCare Partnership has a provider hotline to assist your network providers with confirmation ofcoverage for CHIP members. Instructions for accessing the hotline are attached to this letter. Please notethat providers must have a Provider ID number to access the automated voice response system. TheTexCare Partnership issues each participating health plan a unique Provider ID number for this purpose.Please make this number available to all of your network providers so they can access the system. TheClarendon National Insurance Company Provider ID number to be used with the eligibility hotline is:99991.

If you have questions or need help, call me at 1-512-336-3336. I am available Monday through Fridaybetween 8:00 a.m. and 5:00 p.m. Thank you for your attention to this matter.

Sincerely,

Steven P. DavisHealth Plan Liaison

45

PROVIDER HOTLINECHIP Member Eligibility Information Service

1-800-645-7164

In order to use the hotline to determine if a member is currently enrolled in CHIP, providers must have the5-digit Provider ID Number and either the 9-digit CHIP Member ID Number or the CHIP Member SocialSecurity Number.

When providers call the hotline, they will receive the following prompts:

1. The caller is prompted to select English or Spanish.2. The caller is prompted to verify CHIP member eligibility by Automated Voice System or

by speaking with a Provider Service Representative.3. The caller is prompted to enter the Provider ID number.4. The caller is prompted to confirm the Provider ID number.5. The caller is prompted to select an option to have the inquiry results Faxed, or reported

using the Automated Voice System.• The FAX option will not report the inquiry results using the automated voice system,

but will fax a hard copy to the caller• The AUTOMATED VOICE SYSTEM will not produce a hard copy of the inquiry

results, but will return the results immediately6. The caller will be prompted to direct the inquiry by CHIP member ID or CHIP member

Social Security number.7. The caller is prompted to confirm the CHIP member ID or Social Security number.

• The hotline searches the database and returns the following information by fax or byautomated voice system:• The child’s enrollment status (enrolled, not enrolled, or application pending)• If the child is enrolled, the following information will be provided:

1) Child’s enrollment START DATE2) Child’s enrollment END DATE3) Child’s HEALTH PLAN

8. The caller is prompted to request eligibility information for another child (up to 10children) or exits the system.

46

Requirements by which Providers are Governed

I. All providers participating in the EPO network agree to provide health care services in conformitywith accepted prevailing medical, surgical, chiropractic, physical therapy and mental health/substanceabuse practices in the community in which Provider practices. Provider also agrees to meet and complywith the below credentialing standards as set forth by USA MCO. Clarendon recognizes the professionalstandards/guidelines of practice as established by AAP, AAFP, ACIP, USPHS, ACOG or otherprofessional specialty organization(s) under which the physician or physician extender practices.Clarendon expects that each provider will deliver care consistent with the standards/guidelines appropriateto his/her scope of practice and the requirements by which providers in the EPO Network are governed

A. Applicants are subject to a credentialing process and must minimum standards forparticipation. This is an ongoing process and is updated regularly. The following list of“Core Competencies” is required for physicians and allied health professionals. Allied HealthProfessionals are defined as: psychologists and mental health/substance abuse clinicians,optometrists, physical therapists, audiologists, speech/language pathologists, physicianassistants, certified registered nurse anesthetists, nurse practitioners, registered nurses andchiropractors. Those applicants not able to meet the following standards, will not beconsidered for Network participation.

Physicians:

1. Physicians must be graduates of an accredited allopathic or osteopathic medical school;

2. Physicians must have completed an approved residency program.

3. Physicians must possess a current, unrestricted license to practice medicine;

4. Physicians must possess a current, valid, unrestricted DEA/CDS license (if thephysician’s scope of practice allows prescribing);

5. Physicians must maintain current, adequate malpractice insurance;

6. Physicians must not have been convicted of any felonies;

7. Physicians must not have been convicted of any fraud; and

8. Physicians requiring certification by State Workers’ Compensation boards must maintaincurrent adequate certification, if participating in USA’s Workers Injury Network.

Allied Health Professionals:

1. Applicants must be graduates of an accredited post graduate program;

2. Applicants practicing the specialties listed below must possess the followingcertifications or educational requirements:

a. Mental health/substance abuse clinicians, audiologists, speech/language pathologistsmust have completed a minimum of a Master’s level degree.

b. Speech/language pathologists must have a Certificate of Clinical Competence (CCC)established by ASHLA.

c. Providers requiring certification by State Workers’ Compensation boards mustmaintain current, adequate certification, if participating in USA’s Workers InjuryNetwork.

3. Applicants must possess a current, unrestricted license to practice;

4. If the applicant’s scope of practice allows prescribing, the applicant shall possess acurrent, valid, unrestricted DEA/CDS license;

47

If the applicant’s scope of practice does not allow prescribing, this requirement shall bewaived.

5. Applicants must maintain current, adequate malpractice insurance;

6. Applicants must not have been convicted of any felonies;

7. Applicants must not have been convicted of any fraud; and

8. Applicants must provide two letters of recommendation from authoritative personnel,personally acquainted with the applicant’s professional and clinical performance either ina teaching facility or in other healthcare settings.

B. All applicants must meet the following “Competency” standards. Those not meeting thecompetency standards will be referred to the USA Medical Director and/or USA/MCOCredentials Committee for review and evaluation. Evaluations and participation decisionswill be made on an individual basis, and in response to documented local needs.

1. Applicants must have the ability to demonstrate a history of no license restrictions,modifications, revocations and/or history of probation.

Applicants with a history of license restrictions, modifications, revocations and/orprobation may be considered with the following supporting documentation;

a) Narrative statements from the applicant addressing previous license restrictions,probation, suspensions, modifications and/or revocations, together with any otherdocumentation as may be requested by the Medical Director and/or CredentialsCommittee.

2. Applicants must not possess a history of chemical dependency or substance abuse.

Applicants with a history of chemical dependency or substance abuse may be consideredwith the following supporting documentation:

a) Narrative statements from the applicant addressing the chemical dependency and/orsubstance abuse issues and any other documentation as may be requested by theMedical Director and/or Credentials Committee.

3. Applicants must not possess a history of physical or mental illness that has the potentialto affect the applicant’s ability to function as a physician.

Applicants with a history of physical or mental illness may be considered with thefollowing supporting documentation:

a) Narrative statements from the applicant addressing the physical or mental illnessissues and any other documentation as may be requested by the Medical Directorand/or Credentials Committee.

4. Applicants must not possess a history of unprofessional conduct or involvement indisciplinary action by any hospital, medical society or state licensing agency including,but not limited to, receipt of letters of concern, admonition or censure.

Applicants with a history of disciplinary action or unprofessional conduct may beconsidered with the following documentation:

a) Narrative statements from the applicant addressing unprofessional conduct issues ordisciplinary action including, but not limited to, receipt of letters of concern,admonition or censure and any other documentation as may be requested by theMedical Director and/or Credentials Committee.

5. Applicants must not possess a history of malpractice/negligence settlements orjudgments.

48

Applicants with a history of malpractice/negligence settlements or judgments may beconsidered with the following supporting documentation:

a) Narrative statements from the applicant addressing the settlement and/or judgmentissues and any other documentation as may be requested by the Medical Directorand/or Credentials Committee.

C. Provider Notification of Declination or Termination

The determination granted by the Medical Director and/or Medical Review Committee iscommunicated to the provider in writing. Termination letters are sent via certified mail withreturn receipt requested. The envelopes for both Termination and Declination letters areclearly marked “Personal and Confidential.”

D. Provider’s Right to Appeal

1. An appeals process is available to providers notified of non-acceptance. Uponnotification, the provider has fifteen (15) business days to submit supplementaldocumentation for further review.

2. The Medical Director shall conduct such further investigations, including non-hearings orother proceedings, as deemed necessary and appropriate. Upon completion of theMedical Director's review, a written decision is sent to the provider. Additional licensedindependent practitioners actively practicing in the network are included in the decisionprocess as necessary. This decision shall be the final decision of acceptance or non-acceptance into the USA Network.

3. Providers not accepted may re-apply for network participation, two (2) years from thedate of the final non-acceptance notification.

E. Application

1. All Providers are required to submit an application to be considered for participation inUSA’s Provider Networks. The initial application process must include attestations thatall “Core Competencies” and “Competency” standards are met. If supportingdocumentation is required to meet a “Competency” standard, the documentation will beattached.

2. All Providers are required a signed Credential Verification Release Form.

3. Additional information may be obtained from recognized monitoring organizations. Thismay include, but is not limited to, the following:

a. Staff Roster from JCAHO accredited facility;

b. Staff Roster from JCAHO recognized facility with declaration; and

c. National Practitioner Data Bank (NPDB).

F. Attestations

1. All agreements include an attestation statement. By signing the agreement, the provideris stating that all information supplied to USA and/or contained within the providerapplication is true and correct. Providers must agree to practice within the scope of theirlicensure.

II. Provider agrees to utilize participating facilities, providers, and ancillary services (i.e., laboratory,x-ray, ultrasound, Hubbard Tank, isokinetic equipment, etc.) when not available in Provider’soffice and when consistent with good medical practice.

III. Provider agrees to perform pre-admission testing whenever INSURED is to be hospitalized.

IV. Provider agrees to encourage the use of generic drugs, whenever medically possible, and when inthe best interest of the patient.

49

V. Provider agrees not to bill separately for components of a procedure to increase reimbursement.

VI. While Utilization Management is primarily conducted by telephone, certain situations may requirean on-site visit. Should this occur, Provider agrees to accept Utilization Review Representativeson Provider’s office setting for the purpose of reviewing medical records pertinent to continuedstay or retrospective review of INSURED. Utilization Review Representatives agree to conductreviews in accordance with Provider's policies.

VII. Provider agrees to promote and implement the appropriate treatment of an INSURED that willencourage the timely return to a quality standard of life as well as employment.

VIII. Provider agrees to follow treatment guidelines equivalent to those required by the state in whichProvider provides services or as outlined by Provider’s specialty.

IX. Provider agrees to ONLY provide those services medically necessary to effectively treat anINSURED and ONLY provide treatment that does not constitute “maintenance care”.Maintenance care is defined as treatment that has no definable condition and the treatment goal isonly to maintain INSURED’S condition of health. Provider agrees to ONLY perform those testswhich are needed to properly diagnose and treat INSURED.

X. Current INSURED medical records shall be made available by Provider, upon request, with properpatient authorization, for the purpose of concurrent review and retrospective review in accordanceSection 5 of the contract.

50

CHIP Health Care Provider Marketing Policy3/9/00

Background

The CHIP application process is separate and distinct from the enrollment process. During application, a familywith uninsured children completes the TexCare Partnership application or calls the TexCare Partnership hotline. TexCare Partnership is the umbrella outreach campaign targeted to all families with uninsured children, regardlessof income or citizenship status.

When a family applies to TexCare Partnership, they will be linked to the appropriate children’s health insuranceprogram based on family size, income, and citizenship status. Some families will be referred to Medicaid, somewill be determined eligible for CHIP, and others will be referred to the Texas Healthy Kids Corporation.

Families with CHIP-eligible children must complete an enrollment form in which they choose a health plan andPrimary Care Provider (PCP) and pay the applicable cost-sharing obligation. In areas covered by the EPO(Exclusive Provider Organization), the children will be enrolled in the EPO without any PCP selection.

The following CHIP provider marketing policy is consistent with Texas Department of Insurance standards.

CHIP Provider Marketing Policy

♦ Health care providers may undertake a variety of activities designed to encourage families to apply to theTexCare Partnership. Examples include, but are not limited to:

ü Displaying posters, brochures, or other written materialü Distributing application booklets to families with uninsured childrenü Playing a video that promotes TexCare Partnershipü Informing their patients of the toll-free TexCare Partnership hotline

♦ Providers may educate their patients about TexCare Partnership or CHIP specifically.

♦ Providers may not promote the selection of specific health plans within the context of the CHIPenrollment process.

♦ Providers may not assist families in filling out the health plan selection form.

♦ Providers may not distribute health plan marketing materials in their offices.

Patient Education Procedures

♦ Providers may inform their patients regarding the plans in which they participate.

♦ Providers may inform their patients of the benefits, services, and specialty care providers offer throughthe CHIP plans in which they participate.

♦ At the patients’ request, providers may give patients the information necessary to contact a particularhealth plan.

51

♦ Providers may distribute or display written health educational materials or health related posters (no largerthan 16 x 24) provided it is done for all plans in which the providers participate; these materials may havethe health plan’s name, logo, and phone number.

♦ Providers may display plan stickers (no larger than 6”x 8”) indicating they participate with a particularHealth Plan as long as they do not indicate anything more than “health plan is accepted or welcomedhere.” In the case of CHIP-specific materials, stickers must feature the TexCare Partnership logo.

52

53

54

55

GLOSSARY

The following terms may help you in understanding the Clarendon Kids CHIP Plan. In the event thereis anything you do not understand about the terms outlined herein, please feel free to contact us formore information.

Accreditation: The process by which an organization recognizes a program of study or an institution as meetingpredetermined standards. Two organizations that accredit managed care plans are the National Committee forQuality Assurance (NCQA) and the Joint Commission on Accreditation of health Care Organizations (JCAHO).

Case Management: A method of supervising a patient’s or group of patient’s utilization of services. Thesupervision typically is performed by a nurse or social worker and often is indicated in cases of catastrophic orchronic disease.

Children with Complex Special health Care Needs (CCSHNC): A term used for a child who ranges in agefrom birth through age 18; has a serious ongoing illness, or a complex chronic condition, or a disability that haslasted or is expected to last at least twelve ongoing months or more; has an illness, condition or disability thatresults (or without treatment is expected to result) in limitation of function, activities, or social growth anddevelopment; requires regular, ongoing oversight by trained health care professionals, has a need for health and/orhealth -related services at a level significantly above the usual for the child’s age.

Closed Access: A managed health care arrangement in which covered persons are required to select providersonly from the plan’s participating providers.

Company: means Clarendon National Insurance Company

Copayment: An amount of money that the member pays directly to a provider at the time services are rendered. Copayment is a flat sum such as $5/prescription or office visit.

Cost sharing: Payments made out-of- pocket by patients for a part of the cost of covered services. Thisincludes deductibles, any coinsurance and copayments, but not the share of the premium paid by the personenrolled.

Credentialing: The process of reviewing a practitioner’s credentials – i.e., training, experience, or demonstratedability–for purposes of determining whether criteria for clinical privileges are met.

Customary Charge: One of the factors determining a physician’s payment for a service under the plan. Calculated as the physician’s median charge for that service over a prior 12 month period.

Deductible: A specified amount of covered medical expense that a beneficiary must pay before receiving benefits.

Disallowance: When an insurer declines to pay for all or part of a claim submitted for payment.

Drug Card Plan: Coverage for drugs and medicines which require a doctor’s written prescription when suchdrugs and medicines are:1) required for the treatment of an injury or illness; 2)dispensed by a licensed pharmacist;3) not specifically excluded from coverage by the formulary or other plan provisions.

Elective Surgical Procedure: A surgical procedure that is not considered to be an emergency and doesn’t haveto be performed right away.

56

Exclusions and Limitations: Service or Items, which are not covered under the Clarendon Kids CHIP Plan.

Exclusive Provider/Exclusive Provider Organization: A provider of health care, or a group of providers ofhealth care, that gives exclusive provider services to a member under the plan with an insurer to provide servicesat alternative rates.

Family: The group or the individuals whose income is considered in determining eligibility for the Texas CHIPPlan. The family includes the child with a custodial parent or caretaker relative who resides in the same houseor living unit. The family may also include other individuals whose income and resources are considered in wholeor in part in determining eligibility for the child.

Hospital: means an institution that provides or operates medical, diagnostic and major surgical facilities, whetherat is location or at facilities with which it has a contract, is licensed by the state of Texas and approved by theJoint Commission on Accreditation of health Care Organizations (JCAHO) or the American OsteopathicAssociation and certified by the Medicare Program.

Illness: a sickness or disease which requires treatment by a physician, including pregnancy and nervous andmental conditions.

Medically Necessary Services: Services and/or supplies covered by the Plan must be considered medicallynecessary. They must be consistent with the symptoms, or diagnosis and treatment of the child’s condition,disease, ailment or injury; considered appropriate, safe, and effective with regard to the standards of good medicalpractice; not provided solely for convenience of the child, physician, or the hospital or other health care provider;the most appropriate supply or level of service which can be safely provided to the child. For in-patient care, thismeans that the treatment must be a treatment that couldn’t be provided safely on an outpatient basis.

Non-EPO Provider: means a physician, or a health care provider as defined in Texas Insurance Code, “PreferredProvider Benefit Plans”, or an organization of physicians or health care providers with whom the insurer has notcontracted to provide medical care or health care to members.

Physician: means a person who is licensed to practice medicine and does so within the scope of his license andwho we are compelled to recognize by applicable law.

Primary Care Physician: means a physician who is a member of the EPO, who has been selected by themember to manage the health care of the member.

Service Area: means the geographic area served by the insurer of the Clarendon Kids CHIP Plan.

Documents

CLARENDON KIDS CHIP PLANv Pages 21 –36 Scope of Benefits Outlines benefit coverage through the Clarendon Kids CHIP Plan. v Page 37 Referral Sheet Since there is no benefit for out-of-network