Triad Provider Manual - Triad Healthcare, Inc This manual was prepared to assist you and ... Section 1.10 – You are responsible to verify if your patient is eligible for coverage

2013

Triad Healthcare, Inc.

Triad Provider Manual

2 PVR.PA.EM.001.004 (02/06/2013)

TABLE OF CONTENTS

Welcome to Triad Healthcare, Inc ................................................................................................................. 3

Triad Provider Manual ................................................................................................................................... 4

Triad’s Responsibility to You ........................................................................................................................ 5

Your Responsibility to Triad .......................................................................................................................... 6

Quick Reference Contact Information ........................................................................................................... 7

Network Participation .................................................................................................................................... 8

Utilization Review and Quality Management ................................................................................................ 9

Peer To Peer (P2P) ....................................................................................................................................... 11

Claims Processing ........................................................................................................................................ 13

Appeals and Grievances ............................................................................................................................... 17

Discrimination .............................................................................................................................................. 18

Privacy.......................................................................................................................................................... 19

Plan Specific Addendum .............................................................................................................................. 20

Aetna (New Jersey) .................................................................................................................................. 21

WellCare (Medicare Advantage) ................................................................................................................. 30

Health Care Provider Application to Appeal a Claims Determination Form (NJ Only) ......................... 33

Visiting Nurses Service New York Choice (VNSNY CHOICE) ................................................................ 39

Visiting Nurse Services New York Choice (VNSNY CHOICE) ................................................................ 41

Appendix ...................................................................................................................................................... 46

© 2013 Triad Healthcare, Inc. All Rights Reserved. This document is an unpublished proprietary work of Triad Healthcare, Inc. This document contains certain information as to the methods, processes, procedures, and other confidential information proprietary to Triad Healthcare, Inc. and may not be copied or disclosed, whole or in part, without the prior written consent of Triad Healthcare, Inc. Any copies made of this documentation shall contain Triad Healthcare, Inc.’s copyright notice and any and all proprietary marking or confidential legends, including this paragraph and the two above. Printed in the USA. All trademarks and registered trademarks used herein are the property of their respective owners.

3 PVR.PA.EM.001.004 (02/06/2013)

Welcome to Triad Healthcare, Inc

Triad is a leading musculoskeletal service

company focused on the unique needs of the

patient with painful spine and joint conditions.

We work with providers, patients, health plans

and employers to ensure the person with

musculoskeletal pain complaints receives care

that is safe, efficient and likely to produce a

favorable outcome.

Triad offers programs that identify and

promote the delivery of quality, evidence-

based care to musculoskeletal patients in the

following areas and specialties:

Physical Medicine

Chiropractic

Physical Therapy

Occupational Therapy

Pain Management

Interventional Anesthesiology

Physiatry (PM&R)

Neurology

Musculoskeletal Surgery

Orthopedic Surgery

Neurosurgery

Primary Care management support for

musculoskeletal patients

Internal Medicine

Family Practice

General Medicine

Participating providers are selected on the

basis of an ongoing credentialing review

process based upon standards established by

accreditation organizations for managed care

companies. Triad will encourage, support and

facilitate all participating providers in their

pursuit of evidence-based care. We welcome

your participation under each of Triad’s client

plans and value your contributions in meeting

our shared goal of ensuring the delivery of the

highest quality care.

This manual was prepared to assist you and

your office staff in administering the health

care services to your patients as a

participating provider in one of our programs.

It includes information about Triad's

operations, network and plan participation

requirements, claims submission, utilization

review and network communication. As we

add new clients or revise policies and

procedures, you will receive updated

information in a timely manner.

If you have any questions, please contact our

Customer Service Department. Toll free

numbers are listed in each plan specific

addendum.

4 PVR.PA.EM.001.004 (02/06/2013)

Triad Provider Manual

This Provider Manual is an extension of your Triad Participating Provider Agreement (―Agreement‖).

As such, it is referenced multiple times within that ―Agreement‖. The information and instructions

contained within this Manual are designed to assist you in maintaining compliance with your

―Agreement‖. Please note, where referenced within the ―Agreement‖, the information contained

within this Manual is intended to be equally binding as the language within your ―Agreement‖. To

facilitate your use of this Manual, we have referenced the ―Agreement‖ throughout, by section, to

relate the explanations and detailed information contained within the Manual to your ―Agreement‖.

Below is a bulleted summary of those areas of the ―Agreement‖ that are detailed within this Manual.

This summary is not intended to be a substitute for the ―Agreement‖ itself, which we recommend

you review in detail prior to using this Manual.

5 PVR.PA.EM.001.004 (02/06/2013)

Triad’s Responsibility to You

Section 2.1 – Triad is responsible to obtain and monitor your professional credentials and

communicate these accurately to its Plans and other authorized recipients.

Section 2.2 – Triad is responsible to notify you of any new contract with a Health Plan and

to provide you with complete information about that contract so you can make an

informed decision to participate.

Section 2.3 – Triad is responsible to notify you when entering into an agreement with a

Health Plan where there is an administrative fee, charged to you.

Section 2.4 – Triad is responsible to accept your claims, process and pay them to the

terms negotiated with the Plan and in compliance with State and Federal claims payment

regulations.

Section 2.5 – Triad is responsible to make reasonable efforts to secure Health Plan

contracts for your participation.

Section 4.1 – Triad is responsible to develop and maintain utilization and quality

management programs that ensure that care delivered to Plan Enrollees is safe and

compliant with current evidenced based medicine.

Triad is responsible to communicate to you, through this provider manual and periodic

additions and deletions to it, all the information necessary for you to comply with your

obligations under the Triad Participating Provider Agreement.

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Your Responsibility to Triad

Section 1.2 – You are responsible to accept Plan Enrollees as patients unless you notify Triad

that your practice is closed to new patients. You may not discriminate against any Plan

Enrollee.

Section 1.4 – You are responsible, when contemplating a referral to another provider, to

utilize a participating provider of your patient’s health plan.

Section 1.5 – You are responsible to create and maintain adequate medical records on your

patients and share them with Triad upon our request. Provider shall furnish such records at

no charge to Triad, upon reasonable notice during reasonable business hours, to the extent

necessary for utilization review activities, claims processing and payment, and for the

purpose of inspection.

Section 1.6 – You may not engage in discussions with other Participating Providers about

refusing to deal with any proposed or active Plan contracts entered into by Triad.

Section 1.10 – You are responsible to verify if your patient is eligible for coverage under the

applicable Health Plan. Please note, Triad has developed an easy to use online tool for you to

verify member status. Please access Triad’s public website,

http://www.triadhealthcareinc.com, and select “Provider Portal” from the Provider

drop-down menu to register.

Section 1.13 – You may not engage in any activity designed to encourage a patient or an

employer to terminate their coverage with a Plan or their participation with a Triad program.

Section 5.4 – You are responsible to accept payment for your claims under the terms of the

Triad Participating Provider Agreement and the Plan contract, as payment in full. You may not

collect additional fees from your patient unless a waiver has been obtained under the terms

of this agreement.

http://www.triadhealthcareinc.com/

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Quick Reference Contact Information

Credentialing Please fax all credentialing documentation to 888-844-6645 or

you can mail to: Triad Healthcare, Inc.

Attn: Credentialing Department 80 Spring Lane Plainville, CT 06062

Medical Policies Please access Triad’s Medical Policies at the below link:

http://www.triadhealthcareinc.com/providers/policies.aspx

Claims Triad electronic claims submission is available through MD On-Line, payor

id (39181). Please submit your paper claims to: Triad Healthcare, Inc.

Attn: Claims Department 80 Spring Lane

Plainville, CT 06062

Utilization Review You can fax approval forms and/or

medical records to 1-866-225-1033 For all general Utilization

Management inquiries please call number listed in each plan specific addendum.

Eligibility

To verify patient eligibility please contact the patient’s health plan directly, access Triad’s provider

portal or call Triad’s Customer service Department. Toll free

numbers are listed in each plan specific addendum.

P2P (Peer to Peer)

If you wish to speak with a Clinical Peer please call Triad’s Customer Service Department. Toll free

numbers are listed in each plan specific addendum.

For additional support, please access Triad’s public web site,

http://www.triadhealthcareinc.com, and select “Provider Portal” from the Provider drop-down menu.

Triad’s Customer Service Department is accessible Mon-Fri from 8:00 AM to 6:00 PM. Please note: Times may vary depending on plans. Please refer to

plan specific addendums for hours of operation.




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Network Participation

Triad’s Participating Provider Network

represents providers who meet minimal health

care industry criteria for educational and

professional quality standards as well as Triad

established criteria for patient accessibility,

and clinical performance. The network

participation process includes both initial

credentialing and periodic re-credentialing

activities. Healthcare providers who participate

in Triad’s Networks are eligible to provide

healthcare services to Triad’s Health Plan

clients as well as serve on Triad’s Quality

Committees and Clinical Staff.

Triad Healthcare is a member of the

Council of Affordable Quality Healthcare,

Universal credentialing application data

source (CAQH).

You may access a CAQH Universal

Credentialing Application on-line at

https://upd.caqh.org/oas/

Triad’s Credentialing and Re-credentialing

Programs are currently accredited by both

NCQA and URAC.

All providers billing under the same Tax ID as

you, must be credentialed with Triad. Call the

number listed in each plan specific addendum

to request applications for new associates.

The following is required for network

participation.

A fully executed Triad Participating

Provider Agreement.

A current unrestricted license to practice in

the state of practice location.

You must NOT be restricted from

participating in any Medicare/Medicaid

programs or any other third party

reimbursement programs.

You must NOT be subject to disciplinary

action by any state or territorial board of

medical examiners.

You must NOT have been convicted of a

felony.

You must be in good physical and mental

health.

You must carry a minimum of one

Million/three million claims made or

occurrence professional liability insurance.

You must provide a minimum of 20 patient

contact hours per week.

You must provide covered services for

members within the scope of your license.

You must provide coverage 24 hours per

day, 7 days a week, and 52 weeks a year.

You must meet OSHA standards and

maintain compliance with all federal and

state health and safety regulations.

In addition, upon re-credentialing Triad

may require you to meet certain quality

standards as established annually based

on:

o Member complaints or grievances

o Utilization performance.

o Member satisfaction survey results

https://upd.caqh.org/oas/

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Utilization Review and Quality Management

Triad commonly provides utilization review and quality management programs to Health Plans.

These programs are designed to ensure that the delivery of health care services to Health Plan

Enrollees is safe, effective and consistent with evidenced based medicine and to collect the data

necessary to report this information to authorized stakeholders. Generally, these programs apply to

both participating and non-participating providers who treat Health Plan Enrollees. Triad Participating

Providers may elect to utilize voluntary prior approval processes that Triad does not make available

to non-participating providers.

For each Health Plan, there may be slightly different utilization and/or quality management

processes that you must follow. The UR/QM process is defined specific to each Health Plan under the

section of this Manual called PLAN SPECIFIC ADDENDUM.

All of Triad’s utilization review decisions will be communicated to you and to your patient in either

written or verbal format as required by law. Unless otherwise required, Triad will provide you with a

utilization review determination in the same format as you used to submit a claim or request for

prior approval. For example, if you fax your prior authorization form, you will receive our response

by fax. All utilization review determinations sent to your patients by Triad, will be sent by standard

U.S. Postal Mail.

Triad collects information from health plans, providers and members through claims forms, medical

records, surveys and other sources that are used to manage the cost and quality of care, process

claims and generate reports. We strive to collect this information as efficiently as possible.

Prior Authorization Forms

Triad administers prior approval using standardized authorization forms – Physical Medicine

Authorization & Musculoskeletal Services Authorization. Triad’s authorization forms include provider

and patient demographics only. Medical Records must accompany the authorization form. Forms

with records can be submitted to Triad via dedicated fax lines, postal mail, and customized web

interfaces (Triad’s Provider Portal). Triad will use these forms, and any accompanying medical

documentation, to determine medical necessity and notify you of such determination.

The information on this form is used by Triad to identify you and the member for whom you are

requesting prior authorization.

While we can accept these forms telephonically, medical records must be sent via fax or web.

Forms are available on Triad’s website: http://www.triadhealthcareinc.com/providers/forms.aspx

Medical Records

Medical Records should always be submitted with your prior authorization form. If you choose not to

prior approve care, Triad’s clinical staff will review your claims as they are received. If additional

clinical information is required to make a determination of medical necessity, medical records will be

requested of you at that time. Medical records may also be requested of you following a Peer to

Peer call to document any verbal information you have provided. Triad will request only that

information necessary for the review. The medical records you provide to Triad should contain your

http://www.triadhealthcareinc.com/providers/forms.aspx

10 PVR.PA.EM.001.004 (02/06/2013)

clinical records for all dates of service for the submitted claim or prior authorization request including

but not limited to: exam narrative, office notes, diagnostic tests and/or any equivalent notes which

demonstrate your patient’s condition and/or progress to date. Use black ink for clarity and quality of

copying. If handwriting is not legible, records should be typed. Notes should be timely, brief, and

include all pertinent data. Standard accepted medical abbreviations are suitable. Copies of all

correspondence regarding a case, including return-to-work notes, referral letters, reports, telephone

communication, written authorization to release information, consent to treat forms, etc. should be

maintained.

11 PVR.PA.EM.001.004 (02/06/2013)

Peer To Peer (P2P)

Triad recognizes that most of our Participating Providers also participate with other UR/QM

programs. In addition, not all of our Participating Providers approach patient care from exactly the

same perspective or use the same scope of services. These factors, in combination with the rapidly

evolving medical evidence base, can make understanding and complying with UR/QM programs

more difficult than it should be.

One of the more important aspects of our program involves the understanding of Triad’s clinical

rationale language and the clinical logic and medical evidence used to make clinical determinations.

Triad engages only experienced, actively practicing health care providers to serve as Peer Reviewers

for our UR/QM programs. We define ―Peer‖ to mean a healthcare professional with the same

educational credentials and professional degree as you, who may also practice within a similar

geographic region (state or locality). Our goal is to ensure when clinical judgment is required to

make a determination of medical necessity, it is done by someone who is treating patients like yours

everyday, just like you.

We appreciate that it may be difficult to find a Peer who is exactly like you with a practice that is

exactly like yours, but we take special efforts to get it as close as possible.

In addition to their clinical experience, Triad’s clinical staff is trained in four primary areas:

1. Medical policy and evidence based literature.

2. NCQA and URAC accreditation standards

3. Triad’s Care Management Process

4. Conducting Peer to Peer dialogue

Each of our clinical staff, in addition any committee duties they volunteer for, has two primary

responsibilities, the first is to perform utilization review, the second is to respond to telephonic

requests for additional discussion from our Participating Providers, something we call Peer to Peer

Dialogue or P2P.

Anytime Triad receives a request for information that involves further explanation of a utilization

management determination, review of medical policy or the medical evidence behind the medical

policy, the understanding of Triad clinical rationale language or an understanding of the UR/QM

process itself, the caller is provided access to a Triad Clinical Peer for that discussion.

We make every effort to accommodate you immediately with a clinical Peer, however because our

Peers are in their offices, just like you, sometimes these calls have to be scheduled at a later time

that is convenient for you.

Our Peers are authorized to do the following with you by telephone:

1. Review clinical determinations and any related correspondence sent to you from Triad.

2. Accept additional clinical information that may not have been included in your original clinical

documentation.

3. Discuss specific aspects of an individual case to best understand its unique aspects, directly from

you.

4. Review current Triad medical policy and clinical criteria.

5. Approve services that were initially denied.

12 PVR.PA.EM.001.004 (02/06/2013)

We strongly recommend that you take advantage of this service to streamline the UR/QM process

and get accurate, direct answers to your clinical questions. If you wish to speak with a Clinical Peer

please call Triad’s Customer Service Department. Toll free numbers are listed in each plan specific

addendum.

13 PVR.PA.EM.001.004 (02/06/2013)

Claims Processing

Triad commonly processes healthcare claims

for Health Plans. We strive to exceed industry

standards for processing turn around time and

payment accuracy. Generally, there is little

variation in the claims submission process

from one Health Plan to another, but

occasionally there is.

The claims process is defined specific to each

Health Plan under the section of this Manual

called PLAN SPECIFIC ADDENDUM.

Claims Processing Methodology

Triad currently employs two claims processing

methodologies. Each methodology is offered to

Health Plans as options for Claims Processing.

Consequently, the methodology may vary

from one Health Plan to another. Please refer

to the PLAN SPECIFIC ADDENDUM to this

Manual to determine which methodology

described below is being utilized with which

Health Plan.

1. Fee for Service (FFS)

a. This methodology applies

coverage determinations based

on benefits and medical

necessity determinations across

each service (CPT code) that

you bill and reimburses for each

service.

2. Bundled Encounter (BE)

a. This methodology applies

coverage determinations and

medical necessity

determinations across only the

service date (encounter) that

you bill and reimburses one rate

per covered encounter.

Claim Submission

Electronic Submission: Triad Healthcare,

Inc. has partnered with MD On-line for

electronic claim submission. Claims can be

individually entered free of charge. To

access this benefit, log on to

www.triadhealthcare inc.com/providers

and click the ―Submit‖ button under Online

Solutions. This will route you to MD On-

line’s portal for Triad’s providers. Please

include Triad’s address (see below) and

electronic payer ID #39181. To learn more

about MD On-line’s products for submitting

Triad claims electronically free of charge,

please call: 1-888-499-5465

Paper claims can be submitted directly to

Triad at:


Attn: Claims

80 spring Lane


Time Frame for Claim Submission

Unless otherwise specified in a PLAN

SPECIFIC ADDENDUM (Claims Filing

Deadlines) to this manual, Participating

Provider claims must be received by Triad no

later than 180 days from the date services

are rendered (claims filing deadline). Claims

submitted to Triad after the claims filing

deadline will be denied due to late submission.

Submissions received by Triad outside of

business hours shall be considered as received

the following business day.

Clean Claims

Claims will be processed in accordance with all

state and federal guidelines. A ―clean‖ claim

will have no defect or lack of required

substantiating documentation. Documents

required for the claim to be considered clean

include medical documentation (initial exam

narrative, re-evaluations and daily treatment

records) in addition to any pertinent

information that detail the member’s

presenting condition, the member’s

progress/response to treatment as compared

to the member’s initial evaluation baseline and

the member’s expected prognosis/outcome to

treatment for the date(s) of service submitted.

Please refer to the information outlined in the

Required Information for all Claim Submission

14 PVR.PA.EM.001.004 (02/06/2013)

section of the Provider Manual for required

fields on ―clean‖ claims.

―Non-clean‖ claims are incomplete claims,

claims that are missing required data as

outlined by Triad or a claim that requires

additional information from the provider. Triad

applies all state and federal guidelines to

determine if a claim is considered ―non-clean‖.

Paper Claims Guidelines – Effective

October 28, 2010

Submit ―clean claims‖ using CMS-1500

claim forms. For complete, detailed

information about paper claim submissions

refer to the National Uniform Claim

Committee (NUCC) – CMS1500 forms.

Refer to the 837 Institutional

Implementation Guide by Washington

Publishing Company (March 2003) for any

EDI-related issues.

Paper claims must only be submitted on

original (red ink on white paper) claim

forms.

Paper claim forms must not be handwritten

or have any extraneous data printed or

stamped on them except handwritten

information that may be at the top of the

original claim form indicating ―Corrected

Claim‖ in the instance of a re-submission.

In the instance of an encounter

submission, ―Encounter‖ may be written or

stamped in red on the paper claim, only if

it does not obscure any of the claim’s

information.

Any missing, incomplete or invalid

information in any field will cause the

claim to be rejected.

The font should be: legible; typed in

black ink; in large, dark font in capital

letters. The font should not have:

broken characters; script, italics or

stylized font; red ink; mini font; or dot

matrix font.

Required information for all claim

submission

Claims submission Guidelines are posted on

Triads website:

www.triadhealthcareinc.com/providers/claim.a

spx . If any required field is omitted, or

otherwise illegible, you will receive notice that

you have failed to follow the proper procedure

for filing a clean claim. Such notice shall be

provided to you within statutory time frames

and shall include a description of the failure

and the proper procedures to follow in order to

rectify and re-submit the claim.

Remittance Advice

Once a claim has been adjudicated, providers

will receive a Remittance Advice via US postal

mail. The Claims Payment System assigns

applicable payment/non-payment codes and

descriptions for all billed services. Provider

Remittance Advice notices contain

payment/non-payment descriptions listed in

the provider payment description table. In

compliance with applicable federal and state

regulations, Provider Remittance Advice

notices provide: (1) instructions for filing a

grievance and appeal, including timeframes for

filing; and (2) CMS appeals language,

including time frames for filing, as applicable.

Providers are afforded a right to appeal an

adverse claim decision. Additional days may

be afforded as allowed by state. Member

Explanation of Benefit (EOB) notices are also

generated and mailed for members with

Medicare or Commercial plan benefits upon

claim adjudication. Member EOB notices

contain payment/non-payment descriptions

listed in the member payment description

table.

Reimbursement

Unless otherwise specified in a PLAN

SPECIFIC ADDENDUM of this manual, both

electronic and paper claims identified as

―clean‖ will be paid within 30 calendar days

after receipt. If additional information is

needed, Triad will request from the

insured/provider within 30 days of receipt of

claim. Once additional information is received,

the claim will be paid within 30 days of the

receipt of the additional information.

Fee Schedules

Triad has developed competitive fee schedules

for participating providers for each of our

programs. Fee schedules may vary depending

on client, state and region. All of our fee

schedules are made available to our providers

upon request and in advance of changes or

new programs. You can request a copy of a

fee schedule by calling Triad’s Customer

http://www.triadhealthcareinc.com/providers/claim.aspx

http://www.triadhealthcareinc.com/providers/claim.aspx

15 PVR.PA.EM.001.004 (02/06/2013)

Service Department. Toll free numbers are

listed in each PLAN SPECIFIC ADDENDUM.

Eligibility and Benefit Verification

Your office staff may contact Triad, or access

Triad’s Provider Portal, to verify member

eligibility and inclusion in each of our clients’

programs. Coverage for each client, plan and

member may vary; therefore, it is important

to verify coverage for certain procedures by

reviewing Triad’s Plan Specific Addendums and

Covered Services Sections of our client’s

website prior to rendering services. Claims for

members not effective on the date of service

rendered or not included in a Triad program

will be denied.

Balance Billing:

The non-payment of services for any reason

resulting in member responsibility for

Commercial and Medicare claims are

processed according to CMS guidelines, state

mandated requirements, and health plan

delegation agreements, as applicable.

Providers cannot bill the patient for any

covered services deemed not medically

necessary by Triad unless they have obtained

a written agreement to do so from the patient

prior to rendering services. In addition, per

Triad’s Participating Provider Agreement, the

provider will agree not to bill the patient for

any amount above the negotiated fee schedule

for covered services unless otherwise specified

by plan contract.

Overpayment

Triad shall request (in writing) any amount

deemed ―overpaid‖ to a participating provider.

Coordination of Benefits (COB)

Coordination of Benefits (COB) is a provision

which establishes the order in which insurance

plans pay claims when an individual has

coverage under more than one plan. The

concept of COB is to make the member

―whole‖, meaning that payment is calculated

to reimburse up to the allowed amount,

eliminating the member's responsibility or cost

share for services that are coordinated as long

as the paid amount does not exceed the

normal benefit. The Primary Insurer Plans

certificates of coverage contain COB provisions

and Triad will coordinate those benefits with

those available from other Commercial

insurance plans, Federal Medicare, motor

vehicle insurance plans, worker's

compensation issues, third party insurance

plans and multiple Primary Insurer Plans'.

Primary Insurer Plans’ COB department

determines which plan is primary and which is

secondary (or tertiary (third), etc.). The

client’s COB department uses standard

industry rules to determine the order of

payment and will update the member's

eligibility record accordingly. This is referred to

as the order of benefit determination or the

order of payment determination.

Things to remember when submitting

claims to Triad:

1. Verify patient eligibility.

2. Verify patient inclusion in a Triad

program.

3. Verify covered services, limits or

exclusions.

4. Verify claim submission process in the

plan specific addendum.

5. Collect applicable copayments from

your patients.

6. Include all pertinent medical records.

7. Submit current year CPT and ICD

codes.

For more detail please refer to the

PLAN SPECIFIC ADDENDUM

16 PVR.PA.EM.001.004 (02/06/2013)

Required fields for claims submission (HCFA 1500) Please note: medical records must be submitted with a claim in order for the claim to be considered

clean.

Field

1 Medicare/Medicaid/CHAMPUS/CHAMPVA/Group Health

Plan/FECA/other

1a Insured’s ID Number

2 Patient’s Name

3 Patient’s DOB

4 Insured’s name

5 Patient’s Address/City/State/Zip Code/Phone#

6 Patient Relationship to Insured (Self /Spouse/ Child/Other

8 Patient Status- Check either- Single, Married/Other. Employed/FT/PT

9,9a-d Other Insured’s Name/Other Insured’s

Policy#/DOB/Gender/Employer’s Name/Insurance Plan

10 a-c Is the patient’s condition related to: Employment, Auto or Other?

Place?

11 Insured’s Policy Group or FECA Number

11d Is there another Health Benefit Plan?

12 Patient’s or authorized person’s signature

13 Insured’s or authorized person’s signature

21 Diagnosis Codes

24a Date of Service

24b Place of Service

24d Procedure Codes

24e Diagnosis Codes

24f Charge Amounts

24g Days or Units

24i ID. Quality

24j Rendering Provider ID #

24k Rendering Provider’s ID as assigned by payer

25 Federal Tax ID Number, SSN, EIN

26 Patient’s Account #

27 Accept Assignments

28 Total Charge

29 Amount Paid

30 Balance Due

31 Signature of Physicians or supplier and date

32 Name and Address of Facility where services were rendered

32a NPI

33 Physician’s, Supplier’s Billing Name, Zip Code and Phone #

33a NPI

17 PVR.PA.EM.001.004 (02/06/2013)

Appeals and Grievances

APPEALS

You may appeal any adverse determination issued by Triad. Triad will process and respond to your

appeal as described in the PLAN SPECIFIC ADDENDUM. In some cases, Triad may not be

delegated to administer all levels of appeals. In instances where Triad is not delegated, Triad will

immediately forward your appeal to the Health Plan for processing and consideration. Please refer to

the PLAN SPECIFIC ADDENDUM to this Manual for the correct appeals process for each Health

Plan.

Triad shall include an explanation of the relevant appeals process with all adverse determinations to

the provider, member and/or their designee. When delegated, appeals must be submitted in writing

and must be received by Triad within 90 days of receipt of an adverse determination. All written

comments, documents, records and other information submitted to support the appeal will be

reviewed and considered in a timely manner without regard to whether those documents or

materials in making the initial determination.

GRIEVANCES

Triad encourages open communication with our provider community. A grievance or complaint can

be expressed in writing at the address below or by calling Triad’s Customer Services Department.

Toll free numbers are listed in each plan specific addendum. All grievances and complaints will be

researched and responded to in a timely manner, in accordance with state and federal regulations as

applicable.

Once received, your complaint or grievance is logged by Triad’s Quality Management (QM) staff. You

will receive a written acknowledgement within five (5) days. The complaint or grievance will be

evaluated for urgency, categorized and researched. The complaint or grievance with accompanying

research is presented to the complaint committee for review and then sent to QM for the creation

and distribution of the final response. All complaints and grievances are reported to MQIC and are

reviewed for potential opportunities for quality improvement or corrective action.

Written grievances and complaints:


Complaint Department

80 Spring Lane


18 PVR.PA.EM.001.004 (02/06/2013)

Discrimination

Section 1.3 of the Triad Participating Provider Agreement states: Non-Discrimination. Provider shall,

and shall require Associated Providers to, perform healthcare services for all patients in the same

manner, and in accordance with the same standards. Provider shall, and shall require Associated

Providers to, treat Enrollees on at least the same basis as other patients. Provider shall not, nor

shall Provider allow Associated Providers to, discriminate or differentiate with respect to the

treatment, or quality of services, provided to Enrollees on the basis of race, sex, age, religion,

sexual orientation, handicap, place of residence, or health status.

Understanding discrimination is necessary before you can effectively comply with the terms of your

agreement with Triad. Below is a summary of non-discrimination language offered by CMS

referencing Title VI of the Civil Rights Act of 1964. You are responsible to ensure that you and those

you employ are aware of and compliant with the non-discrimination provisions of this law.

―As a recipient of Medicare, Medicaid or other federal funds, Providers cannot exclude, deny benefits

to, or otherwise discriminate against any person on the basis of race, color, national origin,

disability, or age in admission to, participation in, or receipt of the services and benefits under any of

its programs and activities, whether carried out by the Provider directly or through a contractor or any other entity with which the Provider arranges to carry out its programs and activities.

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section

504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the

U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.‖

19 PVR.PA.EM.001.004 (02/06/2013)

Privacy

Section 1.6 of the Triad Participating Provider Agreement reminds you, among other things, to be

aware and comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Among HIPAA’s many important provisions are those that expressly relate to the privacy of

protected health information (PHI). You are responsible to ensure that the PHI you obtain from your

patients and share with authorized parties is protected from unauthorized access. Below is a

summary of the Privacy Rule issued by the U.S. Department of Health and Human Service (―HHS‖)

which should guide your efforts at compliance. You are responsible to take the necessary measures

to ensure that your practice is in compliance with HIPAA and the Privacy Rule.

―The U.S. Department of Health and Human Services (―HHS‖) issued the Privacy Rule to implement

the requirement of the Health Insurance Portability and Accountability Act of 1996 (―HIPAA‖). 1 The

Privacy Rule standards address the use and disclosure of individuals’ health information—called

―protected health information‖ by organizations subject to the Privacy Rule — called ―covered

entities,‖ as well as standards for individuals' privacy rights to understand and control how their

health information is used. Within HHS, the Office for Civil Rights (―OCR‖) has responsibility for

implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil

money penalties. A major goal of the Privacy Rule is to assure that individuals’ health information is

properly protected while allowing the flow of health information needed to provide and promote high

quality health care and to protect the public's health and well being. The Rule strikes a balance that

permits important uses of information, while protecting the privacy of people who seek care and

healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and

comprehensive to cover the variety of uses and disclosures that need to be addressed.‖

20 PVR.PA.EM.001.004 (02/06/2013)

Plan Specific Addendum

The PLAN SPECIFIC ADDENDUM outlines the details of each program you may have elected to

participate with through your Triad Participating Provider Agreement. The forms for each program

can be found at the end of each plan specific addendum. If you should have any questions pertaining

to these programs please call Triad’s Customer Service Department. Toll free numbers are listed in

each plan specific addendum.

21 PVR.PA.EM.001.004 (02/06/2013)

Aetna (New Jersey)

Type of Business

Aetna HMO-based, Health Network Option/Only and Medicare Advantage plans

Triad Program Chiropractic Benefit Management including Network Participation,

UR/QM and Claims Processing

Summary Aetna has delegated the administration of chiropractic benefits to Triad

Healthcare, Inc. for their HMO-based (including Health Network Option/Only and Medicare Advantage plans) members in New Jersey. This delegation

includes network contracting, utilization management and claims payment.

You should contact Triad at 1-800-409-9081 to verify member inclusion in

this program or you may go on-line at

http://www.triadhealthcareinc.com/providers/providers.aspx

Effective Date HMO Northern New Jersey members – 10/1/06

HMO Southern New Jersey members – 7/15/10

UR/QM Triad’s 10 visit UM Threshold

The members first 10 visits of therapeutic care will be adjudicated and

reimbursed without utilization review. In addition, the first 10 visits of

therapeutic care for any established patient who presents with a new

condition will also be adjudicated and reimbursed without utilization review.

Triad will use the CMS definition for a ―new patient‖ as a reference for ―new

condition‖, therefore, a patient with a new condition will be defined as:

―Any established patient with a diagnosed condition for which the treating

provider or another provider within the same practice has not provided care

for that condition within the last three years.‖

The following conditions apply to the 10 visit UM threshold:

Any concurrent evaluation/management, preventative medicine, radiology

or electrodiagnostic service will be reviewed for medical necessity.

For treatment plans extending beyond the 10 visits, participating providers

may elect to prior authorize the 11th and subsequent visits or may provide

care and Triad may review the 11th and subsequent visits retrospectively.

Physical Medicine Authorization forms are available in this section, below,


22 PVR.PA.EM.001.004 (02/06/2013)

or on Triad’s website

(http://www.triadhealthcareinc.com/providers/providers.aspx).

Please note, medical records are required to be submitted with the Physical

Medicine Authorization form.

Physical Medicine Authorizations will be valid for six (6) months from the

date of the determination.

Prior approval is required for Medicare members ONLY.

Voluntary prior approval for Commercial and Self Insured members may be

requested after the patient’s tenth encounter (visit).

Claims

Methodology

Fee for Service (FFS)

Claims Submission Participating providers will need to submit all claims for Aetna HMO-based

members (including Health Network Option/Only and Medicare Advantage

plans) members in New Jersey directly to Triad. Participating provider

claims submitted directly to Aetna for HMO members will be denied by

Aetna and will have to be re-submitted to Triad.

Claims filing

Deadline

Providers have 180 days to submit claims from the date of rendered

services

Fee Schedule Claims are adjudicated according to the Triad/Aetna fee schedule. The fee

schedule is subject to a Maximum Daily Allowed Amount per date of service

for new patients, established patients with evaluation service(s) and

established patient routine visit. You can request a copy of the Triad/Aetna

fee schedule, by calling Triad’s Customer Service Department.

Administrative Fee There is no administrative fee applied to claims for the HMO program with

Aetna.

Appeals NJ Prompt Pay/Administrative Denial Appeals

All providers may initiate an administrative claim appeal on or before the

90th calendar day following receipt of the claims determination. These

Appeals should be completed using the Health Care Provider Application to

Appeal a Claims Determination Form (NJ Only) and mailed or faxed to Triad

(see below). This Form can be found below or can be obtained on-line at

our website www.triadhealthcareinc.com under the Forms & Instructions

section.



23 PVR.PA.EM.001.004 (02/06/2013)

Claims appeals should be sent directly to Triad at:


Appeals Department

80 Spring Lane


Fax: 860-793-3317

If you disagree with Triad’s administrative claim appeal decision, you may

obtain an external review by initiating an arbitration proceeding within 90

calendar days of receipt of an uphold notice. The New Jersey Department

of Banking & Insurance has contracted with MAXIMUS, Inc. as the

Arbitration Organization (AO) to operate the Program for Independent

Claims Payment Arbitration (PICPA). Health care providers may submit an

Application for Arbitration online at https://njpicpa.maximus.com. For

more information, please contact MAXIMUS by phone, fax or mail at:

MAXIMUS, Inc.

Attn: New Jersey PICPA

50 Square Dr., Suite 210

Victor, NY 14564

P#: (585) 425-5326

F#: (585) 425-5296

UR appeals should be sent to:

Medicare

Aetna Medicare Advantage

Grievances and Appeals

PO Box 14067

Lexington, KY 40512

Commercial

Aetna Health Inc.

Customer Resolution Team

PO Box 14625

Lexington, KY 40512

Benefit Limitations Maintenance Care, Wellness Care and Scheduled Supportive Care are not

covered.

P2P If you wish to speak with a Clinical Peer at anytime please call Triad’s

Customer Service at 1-800-409-9081 and a Representative can assist you.

Complaints and

Grievances

A grievance is a complaint expressing dissatisfaction. Triad Healthcare, Inc.

encourages open communication; a complaint can be made by calling

Triad’s Customer Service Center at 1-800-409-9081 or in writing at the

address below. All complaints are researched and resolved in a timely

manner.

Triad Healthcare

https://njpicpa.maximus.com/

24 PVR.PA.EM.001.004 (02/06/2013)


80 Spring Lane


Primary Care

Referral

Triad’s programs do not require a PCP referral for chiropractic; however

any Aetna plans that currently require a PCP referral will continue to do so.

Please contact Aetna to determine if your patient requires a referral.

Customer Service Contact Triad’s Customer Service Department at 1-800-409-9081, Monday-

Friday from 8:00 AM to 6:00 PM EST.

25 PVR.PA.EM.001.004 (02/06/2013)

Health Care Provider Application To Appeal a Claims Determination Form

(NJ Only)

26 PVR.PA.EM.001.004 (02/06/2013)

27 PVR.PA.EM.001.004 (02/06/2013)

28 PVR.PA.EM.001.004 (02/06/2013)

Credentialing Appeal and Grievance Form

29 PVR.PA.EM.001.004 (02/06/2013)

Physical Medicine Authorization Form

30 PVR.PA.EM.001.004 (02/06/2013)

WellCare (Medicare Advantage)

Type of Business Medicare Advantage in the State of New York & New Jersey.

Triad Program Chiropractic Benefit Management for Medicare Advantage Members in

New York and New Jersey. Chiropractic Benefit Management includes

Network Participation, UR/QM and Claims Processing

Summary

Triad will assist WellCare in delivering a chiropractic benefit to their

Medicare Advantage members in New York and New Jersey. Chiropractic

Benefit Management includes clinical data collection, care planning,

healthcare coaching, provider network management, and claims

administration.

Effective Date Medicare Advantage members in New York - May 7, 2007

Medicare Advantage members in New Jersey - January 1, 2008.

UR/QM Prior approval is required after the 1st date of service (encounter). You can

request prior approval of services by submitting the Physical Medicine

Authorization form.




Please note, medical records are required to be submitted with the

Physical Medicine Authorization form.

Claims Methodology Fee for Service

Claims Submission Participating providers will need to submit all claims directly to Triad.

Claims filing

Deadline


services

Fee Schedule Claims are adjudicated and reimbursed at the Triad/Wellcare fee schedule.

You can request a copy of the Triad/WellCare fee schedule, by calling

Triad’s Customer Service Department.

The fee schedule represents the Allowed Amount. Member cost share

(copay, coinsurance, deductible) will be deducted from the Allowed

Amount when final payment is issued by Triad. The member cost share

(copay, coinsurance and deductible) portion of the Allowed Amount will be

identified on the Explanation of Payment and should be collected directly

from the member.

Administrative Fee None


31 PVR.PA.EM.001.004 (02/06/2013)

Appeals

All Participating Provider Claims, Administrative, and

Retrospective (UR) denial of treatment should be mailed to:


Appeals Department

80 Spring Lane


Fax to 860-793-3317

All Member Appeals and Provider Prospective (UR) denial of

treatment should be mail to:

New York members:

WellCare

Attn: New York Appeals Department

PO Box 31368

Tampa, FL 33631-3368

New Jersey Members:

WellCare

Attn: New Jersey Appeals Department

PO Box 31368

Tampa, FL 33631-3368

For a Fast Appeal you or your representative should contact WellCare by

telephone or fax:

Toll Free: 1-800-278-5155

TTY/TTD: 1-877-247-6272

Fax: 1-866-201-0657

For additional information about the appeal process please refer to the

denial letter. You may request another copy of the denial letter by calling

Triad’s Customer Service Center at 1-800-409-9081.

Benefit Limitations Chiropractic Manipulative Therapy (CMT) is the ONLY covered service

under this benefit.


Customer Service at 1-800-409-9081 and a Representative can assist

you.

Complaints and

Grievances

A grievance is a complaint expressing dissatisfaction. Triad Healthcare Inc.

encourages open communication; a complaint can be done by calling

Triad’s Customer Service Center 1-800-409-9081 or in writing at the


manner.

Triad Healthcare


80 Spring Lane


Primary Care Triad’s programs do not require a PCP referral for chiropractic care.

32 PVR.PA.EM.001.004 (02/06/2013)

Referral

Customer Service Contact Triad’s Customer Service Department at 1-800-409-9081,.

33 PVR.PA.EM.001.004 (02/06/2013)

Health Care Provider Application To Appeal a Claims Determination Form (NJ Only)

Health Care Provider Application to Appeal a Claims Determination Form (NJ Only)

34 PVR.PA.EM.001.004 (02/06/2013)

35 PVR.PA.EM.001.004 (02/06/2013)

36 PVR.PA.EM.001.004 (02/06/2013)

Claim Appeal Request Form (All States except NJ)

CLAIM APPEAL REQUEST FORM

TRIAD Healthcare, Inc.

80 SPRING LANE

PLAINVILLE, CT 06062

Fax: 860-793-3317

DATE: _____________

APPELLANT’S NAME: __________________________

Health plan: ___________________________ ID#___________________________________

Reference Numbers being appealed: ______________________________________________

ADDRESS: ______________________________________________________________

TELEPHONE NUMBER: BUSINESS: ____________________________________

HOME: ____________________________________

FAX: ____________________________________

Please provide the reason for requesting this appeal.

Include original issue/complaint, statement of original issue and brief summary.

List CPT Codes being appealed: __________ For Dates of Service: _______________

List CPT Codes being appealed: For Dates of Service: _______________



(USE ADDITIONAL FORMS FOR ADDITIONAL CPT/DATES OF SERVICE)

PLEASE SUBMIT ANY ADDITIONAL SUPPORTING DOCUMENTATION, SUCH AS:

OFFICE NOTES, MEDICAL RECORDS, DIAGONOSTIC STUDIES

_____________________________________________________________________________________

I authorize and direct TRIAD Healthcare, Inc. to investigate the issues described above. I authorize any party identified

above to release information pertaining to this investigation to TRIAD Healthcare, Inc. upon her/his written request.

_________________________________________________________

Name

_________________________________________________________ ____________

Signature Date

Please indicate that you have sent all necessary clinical information to review this appeal Yes No

Will you be submitting additional information with this appeal Yes No

Please submit this form and all documentation in writing to the above address or fax to 860-793-3317.

TRIAD QM Department MS-04-099

Ver052907

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39 PVR.PA.EM.001.004 (02/06/2013)

Visiting Nurses Service New York Choice (VNSNY CHOICE)

Chiropractic

Type of Business Medicare Advantage

Triad Program Chiropractic benefit for Medicare Advantage Members in New York.

Chiropractic Benefit Management includes clinical data collection,

utilization management, healthcare coaching, provider network

management, and claims administration.

Summary Triad began assisting VNSNY Choice deliver its chiropractic benefit to

VNSNY Choice Medicare Advantage members in the following New York

counties: Bronx, Brooklyn, New York, Queens, and Richmond in June 21,

2007. Covered chiropractic services for VNS’s New York Medicare

Advantage members are only available through Triad’s network of

participating providers who also participate with Medicare. VNSNY Choice

offers several tiers of benefits to its members. Please verify covered

services for your patients prior to rendering services.

Effective Date 6/21/2007

UR/QM Prior approval is required after the 1st date of service (encounter). You can

request prior approval of services by submitting a Physical Medicine

Authorization form.




Please note, medical records are required to be submitted with the

Physical Medicine Authorization form.

Claims Methodology Fee for Service

Claims Submission Participating providers will need to submit all claims for dates of service

from June 21, 2007 forward for VNSNY Choice Medicare Advantage

members directly to Triad. Participating provider claims submitted directly

to VNS will be denied by VNS and will have to be re-submitted to Triad.

Claims filing

Deadline


services

Fee Schedule Claims are adjudicated and reimbursed at the Triad/VNS fee schedule.

You can request a copy of the Triad/VNS fee schedule, by calling Triad’s

Customer Service Department.

The fee schedule represents the Allowed Amount. Member cost share

(copay, coinsurance, deductible) will be deducted from the Allowed

Amount when final payment is issued by Triad. The member cost share


40 PVR.PA.EM.001.004 (02/06/2013)

(copay, coinsurance and deductible) portion of the Allowed Amount will be

identified on the Explanation of Payment and should be collected directly

from the member.

Administrative Fee None

Appeals

All Participating Provider Claims and Administrative appeals should

be mailed to:


Appeals Department

80 Spring Lane


Fax to 860-793-3317

Utilization Review and Member Appeals:

VNS Choice Select

Grievance and Appeal Department

1250 Broadway

3rd Floor

New York, NY 10001

For additional information about the appeal process please refer to the

denial letter. You may request another copy of the denial letter by calling

Triad’s Customer Service Center at 1-800-409-9081.

Benefit Limitations Chiropractic Manipulative Therapy (CMT) is ONLY covered service under

this benefit.


Customer Service at 1-800-409-9081 and a Representative can assist

you.

Complaints and

Grievances


encourages open communication; a complaint can be done by calling

Triad’s Customer Service Center 1-800-409-9081 or in writing at the


manner.

Triad Healthcare


80 Spring Lane


Primary Care

Referral

Triad’s programs do not require a PCP referral for chiropractic care.

Customer Service Contact Triad’s Customer Service Department at 1-800-409-9081,

41 PVR.PA.EM.001.004 (02/06/2013)

Visiting Nurse Services New York Choice (VNSNY CHOICE)

Acupuncture

Type of Business Medicare Advantage

Triad Program Acupuncture benefit for Medicare Advantage Members in New York.

Summary Triad has been selected to administer an Acupuncture program for VNSNY

CHOICE Medicare Preferred (HMO SNP) and VNSNY CHOICE Medicare

Maximum (HMO SNP) members (only) in New York, beginning January 1,

2013. Triad will provide administrative services including; network contracting,

credentialing and claims payment. The program will allow VNSNY members the

opportunity to receive Acupuncture services from a Triad participating provider

based on members benefit.

Effective Date 1/1/2013

UR/QM Prior Authorization is not required for this program. Only the following

Acupuncture services are included and covered under this program. All other

services provided will not be covered under this program.

97810: Acupuncture, one or more needles, without electrical

stimulation, initial 15 minutes of personal one-on-one contact with the

patient.

97811: Each additional 15 minutes of personal one-on-one contact with

the patient, with re-insertion of needles. 97811 cannot be performed

without 97810.

97813: Acupuncture, one or more needles, with electrical stimulation,

initial 15 minutes of personal one-on-one contact with the patient.

97814: Each additional 15 minutes of personal one-on-one contact with

the patient, with re-insertion of needles. 97814 cannot be performed

without 97813.

Claims

Methodology

Fee for Service

Claims

Submission

Participating providers will need to submit all claims directly to Triad for dates

of service January, 1 2013 forward for VNSNY CHOICE Medicare Preferred

(HMO SNP) and VNSNY CHOICE Medicare Maximum (HMO SNP)

members (only) in New York.

Claims Filing

Deadline

Providers have 180 days to submit claims from the date of rendered services

42 PVR.PA.EM.001.004 (02/06/2013)

Fee Schedule Claims are adjudicated and reimbursed at the Triad/VNS fee schedule. You can

request a copy of the Triad/VNS fee schedule, by calling Triad’s Customer

Service Department.

Administrative

Fee

None

Appeals All Participating Provider Claims and Administrative appeals should be

mailed to:


Appeals Department

80 Spring Lane


Fax to 860-793-3317

Utilization Review and Member Appeals:

VNSNY CHOICE

Appeals and Grievance Department

1250 Broadway

3rd Floor

New York, NY 10001

For additional information about the appeal process please refer to the denial

letter. You may request another copy of the denial letter by calling Triad’s

Customer Service Center at 1-800-409-9081.

Benefit

Limitations

Limited to 12 visits per calendar year

Complaints and

Grievances


encourages open communication; a complaint can be done by calling Triad’s

Customer Service Center 1-800-409-9081 or in writing at the address below.

All complaints are researched and resolved in a timely manner.

Triad Healthcare


80 Spring Lane


Primary Care

Referral

Triad’s programs do not require a PCP referral for acupuncture services.

Customer

Service

Contact Triad’s Customer Service Department at 1-800-409-9081, Monday-



43 PVR.PA.EM.001.004 (02/06/2013)

Claim Appeal Request Form (All States except NJ)

CLAIM APPEAL REQUEST FORM

TRIAD Healthcare, Inc.

80 SPRING LANE

PLAINVILLE, CT 06062

Fax: 860-793-3317

DATE: _____________

APPELLANT’S NAME: __________________________

Health plan: ___________________________ ID#___________________________________

Reference Numbers being appealed: ______________________________________________

ADDRESS: ______________________________________________________________

TELEPHONE NUMBER: BUSINESS: ____________________________________

HOME: ____________________________________

FAX: ____________________________________

Please provide the reason for requesting this appeal.

Include original issue/complaint, statement of original issue and brief summary.

List CPT Codes being appealed: __________ For Dates of Service: _______________




(USE ADDITIONAL FORMS FOR ADDITIONAL CPT/DATES OF SERVICE)

PLEASE SUBMIT ANY ADDITIONAL SUPPORTING DOCUMENTATION, SUCH AS:

OFFICE NOTES, MEDICAL RECORDS, DIAGONOSTIC STUDIES

_____________________________________________________________________________________

I authorize and direct TRIAD Healthcare, Inc. to investigate the issues described above. I authorize any party identified

above to release information pertaining to this investigation to TRIAD Healthcare, Inc. upon her/his written request.

_________________________________________________________

Name

_________________________________________________________ ____________

Signature Date

Please indicate that you have sent all necessary clinical information to review this appeal Yes No

Will you be submitting additional information with this appeal Yes No

Please submit this form and all documentation in writing to the above address or fax to 860-793-3317.

TRIAD QM Department MS-04-099

Ver052907

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46 PVR.PA.EM.001.004 (02/06/2013)

Appendix

Triad Committees

Triad’s Medical Quality Improvement Committee (MQIC) is responsible for developing

a proactive approach to continuous clinical quality improvement. The objective of the MQIC

is to establish a system of assessing and resolving clinical issues and concerns by applying

consensus within an environment of professional diversity, clinical subject matter expertise,

cooperation and leadership. This objective is to ensure that Triad’s Medical Management

Programs and processes deliver safe, efficient and effective services to our clients’

members. The MQIC is a diverse group of providers that participates in the development of

medical policies, clinical programs and quality improvement initiatives. This committee is

comprised of clinical providers of various specialties who are experts in their field, and

Triad’s administrative staff.

The Medical Operations Committee (MOC) is responsible for making reasonable effort in

identifying clinical issues through reporting from internal sources that work with or are a

result of contact with Triad’s provider community. Triad’s MQIC has delegated the

responsibility for the identification of clinical issues requiring medical policy development to

the MOC. The MOC clarifies and distills issues from which useful, practical medical policy can

be developed.

The Academic Advisory Committee (AAC) and its members provide professional

expertise in the development of Triad’s medical policies so as to allow for these policies to

be created, modified or deleted with input from the academic/research community. The

Committee is a sub-committee of Triad’s MQIC.

The work of these three committees ensure that Triad’s medical policies are developed with

practical input from the provider community, academic/research community and challenged

by a multi-disciplinary group of Musculoskeletal practitioners. The result is the creation of

reasonable evidence based medical policy that is well accepted by the provider community.

The Credentialing Committee is a sub-committee of MQIC. This committee is comprised

of a group of providers of many different specialties that have oversight of the credentialing

policies and procedures and network participation. Its purpose is to assess the qualifications

of licensed providers and render a decision for participation in the Triad Healthcare, Inc.

network. In addition, it provides appropriate monitoring and re-evaluation for continued

compliance of participating providers with regard to initial credentialing standards, through

the re-credentialing process.