FREQUENTLY ASKED QUESTIONS

WHA is required by our accreditation and licensing agencies to review medical record keeping systems of its contracted providers.

Contact WHA's Member Services department and ask to speak with WHA's Corporate Quality Leader or the Quality Improvement department with any questions regarding medical record requirements.

The effective date of the Timely Access Regulations is 1/17/11.

The Timely Access Regulations establish appointment availability standards for primary care physicians, specialist physicians, ancillary providers (physical therapy, radiology, laboratory, etc.), and mental health providers.

No. The Timely Access Regulations do not apply to:

• Preventive care (including routine physicals and well-child care);
• Periodic follow-up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits for pregnancy, cardiac care, and mental health care;
• Laboratory and radiological monitoring for recurrence of disease.

All of these types of care are not subject to the Timely Access Regulations and may be scheduled consistent with professionally recognized standards of practice.

The applicable waiting time for a particular appointment may be extended only if the referring or treating licensed health care provider, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.

No. This determination may be made only by the referring or treating licensed health care provider, acting within the scope of his or her practice and consistent with professionally recognized standards of practice.

No. The Timely Access Regulations do not set forth specific chart documentation standards, other than to say that this decision must be documented in the relevant record.

"Advanced access" means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician's assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day). If a primary care physician offers "advanced access," it is considered to be in compliance with the appointment availability standards in the Timely Access Regulations.

Health plans are required to measure and monitor the performance of their provider networks against the appointment availability standards. As part of this measurement and monitoring process, health plans will focus on overall performance trends and patterns at the IPA/medical group level.

For patients calling after-hours with urgent, non-emergency, situations that cannot wait until the next business day should receive on of the following options:

• Stay on the line and be connected to the doctor on call.
• Leave a name and number and a physician or qualified healthcare professional will call you back within 30 minutes.
• Reach the doctor at another number, which is given.

• If a patient calling after-hours states he/she is dealing with an emergency the patient must be told to call 911 or referred to the nearest emergency room.

WHA contracts with Alere,® an accredited organization to provide nurse advice line services to all WHA members 24 hours a day, seven days a week, 365 days a year. Alere also has bi-lingual nurses that can assist your patients whose preferred spoken language is Spanish.

WHA's dedicated phone line for the Nurse Advice Line is (877) 793-3655.

WHA's Advantage Referral Program (ARP) allows our members more options when specialty care is needed. Under this unique program members may seek care and services from specialists associated with medical groups other than their own. To qualify, the ARP specialist must be in WHA's network and accept Advantage Referrals. Prior authorization is not required, but a referral from the member's PCP is needed to establish medical necessity and identify the type of specialist that is needed.

Yes, but not all WHA contracted specialists accept Advantage Referrals. Physicians that do not participate in the program are identified in WHA's Provider Directory with a special symbol. The Provider Directory is available on WHA's website (www.westernhealth.com) or you may call a Member Services representative for assistance, Monday - Friday between 8am and 5pm at: (916) 563-2250.

Advantage Referral (AR) specialists may provide consultations and order routine lab work and plain film x-rays when needed. If additional testing, procedures, surgeries or other non-routine services are needed, the AR specialist must notify the member's assigned PCP and obtain prior-authorization to ensure further coverage. The program does not include rehab, PT, ST or OT services from non-group WHA providers.

Send claims for AR services to the Claims Dept. of the member's assigned medical group or IPA, and mark them as "Advantage Referral" for faster processing.

WHA encourages practitioners to give their Medical Group/IPA as much prior notification as possible when leaving a Group. WHA is required by regulatory and accrediting agencies to notify members that are affected by the termination of a practitioner or practice group in general, family and internal medicine or pediatrics, at least 30 calendar days prior to the effective termination date.

Certain covered services require prior authorization (pre-approval) from the PCP's affiliated medical group/IPA or from WHA in some cases, to ensure benefit coverage and/or medical necessity. Each medical group has its own list of services that require prior authorization. Contact the Medical Management/UM dept. of your patient's assigned group for specifics.

Service requests requiring prior authorization are typically reviewed by doctors and nurses at the group level, but some reviews are ultimately performed at the plan level, depending on the type of request. Only experienced physicians can deny or modify a request at either level. Authorization requests (referrals) should be sent to the Medical Management/UM dept. of your affiliated medical group or IPA, and not sent directly to WHA. If WHA needs to make the authorization decision at the plan level, your group will forward the request to WHA for review.

Prior authorization is not needed for initial emergency room treatment. Members may also see a network eye specialist once a year for a routine eye exam, and women may access network obstetrical or routine gynecological services without pre-approval. In addition, Advantage Referrals to out-of-group network specialists do not require prior authorization, but a referral to your group is needed for claims payment purposes. Your affiliated medical group or IPA should know which services require prior authorization and those that can be directly accessed by a member.

By law, a decision to pre-approve, modify or deny a specialty or service referral request must be made within certain timeframes. Turnaround times are based on the urgency of your patient's medical condition and treatment needs, but most decisions are made within five (5) working days of receiving necessary information to make the decision. If fast handling is needed due to urgent medical needs of your patient, you may request "expedited" handling. Expedited requests submitted by the member's physician will be completed as soon as possible based on the patient's individual situation and urgency, but no later than 72 hours of receipt of the request and sufficient information to make the decision.

The PCP/group, member and specialty provider, if any, are notified in writing of the authorization decision. If the decision is adverse (i.e., request not approved), the requesting physician/provider will initially be notified by phone, fax and/or electronic message within one (1) day of the decision. In addition, a written notice of the decision is mailed to the PCP/group, member, and specialist when applicable, within two (2) working days after the initial notice was made for denials, and within three (3) working days of an approval. Adverse decision notices include an explanation of the reasons for the denial, delay or modification and provide information on how/where to file an appeal with WHA. The notice also includes information on how to contact the California Department of Managed Health Care (DMHC) for an independent review of the case.

Insurance eligibility and benefits are verified first to make sure the member has effective coverage. The referral/request is also checked to see if the requested service is from a WHA network provider. Experienced nurse/physician reviewers then evaluate the member's individual situation and compare relevant medical records against review criteria based on recognized standards of practice for the member's diagnosis. In addition to relying on their own clinical expertise, use of established medical criteria helps reviewers decide if requested services are appropriate and medically necessary, and promotes fair and consistent decisions.

WHA's physician reviewers make coverage decisions related to appropriateness of care and services using available medical information about the patient and criteria that are based on recognized standards of medical practice. During these reviews, Plan benefits and individual circumstances of the patient are also considered. Financial incentives or compensation are not linked to these decisions or to the withholding of care.

At the plan level, WHA primarily uses Milliman Care Guidelines and Hayes New Technology Assessment & Experimental Treatment Guidelines to help physician reviewers make medical necessity decisions. Some contracted medical groups/IPAs also use InterQual criteria or their own internally developed guidelines that must meet stringent requirements and receive committee approvals.

Medical necessity review criteria are based on sound clinical principles and treatment practices, and involve actively practicing board-certified specialists in their development. All criteria/guidelines used by WHA and its medical groups must be approved annually by WHA's Quality Committee and Board of Directors to make sure they are still appropriate and current. Decisions related to covered benefits are based on contracts and language contained in the members' individual "Evidence of Coverage (EOC) and Disclosure" booklets, specific to their group health insurance plan. The EOC specifies covered benefits and benefit limitations and exclusions. Whenever changes are made to the EOC documents, they must be reviewed and pre-approved by the Department of Management Health Care (DMHC), which is responsible for licensing HMOs in the state of California.

Yes, WHA's clinical staff is available during regular business hours Monday through Friday, 8am-5pm by calling Member Services at (916) 563-2250 or (888) 563-2250 (TTY/TDD- (888) 877-5378), and asking to speak with a Medical Management representative. If the caller prefers to leave a message for WHA's clinical staff about a UM inquiry or calls after hours, select option 4. The message service is available 24 hours a day/7 days a week. All messages left after hours will be answered with a return call on the next business day. Inquiries can also be faxed directly to WHA's Medical Management Department at (916) 568-0278.

During regular business hours (M-F, 8am-5pm), a network physician may speak directly with WHA's Chief Medical Officer/Medical Director by calling the phone number listed in WHA's Provider Manual and included in all Denial letters. If a confidential voice message is left, a return call will be made by the next business day.

WHA's contracted medical groups/IPAs are responsible for conducting concurrent review of patients admitted to acute hospitals from the ER when the hospital is located within the group's defined service area, which varies among groups. WHA, at the plan level, is responsible for conducting concurrent review of patients admitted through the ER to acute hospitals located outside the health plan's service area. When a patient is hospitalized outside the service area, requires ongoing care, and is stable for transfer, WHA's concurrent review nurse collaborates with the hospital's discharge planner and group's UM nurse to facilitate the transfer to a network facility.

Yes, per California law, all members must be allowed a second opinion when requested, but certain restrictions apply. The second opinion consultation must be provided by a physician with the same specialty as the first opinion physician, and the second opinion provider must be in WHA's network. Prior authorization is needed to ensure coverage. In-network review decisions are made at the medical group level. If the specialty needed for a second opinion is not available within WHA's provider network or network services cannot be provided in a timely manner consistent with the member's situation, the request is forwarded to the health plan level for decision-making, which may result in approval of a non-network second opinion.

Prior authorization timeframes for making decisions for second opinion requests are the same as for all other routine or expedited service requests (completed within 5 working days for routine reviews, or within 72 hrs of receiving sufficient information for expedited handling). For adverse decisions, notification is provided to the requesting physician initially by phone call, fax or EMR within one (1) working day. Written notice of all decisions is made to the physician/group, member and specialist if applicable, within three (3) working days of the decision for routine reviews, and sooner if expedited handling is required. If the plan makes the decision to approve or deny a non-network second opinion, WHA is responsible for notifying all affected parties within the required timeframes.

New diagnostic and surgical procedures, drugs and other healthcare interventions that are not FDA approved or not yet considered the usual standard of practice according to the national and local medical communities, are reviewed by WHA to see if they are safe and effective before they are included as covered benefits. Services determined to be "experimental" by WHA are not covered benefits. If you want your patient to receive a service that might be experimental, submit your request to your affiliated medical group. It will be screened and forwarded to WHA for investigation and decision-making if experimental status is a possibility.

WHA's physician reviewers use special new technology assessment criteria developed by Hayes, Inc. to help with potentially "experimental" decisions. If no criteria exist for the requested service or it is too new to adequately evaluate through other resources, WHA may forward the case to its outside contracted vendor, iMedecs, where independent board-certified physician reviewers provide expert opinions and recommendations. For service requests determined to be experimental, WHA will issue the appropriate denial notices to all affected parties following required timeframes. If a requested service is no longer considered experimental by WHA, it will be returned to your affiliated medical group for medical necessity review and authorization determination.

WHA, at the plan level, reviews all requests for organ and bone marrow transplants, but only after the initial transplant evaluation is completed at the group level. If you have a patient who needs a transplant evaluation, send the referral to your affiliated medical group for prior authorization. If the evaluation results in a recommendation for a transplant, send the referral to the Medical Management/UM dept. of your affiliated medical group and it will be forwarded to WHA for decision-making. WHA will review the records and send the decision notification letters to the physician/group and member within established authorization timeframes.

Once WHA validates the medical necessity of the transplant request, and issues the initial approval notices to requesting parties, all transplant related services, including hospitalization for the surgery/procedure, are reviewed and authorized by the member's assigned medical group.

Send the request (referral), any relevant patient medical records, and specific information about the clinical trial to the Medical Management/UM dept. of your affiliated medical group, and they will forward it to WHA for decision-making. The process is similar to the one used for plan level transplant reviews. Authorization decision notices are issued by WHA to all affected parties.

California law allows certain new health plan members to continue to receive some limited services from providers they accessed under their previous health plan, even if those providers are not in WHA's network. These non-network services are provided under WHA's Continuity of Care program. Typically, those who qualify are receiving active or ongoing care/treatment that should not be interrupted when they become effective with WHA. Allowing new members' access to their current non-network specialists provides more time to establish a relationship with their new WHA PCP, and transition their care to other network providers when it's more appropriate for their individual situation.

To qualify for limited non-network CoC services, the new member must meet specific criteria and submit an application to WHA for review and prior authorization. Examples of qualifying events i nclude, but are not limited to: new members who are pregnant when they become effective with WHA, have scheduled surgeries already approved by their previous health insurance plan, or are undergoing active radiation treatments or chemotherapy for cancer.

WHA is responsible, at the plan level, for reviewing and making CoC authorization decisions for new health plan members. When a decision is made, WHA notifies the member and non-network provider in writing. WHA also notifies the member's new WHA PCP and/or medical group so a case manager can work directly with the patient and treating physicians to transition care/services into WHA's network at the appropriate time. New members with CoC approvals to receive services from certain non-network specialists are still required to establish care with their new WHA PCP and access other care/services from network providers as appropriate.

Case management services are available to any WHA member meeting program criteria. These services are provided by experienced nurses employed by the member's assigned medical group or IPA. Typically, CM services are provided to members with complex or multiple medical conditions that require many visits to specialists or when other multiple services are needed. If your patient needs help managing his or her healthcare needs, please make a referral or call the Medical Management/UM dept. of your affiliated medical group asking for case management assistance. Case managers serve as patient advocates and personally help members through the complexities of the healthcare system.

Anyone can ask for CM assistance, including the member, the member's physician, or a family member/caregiver/friend, etc. Send an online or faxed referral request or to contact your affiliated medical group's Medical Management/UM dept. by phone, call:

• Hill Physicians Medical Group - 1-800-445-5747
• Mercy Medical Group - (916) 379-2885
• NorthBay Medical Group - (707) 646-4241
• UC Davis Medical Group - (916) 734-9900 or 1-800-445-3936
• Woodland Medical Group - (530) 662-3961 x 4361

Healthyroads.com Customer Service
P.O. Box 509040
San Diego, CA 92150-9040
Phone: 1-877-330-2746
E-mail: service@healthyroads.com