QCPI Orientation 2014 Quality Care Providers, Inc. 3350 Peachtree Road NE Suite 1180 Atlanta, GA 30326 Phone: (678) 553-4600 Fax: (678) 553-4601 Email: contact@qcpi.org Confidential Property of Quality Care Providers, Inc.

QCPI Welcome Orientation Managed Care Products through QCPI’s Network HMO Requirements Primary Care Selection Timeliness of Filing LabCorp, National Reference Laboratory for BCBSGA Precertification Requirements Formulary Practice Age Restrictions Accessibility / Call Coverage Credentialing Reimbursement / Clinical Quality Integration Process Incentive Programs Network Manuals Electronic Connectivity BCBSGA Claims Issue Escalation Process Resources Confidential Property of Quality Care Providers, Inc. Slide 2

BCBSGA Managed Care Products Membership growth continues to be in the Blue Open Access HMO/POS Products Commercial State Health Benefit Plan Exchange Products PCPs are encouraged to use efficient technology resources Availity: ICR and Patient Care Summary MMH+ Confidential Property of Quality Care Providers, Inc.

Managed Care Products through QCPI QCPI is the primary care network for the following BCBSGA products: Gatekeeper Products: BlueChoice Healthcare Plan, (HMO) product (a PCP designation is required) BlueChoice Option, (POS) product (a PCP designation is required) Open Access Products: Blue Open Access HMO Blue Open Access POS Exchange Products through Pathway Networks Confidential Property of Quality Care Providers, Inc. Slide 4

Managed Care Products through QCPI Identifying HMO/POS Products Network Name Confidential Property of Quality Care Providers, Inc.

SHBP Member ID card   Network in Georgia: this is the reimbursement you can expect PPO “suitcase” for traveling benefits

HMO Requirements Primary Care Physician Selection: For BlueChoice Healthcare Plan (HMO) and BlueChoice Option (POS) the PCP’s name is on the patient’s card. For Blue Open Access HMO/POS (including SHBP and Exchange plans), no PCP designation is required. Timeliness of Filing: Claims filed (with or without preauthorization) after ninety (90) days from the date of the service will be denied for delay in timeliness of filing. LabCorp: LabCorp is the exclusive national reference laboratory for all BCBSGA patients. All laboratory studies must be referred to LabCorp (or to an HMO contracted specialty or genetic laboratory provider) except those that have been approved as in-office laboratory procedure codes. Precertification Requirements: View at www.bcbsga.com Formulary: View at www.bcbsga.com Confidential Property of Quality Care Providers, Inc. Slide 7

HMO Requirements… cont’d Practice Age Range Restrictions: Internists 15 years and up Family Practitioners ages 0-99 Pediatricians ages 0-20 (a Pediatrician is not to see an adult patient age 21 yrs or older) Office Hours: 20 hours of patient contact per week, 4 days a week Accessibility / Call Coverage: 24 hours, 7 days a week; covering PCP must be a QCPI In-Network PCP (who treats the same age group) Confidential Property of Quality Care Providers, Inc. Slide 8

Credentialing Attained degree of Medical Doctor (MD) or Doctor of Osteopathy (DO) Completed 3 years post-graduate training in internal medicine, family practice or pediatrics Board certified within specialty or board certified within 5 years of completion of post-graduate training * Recertification is required to maintain network participation Valid, unrestricted medical license, active DEA number without limitations Professional liability insurance coverage $1M/$3M Use of CAQH online credentialing is required 120 days to complete the credentialing process for new physicians Recredentialing is required every 3 years Confidential Property of Quality Care Providers, Inc. Slide 9

QCPI Reimbursement –Section 5 of the QCPI Manual QCPI generally provides (30) days written notice of any reimbursement change; however only (10) days notice is required under QCPI Agreement Gatekeeper Products: PCPs are reimbursed either on a fee-for-service or capitation basis pursuant to QCPI’s Clinical Quality Integration Process Open Access Products: PCPs are reimbursed on a fee-for-service basis pursuant to QCPI’s Clinical Quality Integration Process Confidential Property of Quality Care Providers, Inc. Slide 10

Reimbursement / Clinical Quality Integration Clinical Quality Integration - a process which aligns a physician group’s quality of care with its financial reimbursement for BCBSGA/BCBSHP’s managed care products. Physician groups (including solo practitioners), after comparison to its peers, will be reviewed annually to receive a higher level of reimbursement, a lower level of reimbursement, or to remain on the same fee schedule. Physician groups which generate an insufficient amount of data to allow for a meaningful analysis will NOT be affected. The measures used to evaluate reimbursement are available on the QCPI website, and are communicated annually to network physicians. The Physician Quality Report and notice of any fee schedule changes are mailed out annually. Confidential Property of Quality Care Providers, Inc. Slide 11

Quality and Incentive Programs QCPI’s physician quality programs are designed to reward physicians who are able to effectively combine high quality preventive care with efficient use of resources. Recognize & Reward Programs (R&R): Targeted preventive metrics to recognize quality. Those QCPI PCP’s who provide documented, measurable preventive care to their patients are given incentives (subject to the availability of funds) for meeting quality benchmarks. These programs require active participation through QCPI’s Rewards website. Physician Quality Report: Our annual program provides each eligible PCP with a Physician Quality Report. All of the measures for the above programs are available on the QCPI website. Confidential Property of Quality Care Providers, Inc. Slide 12

QCPI PCP Network Manual / Contract Product Participation: Each PCP participates in the Gatekeeper Products and the Open Access Products. Patients: Each PCP should accept new patients who seek to select the PCP as his/her PCP if the PCP is accepting new patients for any other health benefit plan which encourages patients to use a network of health care providers. Panel Closing Policy: A PCP may close his/her patient panel to patients for the Gatekeeper Products and the Open Access Products according to Section 8.1 of the QCPI Network Manual. Patient Move Policy ( See Section 8.3): If you change practices, but remain in the QCPI network (19 county service area) and your move is more than 10 miles to the new practice – your patients will be re-assigned to another QCPI provider. If you leave the QCPI network but remain a BlueCross physician, your patients will be re-assigned to another QCPI provider. Amendments to Manual: 30 days notice Confidential Property of Quality Care Providers, Inc.

QCPI PCP Network Manual / Contract –Changes & Notification Section 11 of the QCPI Network Manual discusses the following: Changing or adding location address Changing Tax ID Adding a new physician to practice Departure of a physician from practice Termination/Resignation by physician Confidential Property of Quality Care Providers, Inc. Slide 14

Coordination With BCBSGA: HMO Physician Office Manual BCBSGA has published a network manual relating to the operations of the BCBSGA Products. The BCBSGA HMO Physician Office Manual addresses operational matters such as: Contact information Provider Services Membership and Enrollment The Primary Care Physician Claims Filing Electronic Connectivity (EDI Services) Laboratory Tests (Lab Corp is required Lab) Utilization Management Preferred Drug List Quality Management Wellness Programs NOTE: The BCBSGA HMO Physician Office Manual is incorporated by reference in your Independent Physician Agreement with QCPI (Agreement) and therefore a part of your entire contract Confidential Property of Quality Care Providers, Inc. Slide 15

Electronic Connectivity – BCBSGA www.availity.com Secure multi-health plan portal with access to claims status, eligibility & benefits, claims status, AIM Specialty Health link, online remits. A a multi-payer portal that gives health care providers secure access with one sign-on to multiple payer’s information Your practice’s use of Availity and Blue Cross and Blue Shield of Georgia’s ProviderAccess portals are currently included in the Technology Use Component of QCPI’s Clinical Quality Integration Process QCPI also encourages its network physicians to: File claims electronically with BlueCross Use Electronic Funds Transfer/Electronic Remittance Advice Use AIM Specialty Health® (AIM®) ProviderPortal - https://www.providerportal.com to pre-certify all advanced imaging studies (CT and MRI). Confidential Property of Quality Care Providers, Inc. Slide 16

Availity: www.availity.com Self service tools like Interactive Care Reviewer (ICR) to request inpatient and outpatient precertifications for many members covered by BCBSGa plans: Ability to find information on a precert previously submitted via phone, fax, ICR, or other online tool Referral requests can also be submitted Access this functionality under Auth and Referral (on the left of Availity website) Secure Messaging for clarification on claims status Patient Care Summary (formerly CareProfile): Consolidated (HIPAA compliant) view of patient health care services for a health plan across providers at no cost 2 year summary of patient medical claims-based information Ability to retrieve separate summaries if patient had coverage with more than one payer Confidential Property of Quality Care Providers, Inc.

Member Medical History Plus – MMH+ Provides access to your BCBSGA patients medical and claims history online Free, up to 5 years of information, HIPAA compliant Medical history includes: past diagnoses, medications filled, lab results, procedures performed, other providers seen and care alerts Access via internet URL Contact Sherry Vallee to sign-up Confidential Property of Quality Care Providers, Inc.

BCBSGA Claims Issue / Escalation Process Claims Payment Inquiry: Use Availity multi-payer Web Portal first for all claims payment inquiries If not successful, inquiries may be addressed through Customer Service (“CS”) for resolution [phone number is listed on back of the member’s ID card] Escalation: In the event that the self-service tools and CS Reps are unable to provide your office with support, then request to speak with a CS Supervisor. A Reference No. will be provided for you to retain in future communications- it is extremely import to keep this Reference No. for future use If no resolution is met after following these above steps, you may request the issue be entered into an Escalation Tool and the Provider Inquiry Resolution Team (PIRT) will follow up with you within 1 business day and follow through to completion Process is designed to ensure you receive answers to claims inquiries Visit BCBSGA website for more information Confidential Property of Quality Care Providers, Inc. Slide 19

BCBSGA Resources The BCBSGA web site www.bcbsga.com provides access to: General information and answers to frequently asked questions Medical Policies and Clinical UM Guidelines BCBSHP HMO Physician Office Manual Most up-to-date provider communications Formulary information Precertification Requirements Confidential Property of Quality Care Providers, Inc. Slide 20

QCPI Resources www.qcpi.org provides access to: General information and answers to frequently asked questions about QCPI Messages and notices about current incentive programs QCPI Primary Care Physician Network Manual https://Rewards.qcpi.org provides access to: QCPI’s incentive and self-reporting programs To access QCPI’s websites, use your login/password. Your login is your firstname.lastname and your initial password was provided to you in your welcome letter Confidential Property of Quality Care Providers, Inc.