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Home :: The Health Plan

Details: Visit Our Health Library. The Health Library is a collection of health and wellness resources created for learning and accessibility. Health Library.

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Clinical Services :: The Health Plan

Details: Utilization management ensures that our members receive quality, effective treatments and seeks to avoid any unnecessary hospital stays and procedures. Led by our in-house team of medical directors, our nurses perform a thorough review of a member’s clinical history and interact with the whole health care team.

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Outpatient Hospital Laboratory Pass Through Billing

Details: Outpatient hospital laboratory pass through billing is federally prohibited for the MHT LOB. A valid Federal Clinical Laboratory Improvement Amendments (CLIA) Certificate Identification number is required for reimbursement of clinical laboratory services reported on a CMS 1500 Health Insurance Claim Form or its electronic equivalent.

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For Providers :: The Health Plan

Details: File a Claim Check Eligibility Appeals Pre-Authorization Coding Issues Forms DME Criteria Billing & EDI Types of Plans

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Clinical Services Department :: The Health Plan

Details: Clinical Services Department. The Clinical Services department ensures the provision of appropriate health care to its members while addressing the effectiveness and quality of the care. The delivery of health care services is monitored and evaluated to identify opportunities for improvement. The program provides for a systematic process to promote the access of …

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Announcements & Newsletters :: The Health Plan

Details: The hospital claims edits will be applied across all THP product lines, which currently include Commercial, Medicare Advantage, Public Employees Insurance Agency (PEIA) and West Virginia Medicaid lines of business. Some examples of ClaimsXTen edits include: Deleted code edits;

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UB-04, Inpatient / Outpatient

Details: Hospital (inpatient and outpatient), hospice, home health, rural health clinic, federally qualified health center, and birthing center must bill on a UB-04. UB-04 Instructions The blocks divided into rows A, B, C reflect the following: A Primary Payer B Secondary Payer C Tertiary Payer

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Referrals & Prior Authorizations :: The Health Plan

Details: For example, some procedures and most inpatient hospital stays require prior authorization. Many other services do not need a prior authorization. You do not need one to see your PCP or in-plan specialists. You don’t need one for routine lab work, X-rays or many outpatient services either. Your doctor will tell you when you need these types

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Data Source Document

Details: Hospital Affiliations. Admitting privileges at the practitioner primary admitting facility are verified with the facility by The Health Plan or its designee initially. If applicable, hospital affiliations specify medical facilities where the practitioner has obtained privileges.

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Provider directory

Details: 3. NETWORK HOSPITAL: A network hospital is a facility that is contracted with The Health Plan to provide healthcare services to self-funded plan participants and their dependents. The hospital listing includes abbreviations for each hospital. These abbreviations appear in both the PCP and SCP listings, indicating at which hospital(s) the

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Provider directory

Details: 3. NETWORK HOSPITAL: A network hospital is a facility that is contracted with The Health Plan to provide healthcare services to plan participants and their dependents. The hospital listing includes abbreviations for each hospital. These abbreviations appear in both the PCP and SCP listings, indicating at which hospital(s) the

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Self-Funded Network Providers :: The Health Plan

Details: Self-Funded Network Providers. Click below on your appropriate network to find a listing of participating providers. If The Health Plan is your network provider, choose our logo below to access our provider search. If you have dental, please call our Customer Service Department at 1.888.816.3096 for assistance.

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Medicare Options :: Medicare 2022 Plans

Details: Covering inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. It is provided by the government, usually with no monthly premium. Medicare Part B is optional medical insurance for which you pay an additional monthly premium that usually comes out of your Social Security benefits. It covers

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› Url: https://medicare2022.healthplan.org/im-looking/learn-about-medicare/medicare-options Go Now

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Corporate Compliance Plan

Details: Current Status: Active PolicyStat ID: 8341125 Origination: 01/2019 Effective: 07/2020 Last Approved: 07/2020 Last Revised: 07/2020 Next Review: 07/2021 Owner: Jill Medley: Government Compliance Officer Area: Compliance Lines Of Business: BMS, …

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Annual Notice :: The Health Plan

Details: The nurse on call is available 24 hours a day, 7 days a week at 1.800.624.6961. Emergency services (including emergency room) are provided by a hospital emergency facility and includes emergency transportation. Emergency services are provided 24 hours a day, 7 days a week whether you are in or out of the service area to evaluate, treat, and stabilize a medical …

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Formularies :: The Health Plan

Details: Formularies. THP Rx offers various plans that cover generic, brand name and non-formulary options. Our formularies are developed to meet the members' needs in a clinical cost-effective manner. Members: Register or login to myplan.healthplan.org to access your pharmacy benefits or to use the "Find a Drug" tool.

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Hospital Readmission Occurring within 30 Days of an Index

Details: The hospital is required to combine the index admission and readmission on one claim to receive payment for the collective stays. Providers are advised to follow the billing guidelines below: Once the corrected claim is received by THP the index admission payment will be …

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Directory Search

Details: Hospital Admitting Privileges Updated as needed but every three (3) years during re-credentialing process. Medical Group Affiliation if available. Languages spoken in office Self reported.

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Compliance & Fraud, Waste & Abuse :: The Health Plan

Details: Compliance & Fraud, Waste & Abuse and Cultural Competency. The Health Plan uses education as a tool to ensure our members receive the highest quality of care by you, the provider. We achieve this through periodic reminders, updates and by communicating various compliance topics to facilitate our preventative approach.

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Shop DSNP :: Medicare 2022 Plans

Details: Shop DSNP :: Medicare 2022 Plans - The Health Plan. The Health Plan proudly offers SecureCare SNP (HMO D-SNP), a plan designed especially for dual-eligible, Medicare and Medicaid enrollees living in our approved service area. If you have Medicare and Medicaid, you may qualify for our Dual-Eligible Special Needs Plan (D-SNP) with more benefits

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West Virginia Medicaid Managed Care Member Handbook

Details: immediate care. Emergency care is given in or by a hospital emergency room. It is to evaluate and treat a medical problem caused by sudden, unexpected symptoms that require immediate medical attention. An emergency is usually a sudden and unexpected illness or injury that needs care to prevent (1) serious

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2022 SUMMARY OF BENEFITS

Details: If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgently needed services. Diagnostic Radiological Service (such as MRIs, CT scans) $0 or $150 copay $150 for CT scans, MRI, MRA, PET and SPECT scans. $0 copay for all diagnostic mammograms and diagnostic bone density exams.

› Verified 8 days ago

› Url: https://medicare2022.healthplan.org/application/files/4616/3043/1635/4JE062400_H3672_013_SB22_001_M__OPT_II_FINAL_.pdf Go Now

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SBC Non-Group HMO Bronze

Details: hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-controlled condition) n The plan’s overall deductible $4000 n Specialist copayment 40% n Hospital (facility) coinsurance 40% n Other coinsurance 40%

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Never Events, Adverse Events, Hospital Acquired Conditions

Details: According to the Bureau for Medical Services (BMS), hospital acquired conditions not present on hospital admission, the wrong procedure performed on a patient and procedures performed on a wrong patient or body part. Serious Reportable Event (SRE) According the NQF, a set or compilation of serious, largely preventable, and harmful

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Readmissions Review Occurring Within 30 Days

Details: hospital • skilled nursing facility • rehabilitation inpatient care • acute care • long-term acute care facility (LTACF). Notification of urgent/emergent inpatient admissions is expected within 48 hours to in-network facilities. Notification is available 24/7 by calling 1.800.304.9101 or faxing 1.888.329.8471 for medical services.

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THP INSURANCE COMPANY, INC. (THP) MEDICARE …

Details: hospital, physician or medical care received in a foreign country, which would have been Medicare eligible coverage, if the care had been received in the United States. The emergency care must have begun during the first 60 consecutive days of each trip out of the United States. Foreign emergency care is

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The Health Plan and West Virginia University Health System

Details: Hospital in Ripley, and Garrett Regional Medical Center in Oakland, Maryland. The WVU Health System also includes five institutes – the WVU Cancer Institute, the WVU Critical Care and Trauma Institute, the WVU Eye Institute, the WVU Heart and Vascular Institute, and the WVU Rockefeller Neuroscience

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Learn About Medicare :: Medicare 2022 Plans

Details: Part A (hospital insurance) and Part B (medical insurance) are combined in one plan, and may include additional benefits beyond Original Medicare, like prescription drug coverage, dental, hearing and vision care. Dual Special Needs Plan (D-SNP)

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THP CAMC MONHEALTH HIGHER PERFORMANCE NETWORK …

Details: Hospital; the highest level new born intensive care unit, highest level pediatric intensive care unit and one of the busiest Level I Trauma Centers. CAMC’s cancer program has been continuously accredited since 1947. • THP works with employer groups to help them select a tiered bene t plan including member

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COVID-19 Therapeutic Treatment Therapies

Details: C. Patient is being treated in a hospital or in a healthcare setting capable of providing acute care comparable to inpatient hospital care. COVID-19 therapeutic treatment therapies covered and reimbursable when billed to the Centers for Medicare and Medicaid Services (CMS) Medicare Administrative Contractor

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THP Network for PEIA Members

Details: and hospital services that are not normally available through In-Network Hospitals. Please note that a prior authorization is required to access a Tertiary hospital. All facilities located in West Virginia are considered In-Network and will not be affected by this change.

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I Ma Pa D P D Ca F

Details: Hospital Invoice– This will be an itemized statement from the hospital resulting from an observation stay. It must include the hospital pharmacy NPI number, date of service, physician name, drug name, drug NDC, quantity, days supply and amount you paid. Please circle the drugs on the statement for which you are submitting a claim.

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ADA 2012 Dental Claim Form

Details: • 21 - Inpatient Hospital • 22 - Outpatient Hospital • 31 - Skilled Nursing Facility • 32 - Nursing Facility The full list of POS codes is available at CMS.gov 39 Number of Enclosures No entry required. 40 C Is Treatment for Orthodontics? Required when reporting the date orthodontic appliances were placed.

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change from 365 days from date Retro Authorization Guidelines

Details: The Health Plan • 1110 Main Street • Wheeling, WV 26003-2704 • 1.800.624.6961 • healthplan.org Medicaid and Medicare guidelines require The Health Plan to have an effective program in place to prevent, detect, and correct fraud, waste and abuse.

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Summary of Benefits and Coverage: Coverage Period: The

Details: If you have a hospital stay Facility fee (e.g., hospital room) $100 copay/ admission Physician/surgeon fees If you need mental health, behavioral health, or substance abuse services Outpatient services may include tests and services described Inpatient services If you are pregnant Office visits Childbirth/delivery professional services

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Medicare Basics :: Medicare 2022 Plans

Details: Medicare has four main parts – A, B, C, and D. They cover certain medical services and prescription medications, as well as supplies in hospitals, doctors’ offices and other health care facilities. Medicare Part A is hospital insurance. It is provided by the government, usually with no monthly premium. Medicare Part B is optional medical

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Effective July 1, 2019

Details: medical and hospital services that are not normally available through in-network hospitals. Please note that a prior authorization is required to access a tertiary hospital. All facilities located in West Virginia are considered in-network and will not be affected by this change.

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THP INSURANCE COMPANY, INC. (THP) MEDICARE …

Details: amount) or if you receive hospital outpatient department services under a prospective payment system, the copayment amount, after the $198 annual deductible is met. Part B covers doctor bills, laboratory services, outpatient hospital services and …

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