Genesis HealthPlan Member

This section of our Web site is your guide to using Genesis HealthPlan (GHP). It includes helpful, easy-to-find information about how to get your health care needs met in an efficient and cost effective manner. If you would like your questions answered personally, just give us a call. One of our customer service representatives will be glad to help you.

Customer Service - at Your Service

One of the many advantages of Genesis HealthPlan is our knowledgeable, friendly customer service staff who are available locally to serve you. You can call or stop in personally. The Genesis HealthPlan office is located at 2550 Middle Road, Suite 601, Bettendorf, Iowa 52722 Phone: 563-421-3000. Our customer service staff will answer your questions in a professional, confidential manner. Customer Service hours are 8:00 a.m. until 4:30 p.m., Monday through Friday. At other times, you may leave a message on the answering machine and a representative will assist you the next working day.

Customer Service can provide assistance in the following areas:

• Benefits and coverage
• Request for additional identification cards
• Dependent status
• Changes in dependent coverage
• Payment of claims
• Participating providers
• Access to providers
• Quality of health care

Member Identification Card - Carry it at all times

Your Genesis HealthPlan Member Identification Card provides information necessary to obtain health care services. Each subscriber and spouse (if applicable) will receive a member identification card. When you receive your ID card, please check the card to make sure the information on the card is correct. If you find an error, let us know right away so we may correct it and issue a new card.

Please carry your ID card with you and be prepared to present it whenever you receive health care services. Additional ID cards will be provided if you lose your card, if you need an additional card for covered dependents away at college, or if the information on your card changes. Contact a Customer Service Representative for your ID card needs.

Selecting a Provider for Your Health Care Needs

As a Genesis HealthPlan member you may choose to see two types of providers:

1. Genesis HealthPlan Participating Provider
   A physician, hospital, lab or other health services provider who has a contract with Genesis HealthPlan to provide services to our members and has agreed to comply with health plan guidelines concerning notification, claim filing and payment.
2. Non-Participating Provider
   A physician, hospital, lab or other health services provider who does not have a contract with GHP to provide services to HealthPlan members, and therefore, is not obligated to comply with HealthPlan guidelines concerning notification, claim filing and payment. Healthcare services provided by a Non-Participating Provider may be covered at a reduced benefit level.

GHP Participating Providers Make Using Your Health Benefits Easy!

To get the most from your health care benefit, use a GHP provider.

A GHP Participating Provider coordinates and manages your health care needs effectively without requiring you to jump through hoops. So forget about the hassles of completing claim forms and making phone calls to pre-certify hospital services. Our GHP providers do that for you! All we ask is that you follow the three C's when using GHP and make managed care easy.

The 3 C's To Using GHP Effectively

1. CARD - Show your ID card before receiving services
2. CO-PAYMENT - Pay your co-payment at the time of service
3. COMMUNICATE - with your GHP Provider about your health care needs and with GHP staff about how we can help you

Genesis HealthPlan Provider Directory

A separate Provider Directory is included with your member materials. The directory lists the names of all Participating physicians, facilities, and ancillary providers along with their address and phone numbers. If you are unsure whether a certain provider participates with GHP, simply call Customer Service.

Medical Management Program

Genesis HealthPlan has developed a Medical Management Program to assure that high quality medical care is provided in the most appropriate setting by the most appropriate provider. Through this program, GHP monitors and manages the health care needs of its members and enables employers and members to achieve significant savings on health care spending. It also contributes to your improved health. A few examples of the medical management programs are listed.

1. Pre-certification/Preauthorization. A program for authorizing procedures and/or hospital admissions prior to the time of service.
2. Individual Case Management. A program for actively coordinating a patient's care to assure the most favorable outcome in terms of quality and cost.

Member and Provider Responsibilities

Please read the following information carefully. The decision you make in selecting your physician makes a difference in the level of responsibility your physician has in coordinating your health care services as compared to the level of responsibility you have. The key responsibilities include claim filing, payment for services, and notification of planned admissions and planned procedures.

The matrix entitled GHP Member and Physician Responsibilities (see table) outlines who is responsible for performing various duties based on the type of provider used. (An explanation of how to fulfill each type of responsibility is provided after the matrix.)

The matrix clearly shows that if you use a GHP Participating Provider, you have very few responsibilities and the GHP Provider performs most all duties for you. On the other hand, if you use a Non-Participating Provider, you must assume more responsibility. Your decision to use a Participating GHP Provider reduces your responsibility for coordinating your health care services and may increase your benefit level.

Claim Filing and Claim Payment - Whose Responsibility?
The GHP Participating Provider agrees to file claims directly to the health plan on your behalf. Genesis HealthPlan will pay the provider directly. A participating provider should only bill you for coinsurance or deductibles not yet satisfied. Your only payment responsibility is for coinsurance and deductibles according to your benefit plan.

The Non-Participating Provider does not agree to file claims directly to GHP. You must file the claim. To file a claim simply obtain a Medical Claim Form from your Employee Relations Department, complete it according to the directions on the claim form, and send to Genesis HealthPlan at the address listed. (See the section entitled GHP Member Claim Filing Process for more information). Payment will be made directly to you, and you are responsible to pay the Non-Participating Provider for any coinsurance, deductibles, non-covered services and charges that exceed Genesis HealthPlan's allowed amount.

Notification of Planned Hospital Admissions and Planned Procedures
As previously explained in the Medical Management program, Genesis HealthPlan requires preadmission certification of all non emergent (planned) hospital admissions, and pre-certification of selected (planned) inpatient or outpatient procedures. The responsibility for notification is determined by the type of provider you select.

A Participating GHP Provider agrees to obtain admission and procedure pre-certification for you. You are not required to contact Genesis HealthPlan.

The Non-Participating Provider may or may not agree to obtain admission or procedure pre-certification on your behalf. If the Non-Participating Provider will not perform these medical management activities for you, it is your responsibility to obtain pre-certification prior to the admission or the procedure. To obtain preadmission certification or procedure pre-certification, call Genesis HealthPlan and provide the following information:

Patient Name & GHP ID Number
Admitting Physician Name
Admit Date
Admitting Facility

Why you are being admitted to the hospital- (medical reason or surgical procedure)

Once we receive this information, we may contact the admitting physician to obtain additional medical information.

Notification of Emergency (Unplanned) Hospital Admissions
If you or a covered dependent are unexpectedly admitted to a hospital, either locally or out-of-the-area, you must contact Genesis HealthPlan within 24 hours of the admission. This helps our professional staff begin managing your health care needs in a timely manner to help you get the most from your benefit plan. The phone number is listed on the back of your member ID card.

Emergent Medical Care - Life Threatening
Genesis HealthPlan defines a medical emergency as a sudden, unexpected illness or injury in which delay in care or treatment would endanger a person's life. Examples include unconsciousness, severe burns, excessive bleeding, suspected heart attack, acute chest pain, or shock. If one of these conditions occurs, go straight to the nearest emergency room or call an ambulance. You are covered for emergencies anywhere in the world. PLEASE NOTE: If you seek treatment at an emergency room, and receive non-emergent care or services, you may be responsible for paying applicable deductibles and/or higher co-insurance. Refer to your Plan Document for more information.

Urgent Medical Problems - Not Life Threatening
An urgent problem is different from an emergency in that it is not life threatening, but you do need to speak to a doctor right away. Examples include most lacerations, sprains, abdominal pain and fractures. If you should have an urgent medical problem, call your GHP doctor for advice on how you should handle the situation. Your doctor may give you first-aid advice over the telephone, tell you to go to his/her office, to a Genesis HealthPlan participating facility such as a FirstMed Clinic or to the hospital emergency room.

If you have an urgent medical problem after office hours, you should follow your doctor's after hours instructions or simply call your doctor's office and ask the operator to page your doctor or the doctor-on-call. The doctor will call you back shortly. Explain your situation and follow your physician's instructions. If you are not familiar with how your doctor handles after-hour calls, discuss this with him/her for future reference.

Out-of-Area Care
GHP provides you with world-wide coverage for urgent or emergency care. Whenever you are out of town and have an emergency, seek treatment at the nearest medical facility. If you are admitted to a hospital you must notify GHP of the admission within 24 hours. For urgent conditions you may go to an urgent care facility (like FirstMed), but we recommend that any follow-up care you need be provided by a GHP physician. If you have to pay for your care at the time of service, ask for an itemized copy of your bill. When you get home, follow the claim filing instructions provided in this member handbook.

College Student Coverage
College students outside the GHP service area are covered for urgent or emergency care only. We recommend that you schedule appointments for routine care to coincide with school vacations or breaks. Another way to handle medical care for college students is to take advantage of student health services available at most colleges and universities. Schools usually charge a reasonable fee for this service, which allows your son or daughter to go to a student health center for minor conditions.

GHP Member Claim Filing Process
When to File a Claim: After you receive health care services, you should file a claim only if your provider has not filed one for you, (eg, claims for services from a non-participating provider). Claims should be submitted within six months or 180 days from the date of service to ensure payment.

How To File a Claim: Use a separate Genesis HealthPlan claim form for each member of your family and each provider. Follow the directions printed on the claim form, complete all sections and sign the claim form. Attach a copy of either the superbill, itemized statement, or a HCFA 1500 form to the claim form. Itemized statements must be on the forms of the health care provider who performed the service and must include the following:

Provider's full name and address 
Provider's Tax Identification Number 
Patient's name 
Date(s) of service 
Date of the injury or onset of illness 
Charge for each service 
Description of each service 
Diagnosis for each service provided 
Where you received the service (office, outpatient facility, hospital, etc.) 
Send claims to the address on the member ID card.

Explanation of Benefits
Once we receive and process your claim, we will send you an explanation of benefits (EOB) form that tells you how we processed and paid your claims. Your EOB will include both medical and dental services (if applicable), and will have a check attached at the lower portion of the form if you are eligible for reimbursement of covered expenses.

Claim Questions
If you think an error was made in paying your claim, we will be glad to review the claim payment for you. To initiate a review, inform our customer service representative that you would like a claim to be reviewed. He/she will ask you to provide some information about the claim (provider, patient, date of service) and the reason for your question and will assist you with the claim review process.

Coordination of Benefits
If you or your family have health coverage from another company, GHP and the other company will coordinate benefits. That way, all of your allowable medical expenses will be eligible for payment without duplicating payment for the same benefit.

GHP will apply general insurance industry coordination of benefits rules: 

1. The coverage you have through your employer pays first (primary coverage). 
2. The plan for which you are listed as a dependent pays second (secondary coverage). 
3. hildren who are covered under both parents' policies have primary coverage under the policy of the parent whose birthday falls earlier in the year (this is known as the Birthday Rule). 
4. Medical expenses associated with an automobile accident are paid by the automobile insurance carrier first. 
5. Medical expenses associated with an injury or illness related to your job are paid by your employer's worker's compensation carrier first.
6. Submit claims to your employer for coverage.

When coordinating benefits, we may request information from you about your other coverage. Please respond as soon as possible. It will help us get your medical bills paid promptly.

GHP Member Rights
Genesis HealthPlan guarantees you specific rights. We are committed to providing you with quality health care in a cost efficient manner while respecting these rights. As a GHP member, you have the right to:

1. Accessible health care services that are prompt and appropriate for the symptoms presented, and when medically necessary, the right to emergency services 24 hours a day, 7 days a week.
2. Receive information regarding your health problems, treatment options, and any risks associated with those treatments. This will help you make an informed decision. 
3. Participate in decisions regarding health care, including the right to refuse treatment recommended by a GHP provider or authorized provider. 
4. Be treated with respect, dignity, and privacy. 
5. Review and access your medical records maintained by the provider or GHP in accordance with the law. 
6. File a complaint or grievance if you experience a problem with a GHP provider or GHP action, according to the procedure outlined in the Summary Plan Description. 
7. Privacy of medical and financial records which are maintained by GHP or any GHP provider in accordance with applicable law.

GHP Member Responsibilities
While GHP guarantees you the above rights, we also ask that you accept the following responsibilities. Doing so helps us meet your healthcare needs and provide you with quality, cost-effective services.

1. Read and understand your benefit plan documents and comply with the rules and limitations as stated.
2. Carry and present your GHP identification card prior to receiving care. 
3. Pay co-payments and deductibles as stated in the benefit plan. 
4. Notify GHP of changes in eligibility for you, your spouse or dependent(s) covered under your policy. 
5. Notify health care providers in a timely manner of appointment cancellations. 
6. Provide information needed for the provision of health care services to health care providers and GHP professional staff. 
7. Follow your health care provider's instructions and guidelines.

Member Complaint and Grievance Procedures
The management of your health care and related services requires extensive coordination among GHP providers, members, and HealthPlan staff. We realize there may be instances when a member is dissatisfied with services provided. To respond to member complaints or concerns, we have established the following Member Complaint and Grievance Procedures. We ask that you start with the Member Complaint Procedure prior to initiating a formal grievance. By doing so, your concern may easily be resolved without further intervention.

Member Complaint Procedure:
Inform our Customer Service Representatives of any dissatisfaction you might have in areas such as access to providers, quality of health care services, accuracy and timeliness of claim payment and response to your inquiries. Our Customer Service Representative will make every effort to resolve your concerns on an informal basis. However, if this is not possible, you may proceed by filing a formal grievance with Genesis HealthPlan.

Grievance Procedure:
Contact a Customer Service Representative to request a Grievance Form. Grievances must be submitted within 90 days of the date of service or event. The Grievance Procedure has four levels and must begin with Level 1.

Level 1:
Send a completed Genesis HealthPlan Grievance Form with an explanation of your problem or concern to:

Genesis HealthPlan 
Attention: Customer Service 
2550 Middle Road, Suite 601
Bettendorf, IA 52722 

Include your name. Address, and any supporting documentation. Upon receipt, we will investigate the matter and review it with our management staff. We will communicate the review decision or action to you within 10-15 business days from receipt of the Grievance Form. If you are dissatisfied with the decision, you may appeal it to the Medical Director.

Level 2 Medical Director Review Procedure:
Send a written appeal to GHP within 30 days from receipt of the Level 1 review decision. Our Medical Director will review all available information and will make a decision within 30 days from the receipt of your appeal. If you are not satisfied, you may appeal the decision to the Grievance Committee.

Level 3 Grievance Committee Review Procedure:
Send a written appeal to GHP within 30 days from receipt of the Medical Director's decision. The Grievance committee will review the appeal and all available information within 30 days from the receipt of the appeal. You have a right to be present at the Grievance committee meeting and you may bring or send a representative on your behalf You or your representative will be given the opportunity to explain your position. Within 14 days of the meeting, the Grievance Committee will notify you of their decision. If you are not satisfied, you may appeal the decision to the GHP Board of Directors.

Level 4 GHP Board of Director's Review Procedure: 
Send a written appeal to GHP within 14 days of the date of the Grievance Committee's decision. The Board of Directors will consider the appeal within 30 days of its receipt. You will be advised in writing within 14 days of the Board of Director's review outcome. The Board of Directors review outcome shall be considered the final grievance procedure.

For further information, contact us at: ghp@genesishealth.com