What is OrthoNet’s role in the authorization process?

Health Net has delegated Network Management, Medical Management and Claims Payment responsibilities for in-network occupational and physical therapy services to OrthoNet. OrthoNet will process all requests for additional therapy services, other than the initial visit, and perform utilization review services.

Which Members are covered by the program?

In New York all Commercial HMO, PPO, POS and Medicare Prime; Medicare Advantage; ASO; HRA and HSA members are included in this program.

What is the effective date of this Agreement?

Effective September 1, 2006, any outpatient rehabilitation services provided to the Health Net members described above will require prior authorization from OrthoNet. Rehabilitation providers may see members upon referral from a physician for an initial evaluation visit without prior authorization. After the initial visit, therapy providers must contact OrthoNet to obtain approval for subsequent visits.

What services does this include?

Outpatient physical and occupational therapy is included. Services provided by chiropractors are excluded. Upper extremity splints dispensed by therapists in their office will also be included in this program.

What services are not included?

This agreement does not include rehabilitation services performed in the home (provided by a home health care agency) or services provided by chiropractors. This Agreement also does not include speech therapy.

Does this change any Health Net member's benefit limits for outpatient rehabilitation?

No, this does not affect any current benefit limits, they will still apply.

Can physicians refer their Health Net patients to any participating Health Net provider for PT/OT?

Effective September 1, 2006 Health Net physicians may refer their patients to any participating physical or occupational therapist found in Health Net’s provider referral directory.

Is a referral required?

No, a Health Net referral is not required to request physical or occupational therapy services for a Health Net member. Physicians do not have to contact OrthoNet for approval prior to referring members for a therapy evaluation.

How does this affect physicians who provide therapy services in their office?

Physicians who have contracts with Health Net to perform office based physical and/or occupational therapy will be required to obtain an authorization from OrthoNet for all visits other than the initial evaluation. They are not required to be part of the OrthoNet Therapy Provider Network.

Where will physicians submit their claims for physical and occupational therapy?

Physicians who are not contracted with OrthoNet will continue to bill Health Net for these services as they do today.Claims for physical and occupational therapy services will be paid according to their existing Health Net agreement.

Will hospital based physical therapy departments be required to obtain authorization?

Yes, all outpatient physical and occupational therapy performed in a hospital must be authorized after the initial evaluation visit.

Will hospitals be required to contract with OrthoNet for outpatient rehab services?

No, hospitals can continue to participate through their existing Health Net Agreement.

Where will hospitals submit their claims for physical and occupational therapy?

Hospitals who are not contracted with OrthoNet will continue to bill Health Net for these services as they do today. Claims for physical and occupational therapy services will be paid according to their existing Health Net agreement.

How do I join the OrthoNet network?

OrthoNet has sent out an information packet to all Health Net therapy providers which contained the necessary information and application forms needed to join its network. Please complete the information requested and send it back to OrthoNet for processing. If you have not received an information packet please contact us. If you call us, the OrthoNet Provider Services Representatives will request the following information from all providers requesting membership in the network:

· Contact Name

· Facilty Name

· Facility Address (Including City, State and Zip Code)

· Phone number

· Fax number

This information will be forwarded to the OrthoNet Network Development Department for the mailing of applicable credentialing materials.

Will I still be able to participate in the Health Net therapy provider network if I don't join OrthoNet?

The majority of Health Net’s participating therapy providers currently are in the OrthoNet network. If a provider is not in the OrthoNet network they are encouraged to join to ensure that they will be able to continue to see Health Net members ongoing. OrthoNet will credential new providers during the initial acceptance period of this program and after that time additional providers may not be added, depending upon geographic need or access requirements. Participating Health Net therapists who do not join the OrthoNet network will be terminated by Health Net effective September 1, 2006.

How will provider payment change when this agreement becomes effective?

Effective September 1, 2006, outpatient rehabilitation providers will be reimbursed according to their OrthoNet agreement.

What happens if a Health Net member receives outpatient therapy without an authorization?

Effective September 1, 2006 any claim submitted for services, other than the initial evaluation, which does not have a valid authorization will be subject to denial or other financial penalty as outlined in Health Net’s policies and procedures. All providers, both participating and non-participating, will be required to pre-certify additional therapy services under this program.

Will this program affect all Health Net members?

In New York all Commercial HMO, POS and Medicare Prime; ASO; HRA and HSA members are included in this program.

How do I obtain an authorization from Orthonet?

Current Health Net and OrthoNet providers will receive a packet from OrthoNet fully explaining the authorization process.

What about patients currently undergoing course of therapy?

Any member whose course of therapy treatment began prior to September 1^st will only need to pre-certify visits that will occur on or after September 15^th. If they will not be continuing with care after September 15^th they will not need to have their visits authorized. Any member commencing their therapy treatment on or after September 1, 2006 will need to have all of their therapy visits (excluding the initial evaluation) pre-certified by OrthoNet.

Does the initial evaluation need to be authorized?

Initial therapy visits do not require authorization in this program. However, subsequent visits do require authorization from OrthoNet prior to the patient being treated. Although no longer necessary, OrthoNet recognizes that many providers will still wish to verify eligibility/benefits and authorize the patient’s initial therapy visit.

Please follow the procedures outlined below for requesting pre-certification of additional visits. Please make sure that you use an OrthoNet-Health Net Fax Request Form for all therapy visit requests.

How do I submit a request for additional therapy visits?

A. Complete the Fax Request Form.

In the Therapy Provider Information section provide either the facility name or treating provider name with their corresponding OrthoNet provider id number. Non-participating OrthoNet providers should enter their Health Net provider id number. Also, to identify offices with multiple locations, please complete the address, city, state, and zip fields of the location where the member is to be treated.

In the Member Information section, fill in the member’s name, date of birth and Health Net identification number. Please fill in the fields from left to right. In the Request Information section, darken the appropriate service type, request type and whether the visits will be used for post-operative therapy. Enter the initial evaluation date as well as the diagnosis code and the requested number of visits in the appropriate fields

B. Submit the Fax Request Form.

Please fax the completed form along with a copy of the completed PT/OT Initial Report Form or its’ equivalent, to OrthoNet’s Medical Management Fax Server at 1-800-450-4189. Please submit only Fax Request Forms and any associated documents to this number.

If you do not have any Fax Request Forms, they may be obtained by accessing our website at www.orthonet-online.com or by calling OrthoNet’s Provider Services Department at 1-800-413-8695 and a package will be mailed to you.

C. Receive the authorization number.

It is OrthoNet’s goal to review the request and supporting clinical data, verify eligibility/benefits, render a determination and assign an authorization number, if approved, within one (1) business day following the receipt of all necessary information.

Providers will be notified via fax of the authorization number assigned and the number of visits approved. Additional information regarding the status of authorizations may be obtained by visiting our website, www.orthonet-online.com and selecting the “Check the status of authorizations and claims”. Please note: You will need to have an active OrthoNet Web Account to access this information.

What will OrthoNet need to render a decision on my request?

In order for OrthoNet to promptly respond to your request, objective clinical data needs to be supplied. Examples of objective clinical data include, but are not limited to: strength, active range of motion, functional status, short and long term treatment goals, and a treatment plan

This information may be supplied on OrthoNet’s PT/OT Initial Report Form, Functional Progress Chart, or on your own forms or clinical notes that would supply the same information.

Who will be reviewing my request?

Your request for additional visits will be reviewed by a licensed rehabilitation professional. Furthermore, OrthoNet has board-certified physicians and professionals that are experienced in the areas of orthopedics, neurology, pediatrics and sports medicine.

When will the decision be made?

OrthoNet understands the importance of the continuity of care for patients receiving rehabilitation services. In order to maintain this continuity, OrthoNet’s goal is to review the request and supporting clinical data, verify eligibility/benefits, render a determination and assign an authorization number, if approved, within one (1) business day following the receipt of all necessary information.

How will I find out about decision?

OrthoNet will fax all decision letters to providers after a decision has been made. These letters will be faxed to the fax number that is on file for each provider. For this reason, it is especially important for facilities that have more than one location to specify the location where the member will be treated on the Fax Request Form.

Why do I have to use OrthoNet's Fax Request Form?

Due to the high volume of requests and updates received daily at OrthoNet, it is imperative that all fax submissions be accompanied by an OrthoNet Fax Request Form. This enables OrthoNet to identify, route, track and review all submissions in a prompt and efficient manner. Submissions without the form or incomplete forms can not be processed.

Can I treat prior to authorization?

If you treat a patient prior to OrthoNet’s authorization determination, for those visits, please be advised that authorization may not have been given and that those visits might not be eligible for benefits. Should you need to, you may call OrthoNet’s Provider Service Department at 1-800-413-8695 to ascertain the status of a member’s authorization request.

Our authorizations all bear expiration dates. Should you wish to request an extension of an unexpired authorization, please call OrthoNet’s Provider Service Department at 1-800-413-8695 prior to the authorization’s expiration date. OrthoNet’s policy is that expiration dates will be extended if calls are received prior to the expiration date as long as it fits within the member’s benefit timeframes

Where do we submit claims?

For all dates of service on or after September 1, 2006, if you have a contract with OrthoNet you will submit all PT/OT claims to them as described below. If you are not contracted with OrthoNet you will continue to submit claims to Health Net as you do today. All services will still require a valid authorization from OrthoNet – whether you are contracted (participating) with OrthoNet or not.

Paper claims can be mailed to OrthoNet at the following address:

OrthoNet
Health Net Claims Department
P.O. Box 5042
White Plains, NY 10602-5042

OrthoNet can not accept and/or process any faxed claims.

Electronic submissions are accepted using Emdeon/WebMD. You must provide # 25681 as the Payor identification number. If you have any questions on electronic submissions, you may contact Emdeon/WebMD directly at 1-800-845-6592.

Where do we send claim appeals?

Only those claims processed by OrthoNet are subject to appeal through OrthoNet.

Claim Appeals can be mailed to OrthoNet at the following address:

OrthoNet
Health Net Claims Appeals Department
P.O. Box 5043
White Plains, NY 10602-5043

You may also fax the information to OrthoNet’s Correspondence Department at 1-914-949-4929.

What is the claims filing time?

Providers have 90 days from the date of service to submit their claims. If a provider wishes to appeal OrthoNet’s claim decision, it must be requested within six months from the last denied or paid date on the claim.

If you should have additional questions regarding this program please visit our website at www.orthonet-online.com or contact OrthoNet’s Provider Services Department at 1-800-413-8695 for further assistance