More than one million individuals are enrolled in health plans that access the NCPPO and HealthLink network. The NCPPO and HealthLink service area includes Maryland, Northern Virginia, Washington DC, Missouri, Illinois, Arkansas, Kentucky, Ohio and Texas.

Multi-Payor System
The NCPPO and HealthLink network program is not tied to any one payor organization. Rather, the program provides network access and administrative services to approximately 200 payors (contracted insurance carriers, self-funded self-administered payor clients and third party administrators) who administer benefits on behalf of self-funded clients who have contracted directly with NCPPO and HealthLink.

NCPPO and HealthLink is not the insurer or claims administrator in these arrangements. In exchange for access to the networks and certain related administrative services, these payors and plan sponsors agree to provide benefit incentives to plan participants who use the network, to administer claims promptly and to make payments, in accordance with NCPPO and HealthLink's negotiated rates and the plan's benefit provisions, to network physicians and facilities.

Reimbursement Model
Negotiated rates with physicians and facilities are based on an agreed discounted fee-for-service basis. Participating physicians, hospitals and other health care professionals may not balance bill patients in excess of the negotiated maximum allowance (i.e., rate) for covered services.

Self-Referral to Health Care Services
Enrollees may self-refer to physicians and other health care services. Referrals are arranged between the physician, patient and specialist. Please refer patients to other participating physicians, hospitals and health care professionals in recognition of the enhanced benefits that typically exist when enrollees utilize our network services. You may contact the Customer Service Department or access NCPPO and HealthLink's website at www.ncppo.com to verify other participants in your area, and/or request a directory.

Claim Repricing/Processing Activity
As a network service, NCPPO and HealthLink receives and reprices claims in accordance with the contract agreements with physicians or facilities. Afterwards, we forward the claims and worksheets to the claims administrator for benefit determination and payment. A repricing worksheet is produced for every claim. The worksheet shows the applicable contracted rate that corresponds to the billed service. NCPPO and HealthLink works with regional and national electronic claim vendors.

NCPPO AND HEALTHLINK PROGRAMS AND SERVICES

Networks
Patient Self-Referral/Physician-Directed Care
Discounted Fee-for-Service Arrangements
Optional Pharmacy Network

Utilization Management
Pre-Admission Certification of Planned Admissions (standard)
Emergency Admission Notification (standard)
Concurrent Hospital Stay Review (standard)
Discharge Planning Assistance (standard)
Major Case Management (elective)
Outpatient/Ambulatory Review (elective)
Second Opinion Surgical Review (elective)

Administrative Services
Claim Repricing
Claim Activity Confirmation Reports
Claim Investigation and Resolution
Payor and Network Contract Administration
Utilization Management (elective)
Toll-Free Customer Service
Network Service Representation
Centralized Credentialing
Network Directory Publication
Web-Based Resources and Promotion

NCPPO and HealthLink Quick Reference

Benefit Information
To verify benefit coverage for health services or patient eligibility, please contact the benefit administrator identified on the patient's enrollee ID card.

Customer Service Call Center
For inquiries about referral resources, claim status, and inquiries about benefit administrator phone numbers to verify patient eligibility or covered services, please call:

Customer Service
Toll-free 1-800-624-2356
Hours: 8:30 a.m. to 6:30 p.m. EST
Open business days.

Please note: Enrollee ID cards identify the office phone number of the benefit administrator. Questions regarding eligibility or benefit coverage may most efficiently be directed to the patient's benefit administrator.

You may also obtain claim status and payor information at the patient account level through our IVR (Interactive Voice Recognition). Your PIN number (EDI claim filing and claim status authorization number) will allow you to access claim activity up to nine months old for multiple or single patient accounts specific to the practitioner or facility. IVR and web access for claims information are available from 5:00 a.m. to midnight CST.

Utilization Management
Utilization Management components vary among health plans accessing the NCPPO and HealthLink network program. Please refer to your patient's enrollee ID card for specific directions and components of Utilization Management. The following Utilization Management components may be included in the program:

• Pre-Admission Certification of Planned Admissions (standard)
• Emergency Admission Notification (standard)
• Concurrent Hospital Stay Review (standard)
• Discharge Planning Assistance (standard)
• Second Opinion Surgical Review (elective)
• Major Case Management (elective)
• Outpatient/Ambulatory Review (elective)

For pre-certification of inpatient and select outpatient procedures, please call:

Utilization Management
Toll-free 1-877-284-0102
Hours: 9:00 a.m. to 6:00 p.m. EST
Recorded messages after 6:00 p.m. EST

For pre-certification, please be prepared to provide the following information:

• Patient Name
• Diagnosis
• Patient ID Number (SSN)
• Procedure Required
• Hospital Name
• Date of Admission
• Admitting Physician Name and Tax ID Number

Select insurance companies and third party administrators are allowed to provide Utilization Management services directly or through a vendor, provided they are URAC-accredited and suitably licensed. Please refer to your patient's enrollee ID card for verification.

Network Services
For general information about programs, contracts, administrative services and credentialing information, please call your Network Consultant. If your consultant is out of the office, you may leave a voicemail message or contact the Customer Service Call Center for assistance and/or transcription of your inquiry:

Network Services
Toll-free 1-800-624-2356
Hours: 8:00 a.m. to 5:00 p.m. CST
Open business days.

Messages to Network Consultants will be returned within two business days.

Claims Submission
Submit electronic claims through your electronic clearinghouse vendor:
Payor ID 90001

Submit paper claims to:
Specific PO Box and claim filing addresses listed on the patients' ID cards.

Office Visit Co-payment
The office visit co-payment varies by employer group and/or payor. Typically, a specific dollar amount co-payment is indicated on the patient's enrollee ID card if the plan coverage includes a flat co-payment. Collect this co-payment at the time of service. If the plan has a coinsurance percentage and/or deductible, the amount payable by the patient may vary as benefits are used during the plan benefit year. Coinsurance and deductibles usually are not printed on the patient's enrollee ID card.

File your claim as directed on the patient's enrollee ID card. The explanation of benefits will advise you and your patient of the expense paid by the health plan and the amount payable by the patient, if any. Practices are responsible for collecting any monies due from patients.

Appeals Submission
Claim denials, payment reviews (not pertaining to fee allowances), claim status, lack of pre-certifications, etc. should be directed to the claims administrator listed on the patient's enrollee ID card.

For all other types of administrative, service and clinical appeals, please submit a typed explanation of the appeal consideration along with supporting information, and mail to:

NCPPO and HealthLink Appeals Division
P.O. Box 411424
St. Louis, MO 63141