Resources UVa Health Plan Filing Complaints and Appeals Reconsideration of Adverse Decisions Expedited Appeals Process Health and Medical Advice on the Internet Frequently Asked Questions

• Explain the UVa Health Plan policies and benefit coverage
• Provide answers to questions regarding the UVa Health Plan
• Listen to complaints and concerns regarding the UVa Health Plan
• Make UVa Health Plan information available to UVA employees
• Provide information concerning complaint and appeal procedures and advise employees which review level is appropriate
• Investigate payment problems for claims submitted to the UVa Health Plan that employees have been unable to resolve themselves
• Refer issues to other university offices or committees as appropriate
• Promote healthy living

• The quality of health care service received;
• General inquiries about Covered Services; or
• Your rights.

• Issues about the scope of coverage for health care services;
• Medical Necessity of services requested;
• Denial of care/services/claim; or
• Other Adverse Benefit Determinations, as defined below.

• Adverse Administrative Decision: An Adverse Benefit Determination that is not an Adverse Decision.
• Adverse Benefit Determination: A denial of a request for service or a failure to provide or make payment (in whole or in part) for a benefit. An Adverse Benefit Determination also includes any reduction or termination of a benefit. An Adverse Benefit Determination based in whole or in part on a medical judgment, including the failure to cover services because they are determined to be Experimental/Investigational or not Medically Necessary, is also considered a final Adverse Decision.
• Adverse Decision: An Adverse Decision is a utilization review determination by the Claims Administrator that the health care service rendered or proposed to be rendered was or is not Medically Necessary, when such determination may result in noncoverage of the health care service. A final Adverse Decision is a type of Adverse Benefit Determination that may result in an Independent External Review.
• Authorized Representative: An Authorized Representative is an individual authorized by the Member or state law to act on the Member’s behalf in obtaining claim payment or during the appeal process. A provider may act on the Member’s behalf with the Member’s express written consent for all appeals except Expedited Appeals when the provider does not need the Member’s express consent to act as Authorized Representative.
• Complaint: A Complaint is an inquiry to the Claims Administrator about Covered Services, Member rights or other issues or the communication of dissatisfaction about the quality of service or benefit or other issue which is not an Adverse Benefit Determination. Complaints do not involve utilization review decisions.
• Expedited (Urgent Care) Appeal: An Expedited Appeal is an appeal that must be reviewed under an expedited process because the application of non-expedited appeal time frames could seriously jeopardize a Member’s life or health or the Member’s ability to regain maximum function. In determining whether an appeal involves urgent care, the Claims Administrator must apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. An Expedited Appeal is also an appeal involving (a) care that the treating physician deems urgent in nature; (b) the treating physician determines that a delay in the care would subject the Member to severe pain that could not adequately be managed without the care or treatment that is being requested; or (c) the Member is a cancer patient and the delay would subject the Member to pain. Such appeal may be made by telephone, facsimile or other available similarly expeditious method.
• Independent External Review: If the Member receives a final Adverse Decision of an appeal, the Member or the Member’s Authorized Representative which may include the treating provider may appeal the Adverse Decision by filing a request for an Independent External Review. The Independent External Review process is explained below.
• Physician Advisor: A Physician Advisor is a physician licensed to practice medicine in Virginia or under a comparable licensing law of a state of the United States and who provides advice regarding the medical necessity of a service to the Claims Administrator as part of its utilization review activities.
• Post-service Appeal: A Post-service Appeal is an appeal for which an Adverse Benefit Determination has been rendered for a service that has already been provided.
• Pre-service Appeal: A Pre-service Appeal is an appeal for which a requested service requires Prior Authorization, an Adverse Benefit Determination has been rendered, and the service has not been provided.
• Reconsideration: A review of an Adverse Decision by either the Claim Administrator’s Medical Director, a Physician Advisor, a peer of the treating provider who is licensed in the provider’s same or similar specialty, or a panel of other appropriate health care providers with at least one Physician Advisor or peer of the treating health care provider on the panel. The provider on behalf of the Member shall request a Reconsideration of an Adverse Decision.

• Your name;
• Your provider’s name;
• The date of service;
• Your or your authorized representative’s mailing address;
• An explanation of why the Claims Administrator should consider reversing the original decision; and
• A copy of any information that will support your request.
• A letter notifying you that the appeal has been received will be sent within five days of its receipt.

• Your name;
• Your provider’s name;
• The date of service;
• Your or your authorized representative’s mailing address;
• An explanation of why the Claims Administrator should consider reversing the original decision; and
• A copy of any information that will support your request.

• Your name;
• Your provider’s name;
• The date of service;
• Your or your authorized representative’s mailing address;
• An explanation of why the Claims Administrator should consider reversing the original decision; and
• A copy of any information that will support your request.

UVa Health Plan Ombudsman
University Human Resources Benefits Division
914 Emmet Street
P.O. Box 400127
Charlottesville, VA 22904-4127

United Behavioral Health
Attn: Appeals/Complaints
PO BOX 411517
Saint Louis, MO 63141-3517
Telephone: 1 (800) 975-8919
Facsimile: 1 (866) 209-9317

UVa Health Plan Ombudsman
University Human Resources Benefits Division
914 Emmet Street P.O. Box 400127
Charlottesville, VA 22904-4127

CVS Caremark
Clinical Department-Appeals Process 1
620 Epsilon Drive
Pittsburgh, PA 15238-2845

CVS CAREMARK
Clinical Department-Appeals Process 2
620 Epsilon Drive
Pittsburgh, PA 15238-2845

UVa Health Plan Ombudsman
University Human Resources Benefits Division
914 Emmet Street
P.O. Box 400127
Charlottesville, VA 22904-4127

United Concordia
P.O. Box 69420
Harrisburg, PA 17110

UVa Health Plan Ombudsman
University Human Resources Benefits Division
914 Emmet Street
P.O. Box 400127 Charlottesville, VA 22904-4127

• My ePHIT- UVa Health Plan members can participate in Southern Health's new feature of their WellBeing program, My ePHIT, by logging in at the Southern Health member website and logging in to My Online Services and click on the View WellBeing Programs. Utilizing cutting-edge technology and proven techniques, My ePHIT engages individuals in activities promoting physical fitness, good eating habits and behavioral management. With the help of accredited doctors, psychologists, dieticians, and personal trainers, the health improvement program provides customized wellness plans based on individuals' personal fitness goals and current state of health.
  
  
• UVA Health System - This site has an A-Z directory that offers easy-to-understand information on a wide range of health topics.
  
  
• The UVa Health Resource Center - (formerly known as "Bodytalk") is a confidential free service designed to provide you, your friends, and neighbors with easy access to health information in everyday language.
  
  
• WebMD - provides valuable health information, tools for managing one's health, e.g. symptom checker, and support to those who seek information. Users can look up information on health conditions, clinical trials, and medications.
  
  
• KidsHealth - provides doctor-approved health information about children from before birth through adolescence. Created by The Nemours Foundation's Center for Children's Health Media, the award-winning KidsHealth provides families with accurate, up-to-date, and jargon-free health information they can use.
  
  
• The National Institutes of Health (NIH) is the primary Federal agency for conducting and supporting medical research. This website contains links to numerous health topics by body part location/ system, clinical trials, medication search information, and links to health topic specific hotlines.
  
  
• DrugDigest - This site provides general health information related to drugs and drug therapies. It contains information on drug interactions, vitamins, and herbs and strives to help consumers make informed choices. It believes that the better informed you are, the healthier you'll be.
  
  
• CDER - This site is the U.S. Food and Drug Administration's source of information on the Center for Drug Evaluation and Research. It contains drug information, consumer information, breaking news on drugs, and quick links to associated sites.
  
  
• America on the Move - Part of the Governor of Virginia Healthy Virginians Initiative, America on the Move Program can help you to start a walking program and track your progress. Learn tips on eating healthier lunches at the Lunch Well website.

1. How can I obtain the highest level of health plan benefits?
   
   
   • Check to see that your selected provider is in network before receiving services.
     
     
   • Be sure that pre-authorization for required services, such as for physical and occupational therapy services and DME, is obtained by the provider from Southern Health before receiving services. Be sure that you receive service in the time period that has been authorized.
     
     
   • Enroll in the National Network /OOA program if you or a dependent will be away from the network area for more than 90 days. http://www.hrs.virginia.edu/forms/OOAEnrollmentForm.pdf
     
     
   • Know the important deadlines related to the plan:
     
     
     • If you are an active employee, you must make changes related to mid-year qualifying events (births, deaths, marriages, divorces, etc.) within 60 days of the event or within the same plan year. If you are a retiree, you have 31 days from your retirement date to enroll in the retiree health plan, and 31 days to make changes related to mid-year qualifying events (births, deaths, marriages, divorces, etc.).
     • You must enroll in COBRA within 60 days of your termination date, or the date of your COBRA notice, whichever is later.
       
       
   • Know your responsibilities and reference the Description of Benefits found on the University Human Resources web site: http://www.hrs.virginia.edu/forms/descben.pdf. Be aware of plan exclusions found in the DOB (Description of Benefits), such as, acupuncture, TENS units, speech therapy for developmental delay disorders, and over-the-counter items.
     
     
   • Be aware that UVa Health Plan members will be required to obtain all specialty and injectable medications through CVS Caremark Specialty Pharmacy or through a participating retail Pharmacy if available. This means that the UVA Health Plan participants can not purchase specialty drugs directly from their physician, and charges for these drugs cannot be billed as medical claims through Southern Health. Please review the list of specialty /injectable medications and order through Specialty pharmacy which can send the medication to your physician office or to your home. This requirement applies to injectables, such as Rhogam and Synvisc, administered at a physician office.
     
     
     
2. What do I need to do for my dependent child who is going out of state to attend college?
   
   Members who will be residing outside of the Southern Health network service area for more than 90 days need to enroll in the National Network and use the participating National Network (a.k.a First Health ) providers in order to receive the highest level of benefits and pay the lowest cost-sharing amounts. This applies to all out-of-area participants, including retirees, COBRA enrollees, and dependents who are away or at school. Members who reside outside of the United States or who do not have access to sufficient providers in the National Network will be Out-of-Area enrollees, and will not be required to use the National Network.
   
   To enroll in the National Network and OOA, you must complete a National Network/ Out of Area form and should submit it to the UHR Benefits Division before the desired start date. A member who is enrolled in the National Network program and who sees National Network providers or Southern Health (SH) providers is eligible to receive in network benefits for covered services - one major point is that the member (not the provider ) is responsible for ensuring preauthorization is obtained prior to receiving services that require preauthorization. Call SH Customer Service at 1-888-975-9557 prior to accessing services to determine whether preauthorization is necessary and to check on the status of a pre-authorization for a particular service. A list of services requiring preauthorization is available at http://www.hrs.virginia.edu/forms/preauthlist.pdf.
   
   For more information about the National Network and OOA enrollment, see the UHR website information posted at: http://www.hrs.virginia.edu/benefits/ooa.html
   
   You may also read “Points to Consider” on the enrollment form, which is available at http://www.hrs.virginia.edu/forms/OOAEnrollmentForm.pdf.
   
   Providers in this National Network can be found on the Southern Health website (http://www.southernhealth.com) or by contacting SHS Customer Service at 1-888-975-9557. Members enrolled in the National Network may also seek care from Southern Health participating providers.
   
   If you do not enroll the college dependent in the National Network and he/she will be living away from the SHS network area, then the dependent will only be covered for urgent/emergent situations under the traveling coverage described below.
   
   
3. Am I covered when traveling out of the network?
   
   If you or a covered family member get sick while traveling outside the service area and visit an urgent care provider, the following criteria must be met to be considered for in network coverage. You:
   
   
   • Must be traveling outside the network service area.
   • Could not reasonably be expected to return to the network for treatment.
   • Could not have anticipated the care before leaving the service area.
   • Are advised to contact Southern Health within 48 hours to notify them of urgent care treatment at a non urgent care facility.
   • Must have a claim submitted that is deemed as an urgent care situation and needed services sooner that a routine doctor’s office.
   
   For detailed information about urgent care coverage, click here.
   
   If you have a medical emergency (see below), go immediately to the nearest appropriate medical facility. If you are admitted to a hospital, you or your representative should contact Southern Health as soon as possible to ensure proper pre authorizations are obtained.
   
   *Remember that any follow up care must be obtained in network or must be preauthorized by Southern Health at in network benefits to receive the highest level of health plan benefits.
   
   Follow up care is defined as treatment occurring after discharge from the emergency or urgent care medical facility, or hospital admission through the emergency room. This can include outpatient surgery following an Emergency room visit, such as for surgical repair of a fracture.
   
   
4. What are the criteria for coverage for emergency room care?
   
   An emergency is the sudden, unexpected onset of a medical or psychological condition with severe symptoms that could result in serious harm to you if left untreated. Examples of conditions that require emergency room treatment include but are not limited to:
   
   
   • Severe or unusual bleeding
   • Trouble breathing
   • Suspected poisoning
   • Prolonged or repeated seizures
   • Unconsciousness
   • Severe burns
   
   Claims for emergency room visits that do not meet emergency room criteria, such as for sore throat, may not be covered at all by your insurance.
   
   
5. Do I need to notify anyone if I move to a new address?
   
   Yes. If you are an active employee and you plan to move to a new address, contact your employee records department to get your address updated in the employee records system (e.g. People Soft, Oracle). The address update in the employee records system will be sent to Southern Health, UCCI, and CVS Caremark (formerly CVS Caremark) for active UVA Health Plan members. If you are a COBRA enrollee, retiree, or dependent of the member and you move to a new address, contact the UHR Benefits Division at 434-924-4392 to complete a change of address form. The UHR Benefits Division will notify Chard Snyder of COBRA address changes. The UHR Benefits Division also notifies Southern Health of the address changes, who in turn will notify UCCI Dental, and CVS Caremark.
   
   Note: You will also need to complete an Out of Area form to enroll in the National Network /OOA plan for your health plan coverage if you plan to be away from the network area for over 90 days. Otherwise your claims will process at Out-of-Network.
   
   
6. I want to go to an Out-Of-Network provider because I feel he can provide the best care for my condition. What are the costs going to be for me?
   
   Be aware: Obtaining care from Out-of-Network provider will result significantly higher out of pocket costs than using network providers. You will have to satisfy an annual deductible; pay a co-payment of 25% or 40% of the Southern Health allowable rate for the service, depending on your plan; and be responsible for all of the amounts above allowable that the provider charges. And you are required to obtain preauthorization from Southern Health for Out-Of-Network services, such as for DME or procedures and tests, or entire claims can be denied. Preventive visits to an Out-Of-Network provider are not covered at all by your health plan.
   
   What You Need to Do
   
   If you want to seek care from a physician located outside of the Southern Health network, (for example, a physician from a center of excellence like Cornell or Johns Hopkins), you need to ask your participating network physician to submit a pre-service request for prior authorization at “In Network benefits” to Southern Health. Authorization at “In-Network” rates is only granted when Southern Health determines that there are no providers in the Southern Health network able to perform the service. THIS IS TRUE EVEN IF YOUR PARTICIPATING DOCTOR REFERS YOU “OUT-OF-NETWORK”. If the authorization is not granted by Southern Health with “In-Network” benefits, the authorization may be granted with “Out-Of-Network” benefits which can be extremely expensive to the member. So read your authorization letter very carefully and ask the UVa Health Plan Ombudsman for clarification or assistance. Get the authorization information directly from Southern Health –do not rely on translated benefits from your doctor office/hospital.
   
   Be attentive to the limits and type of the authorization you receive and be sure any follow up care and additional procedures/tests are also pre-authorized.
   
   Important Note About Costs
   
   Out-Of-Network payments by Southern Health can be a small percentage of the actual provider charges and also can be limited, such as the current $2,823 per day allowable rate for inpatient admissions. Out-Of-Network outpatient allowable amounts paid by Southern Health are currently capped at 105% of the Virginia Medicare rate. You will be responsible for not only a deductible and 25% (or 40% if Low Premium) co-insurance of the allowable amount, and often a very large “amount above the allowable”.
   
   If you are considering receiving medical services from an Out-Of-Network provider for a non-emergency, it is advisable to thoroughly research your potential costs before making your final decision. The Southern Health Customer Service toll-free line at (888) 975-9557 is one resource. It is also perfectly reasonable to ask your Out-Of-Network provider to send you a pre-service estimate of the costs and procedure codes, assuming there are no complications. You should then compare the estimated costs from each provider to the Southern Health allowable rates for your specific procedure codes.
   
   
7. How can I appeal a denial for a pre-authorization for procedure my doctor says I should have?
   
   You have the appeal rights described in detail in your Description of Benefits manual, which is available on the Benefits website: http://www.hrs.virginia.edu/forms/descben.pdf. Your physician can promptly call Southern Health for a peer-to-peer review if a request is denied. If this peer-to-peer review results in the procedure remaining denied (adverse decision), you can proceed with the appeal process for decisions involving Utilization Review. If requested by the member, cases involving Utilization Review (medical necessity) can be appealed through an external review panel by writing to the UVa Health Plan Ombudsman within 30 days of the final adverse decision from Southern Health.
   
   
8. My wife is pregnant; how can I be sure that our child will be covered?
   
   To enroll your baby in the health plan, complete an enrollment application within 60 days of the birth of your new baby. If an application is received within 60 days of the date of birth, coverage will be effective retroactive to the first of the month of date of birth. Applications, received after 60 days but within the same plan year, will only take effect the first of the month following receipt of the application and the newborn’s hospital /physician bills related to the birth will not be covered retroactively.
   
   
9. What do I need to do to add my new spouse if I marry?
   
   When you marry, your spouse is not automatically covered under your benefits. You may enroll your spouse and new eligible dependents for coverage under the University of Virginia Health Plan by submitting a UVa Health Plan Application along with a copy of your marriage certificate within the same plan year of the date of marriage, or within 60 days, whichever is greater. Coverage is effective the first of the month following the date of receipt of the application.
   
   
10. What do I need to do to drop my former spouse if I become divorced?
    
    Coverage eligibility for your former spouse under your Health Plan ceases at the end of the month that you divorce. You must complete a UVa Health Plan application to terminate your former spouse from the Health Plan and submit it to the University Human Resources Benefits Division within 60 days of the date of the divorce so that you will not continue to pay a premium for this coverage. You will also need to provide a copy of the signed pages of the divorce decree verifying the parties involved and the date of divorce, along with your application to terminate coverage.
    
    
11. Can my former spouse continue health plan coverage?
    
    Notification of the divorce must be received by the UVA Benefits Division within 60 days of the divorce for the former spouse to be eligible for COBRA. Your former spouse may elect to continue health care coverage under the UVA Health Plan by purchasing coverage under COBRA for up to 36 months. Refer to the Continuation of Coverage/COBRA in the Description of Benefits for more information: http://www.hrs.virginia.edu/forms/descben.pdf
    
    The spouse has within 60 days of the divorce, or within 60 days of the date of the letter of COBRA Notification from Chard Snyder, or by the date that Plan coverage would be otherwise lost, if later, to enroll in COBRA coverage. Here is the link to the COBRA enrollment form: http://www.hrs.virginia.edu/forms/cobraexplanation2008.pdf
    
    In order to protect your family's rights, you should keep the COBRA Administrator, Chard Snyder, informed of any changes in addresses of family members. For information on COBRA rates and enrollment, you may contact the University Human Resources Benefits Division at 434-924-4392 for details.
    
    
12. How do I get a replacement Southern Health medical insurance card?
    
    You may request a new Southern Health medical insurance ID card by:
    
    
    • Visiting the Southern Health website: http://www.southernhealth.com/. Click on “Members,” then “FAQs” (in the far left column), then on “ID Cards” for directions to request a new card and/or print a temporary ID card. OR
      
      
    • Calling Southern Health Customer Service at 1-888-975-9557. OR
      
      
    • Contacting the UHR Benefits Division at 434-924-4392, who can request an ID card on your behalf and /or print a temporary ID card.
      
      
13. How do I get a replacement CVS Caremark pharmacy card?
    
    You may request a new CVS Caremark pharmacy ID card by:
    
    
    • Visiting the CVS Caremark (formerly PharmaCare) website: http://www.pharmacare.com/index.asp OR
      
      
    • Calling the CVS Caremark Customer Service toll free phone number:
      1-866-UVA-3707 OR
      
      
    • Contacting the UHR Benefits Division at 434-924-4392.
      
      
14. How do I get a replacement Eye Benefits discount vision card?
    
    You may request a new Eye Benefits discount vision card by:
    
    
    • Calling the Eye Benefits Customer Care Line at 1-800-621-7900 ext 4, OR
      
      
    • Visiting the Eye Benefits website http://www.eyebenefits.com. (this option is only available to actively employed subscribers with registered UVA email addresses). Click on "My Account" at the bottom of the homepage sign on with the username and password sent to you from Eye Benefits. If you do not know your username, click on "What if I forgot my User Name or Password?", and enter your UVA registered e-mail address in order to receive your login and password. OR
      
      
    • Contacting the UHR Benefits Division at 434-924-4392.
      
      
15. How can I get a replacement United Concordia dental card?
    
    You may request a new Dental ID card by:
    
    
    • Visiting the United Concordia website: http://www.ucci.com/ OR
      
      Calling UCCI customer service at 1-866-215-2354, and following the voice prompts to order a new ID card. OR
      
      
    • Contacting UHR Benefits Division at 434-924-4392.
      
      
16. Are non sedating antihistamines, such as Claritin, covered under the Plan?
    
    The UVA Health Plan Prescription Drug Plan was enhanced in 2006 by the addition of a discount price benefit for a number of prescription drugs that are not otherwise covered under the Prescription plan. With the enhanced benefit, when you use your CVS Caremark card to purchase these drugs, you will pay the discounted price negotiated by UVA’s Pharmacy Benefit Manager instead of the full retail price. Although you will still pay 100% of the cost rather than a co-payment, the cost will be less than the retail cost in most cases. Examples include non-sedating antihistamines, vitamins and diet pills, nicotine gum, infertility medication, travel-related drugs, and drugs not considered medically necessary, such as cosmetic drugs. Experimental or investigational drugs and other standard exclusions will not be included in the discount price benefit.
    
    
17. I need to take a prescription medication that CVS Caremark is denying for prior authorization. What should I do?
    
    Your physician needs to complete a prior authorization form and send it to CVS Caremark for review. Once approved, your authorization will be on file at CVS Caremark and you can obtain your prescription. A similar process is in place for medications requiring Step Therapy, such as Prilosec or for Quantity Limitation override requests. Click here for details on the Step therapy for PPI prescriptions. Prior authorization forms also available at CVS Caremark website. Go to www.pharmacare.com , click on the “Healthcare Professionals” tab twice, and click on PA Forms on the left hand margin.
    
    
18. My doctor has ordered a brand name medication because he thinks it is better than the generic for me, but when I went to pick it up, I was told my copay would be over $150. How can this be?
    
    Under the UVA Health Plan, when a member uses their prescription drug card to obtain a brand name medication when there is a generic available, either because it is ordered that way by the doctor or a patient preference, the member pays a lot more money. The member pays the difference between the cost of the generic medication and the cost of the brand name -at either retail or through mail order. So it is most cost effective for the member to use generic brand whenever possible.
    
    
19. What is the optional premium vision program available in 2008 to new UVA Health Plan members?
    
    In 2008 there is a new voluntary vision insurance benefit administered by Davis Vision that is available with payment of a separate premium, in addition to the existing discount vision plan through Eye Benefits. The Davis Vision plan provides for an eye examination (with a specialist co-payment), as well as glasses or contacts every 12 months, while the discount plan gives you access to a national network of vision care professionals at discounted prices. Best of all, you can use the two plans simultaneously.
    
    
20. How can I obtain a Blood glucose monitor through Southern Health?
    
    UVA Health Plan members who have a prescription for a blood glucose meter can call Southern Health Customer Service (1-888-975-9557) to obtain a free Life Scan meter. Southern Health will connect the member to a Life Scan representative. To learn more about specific meters covered by Southern Health Services /CareNet see www.Lifescan.com. The member may also call Life Scan directly at 1- 800-611-1274