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IMPORTANT CONTACT INFORMATIONBelow is a complete list of Paramount departments and contact information for each.DEPARTMENTASSISTANCE AVAILABLECONTACTCredentialingMonday – Friday8:30 a.m. – 5 p.m. New provider applicationsRe-credentialing questionsEmail: PHCCredentialing@ProMedica.orgMember ServicesMedicaidMonday - Friday7 a.m. – 7 p.m. Member questions and complaintsPrimary care provider changerequestsInterpreter servicesTransportation issuesSpecial Needs documentationPhone: 800-462-3589Phone (TTY): 888-740-5670Fax: 888-740-0222Commercial,MarketplaceExchange, OBAMonday - Friday8 a.m. – 5 p.m. MedicareApril – SeptemberMonday – Friday8 a.m. – 8 p.m.October – MarchSunday– Saturday8 a.m. – 8 p.m.PharmacyMonday – Friday8:30 a.m. – 5 p.m. Obtaining drug priorauthorizationsPhone: 800-327-3974 (Magellan, medically billeddrugs)Fax: 844-256-2025 (Pharmacy)Provider InquiryMonday – Friday8:30 a.m. – 5 p.m. Member benefits and eligibilityClaim status inquiriesClaim processing issuesReferral/authorization verificationPhone: 419-887-2564Phone (TTY): 888-891-2564Fax: 419-887-2014Fax: 855-448-4705Email: Paramount.ProviderInquiry@ProMedica.orgProvider RelationsMonday – Friday8:30 a.m. – 5 p.m. Provider and office staff educationContract issuesOrientations/webinarsNew product participationrequestsRepresentative office visitrequestsPhone: 800-891-2542Fax: edica.orgInformation/questionsEmail: PHCquality@promedica.org QualityImprovementMonday – Friday8:30 a.m. – 5 p.m.11

Transportation(Medicaid members,only)Monday – Friday7 a.m. – 7 p.m. Modify/cancel ing/pick-upPhone: 866-837-9817Phone (TTY): 800-750-0750Must schedule two business days, andup to 30 business days, In advance.Utilization/CaseManagementMonday – Friday8 a.m. – 6 p.m. Obtaining in-plan and out-of-planprior authorizationsCase/care managementBH out-of-plan requestsGeneral clinical -282-4907844-282-4908Mental health, chemical dependencyGeneral inquiriesHome health careImagingInpatient, acute careMed., surg., DME, genetics, pre-DOut-of-planSNF, rehabilitation, LTACUPDATE YOUR CONTACT AND PROVIDER DIRECTORYINFORMATIONTo ensure our provider directory information is accurate and updated timely, Paramountrequires provider offices to notify the health plan of any of the following demographicchanges: Office locations and phone numbers Hospital affiliations Accepting new patients Additions to office/ group or terminationsParamount is requesting this information be shared as timely as possible, and within 30days of the provider office identifying the change(s). This is to ensure our members andyour patients can reach you when accessing care, and that our provider directoryreflects current and accurate information.12

CLAIMSHOW TO SUBMIT A CLAIMElectronicParamount strongly recommends electronic claims submission, through the provider's preferredclearinghouse or through myParamount portal, TransShuttle.Paramount currently accepts electronic claims submissions from a variety of clearinghouses. Inorder to submit claims using a clearinghouse vendor you will need to sign our Trading PartnerAgreement. Our list of clearinghouses, along with our Trading Partner Agreement form, areavailable on our website.If you would like to learn more about our electronic claims submission process, please visit ourwebsite or contact our Electronic Claims Submission (ECS) system coordinator at 419-8872532.Additionally, myParamount portal, TransShuttle, offers the following benefits to claimsprocessing: Convenient access: Available 24/7 at no additional costEnhanced capabilities: submit corrected claims, and void claimsTimely statuses: Check claims statuses and receive timely notification of changes instatusIf you need access to TransShuttle, please email proivderrelations.paramount@promedica.orgPaper ClaimsPaper claims need to comply with the same standards as those for electronic submissions, setforth by the American National Standards Institute (ANSI).Please review and adhere to the following requirements: 13Paramount will only accept the most current version of the industry standard CMS-1500(02-12) and UB-04 forms printed in red drop-out ink.Printed information should go on the reverse side of the form. All mandatory fields onpaper claim forms must be completed.Black and white versions of claim forms, including photocopied or faxed versions, andresized forms that do not replicate the scale and color of the standard claim form will notbe accepted.The size of the form should be 8 ½ X 11 with the printer pin-feed edges removed alongthe perforations.Forms should be free from excessive creases or tears. Do not fold or staple forms.Forms should be clean and free from stains, notations, strike outs, crossed out orhighlighted information, liquid correction tape, glue, and tape.Please use industry-standard procedure codes, diagnosis codes, location codes andmodifiers.

Paper claims should be mailed to: Paramount, P.O. Box 497, Toledo, OH 43697-0497Nonstandard forms will be returned to the address identified in Box 33 of the CMS-1500 form orBox 1 of the UB-04 form with instructions to resubmit the claim using the appropriate claim form.A new claim with the correct information must be submitted for the claim to be processed.HIPAA 5010 TRANSACTIONSIn 2009, the United States Department of Health and Human Services released a final rule toupdate standards for electronic health care and pharmacy transactions. This was in preparationfor implementing ICD-10 CM codes on October 1, 2015.The new standard is the HIPAA 5010 format. All trading partners and payers must be 5010compliant. For more information, please click here to visit the CMS Adopted Standards andOperating Rules webpage.CLAIM REQUIREMENTSYour National Provider Identifier (NPI) number and Tax Identification Number (TIN) are requiredon all claim’s submissions. Claims submitted without these numbers will be rejected. Pleasecontact your Electronic Data Interchange (EDI) vendor if you have questions regarding wherethese identifying numbers should be placed on your forms.Please note: On paper claims, the NPI number should be placed in the following boxes basedon form type: CMS 1500: Box 24J for the rendering Provider’s NPI and, if applicable, Box 33A for thegroup NPIUB04: Box 56ADA: Box 54 for the treating Provider’s NPI and, if applicable, Box 49 for the group NPIPAYMENT PROCESSING GUIDELINESProviders are responsible for the accuracy of claim submissions. Please adhere to the followingcoding requirements: 14For diagnoses: International Classification of Diseases, 10th Revision, ClinicalModification ICD-10-CMFor professional and outpatient procedures: The Healthcare Common ProcedureCoding System Level 1 (CPT codes), Level 2 and 3 (HCPCS codes)For inpatient hospital claims: ICD-10-PCS (International BD Classification ofDiseases, 10th Revision, Procedure Coding System)Claims must be coded in accordance with the HIPAA transaction code set guidelinesand follow the guidelines within each code set.

SUBMISSION TIMELY FILINGPlease visit the links below to view each the timely filing policy for each plan: Paramount Advantage MedicaidParamount Elite MedicareParamount CommercialPROCEDURE/DIAGNOSIS CODESProviders must bill for services using the most current CMS-approved diagnostic and proceduralcoding available for the date the service or for the date of discharge if the claim is an inpatientfacility claim.CODE EDITING SOFTWAREParamount utilizes comprehensive bundling logic software, which is fully automated to audit andverify the clinical accuracy of claims prior to payment. Our claims editing software applicationcontains a set of rules to address coding inaccuracies such as unbundling, frequencylimitations, fragmentation, up-coding, duplication, invalid codes, mutually exclusive procedures,and other coding inconsistencies. Each rule is linked to a generally accepted coding principle.Guidance surrounding the most likely clinical scenario is applied.The software is sophisticated and has clinical logic based on clinical practice andreimbursement standards, and input from medical experts. The software applies edits that arebased on the following sources: 15Centers for Medicare & Medicaid Services’ (CMS) National Correct Coding Initiative(NCCI) for professional and facility claims. NCCI status code indicator to determinepackaging or discounting, including medically unlikely edits (MUE), exclusive andoutpatient code editor (OCE) edits. These edits were developed by CMS to controlincorrect code combination billing contributing to incorrect payments. Public-domainspecialty society guidance (i.e., American College of Surgeons, American College ofRadiology, American Academy of Orthopedic Surgeons)CMS Claims Processing ManualCMS Medicaid NCCI Policy ManualState Provider Manuals, Fee Schedules, Periodic Provider Updates(bulletins/transmittals)CMS coding resources such as, HCPCS Coding Manual, National Physician FeeScheduleProvider Benefit Manual, Claims Processing Manual, MLN Matters and ProviderTransmittalsAMA resourcesCPT manualAMA websitePrinciples of CPT CodingCoding with ModifiersCPT Assistant

CPT Insider’s ViewCPT Assistant ArchivesCPT Procedural Code DefinitionsHCPCS Procedural Code DefinitionsBilling Guidelines Published by Specialty Provider AssociationsGlobal Maternity Package data published by the American Congress of Obstetriciansand Gynecologists (ACOG)Global Service Guidelines published by the American Academy of Orthopedic Surgeons(AAOS)State-specific policies and procedures for billing professional and facility claimsHealth Plan policies and provider contract considerationsMore information on Paramount code editing can be found in Reimbursement Policy RM013.16

UTILIZATION MANAGEMENTOVERVIEWUtilization management (UM) ensures effective and efficient medical care, including behavioralhealth care. Paramount’s UM Department performs internal reviews of medical policies andmedical criteria through a Medical Policy Steering Committee to ensure Paramount is utilizingthe most current clinically indicated criteria to perform medical necessity reviews. We evaluatethe cost and quality of medical services provided by participating physicians, hospitals, andother ancillary providers. To ensure appropriate utilization, we evaluate both potentialoverutilization and underutilization.Paramount’s UM department maintains the quality, efficiency and appropriateness of healthcareservices provided to Paramount members. We manage all UM activities, including priorauthorization processing, concurrent review, discharge planning, transition of care coordination,and more. Our goal is to ensure Paramount members receive the proper level of care in themost appropriate setting, and that the resources utilized align with their insurance plan benefits.Paramount adheres to nationally recognized criteria, medical policies, and state and federalguidelines to determine medical necessity and appropriateness of services. In addition, internalcriteria standards are in place for appropriateness of care and the existence of coverage whereother sources of standard are not defined.Our program focuses on the following objectives: To assure effective and efficient utilization of facilities and services through an ongoingmonitoring and educational program. Our program is designed to identify patterns ofutilization, such as overutilization, underutilization, and inefficient scheduling ofresources.To assure fair and consistent UM decision-making.To focus resources on a timely resolution of identified problems.To assist in the promotion and maintenance of optimally achievable quality of care.To educate medical providers and other healthcare professionals on appropriate andcost-effective use of healthcare resources.To ensure continuity in the transition of care process by fostering close collaboration withour case management team.For More InformationIf you have questions regarding our UM program, decisions or authorization of care, please visitour webpage or call us. The UM team is available at 800-891-2520, Monday – Friday, 8 a.m. –5:30 p.m. If you need to leave a voicemail after hours, we will return your call in one businessday. You can also visit paramounthealthcare.com/providers to find information anddocumentation related to: 17Medical policiesPrior authorization criteria, decision timeframes, and complete listPopulation health/condition management servicesPublications

Documents and forms: Forms printed from links in this manual are current as of the printdate.UTILIZATION CARE MANAGEMENT PROCESSParamount’s UM departmental operations policies and procedures are reviewed on an annualbasis. These policies and procedures serve as a framework of authority for our operationalteams.Our UM coordinators are authorized to approve prior authorization requests when medicalnecessity criteria are met based upon medical policies, InterQual criteria, clinical criteriasoftware, and/or appropriateness of care and services for covered services. Prior authorizationrequests which fail to meet medical policy and clinical criteria will be escalated to a medicaldirector for final review and determination of medical necessity.Paramount’s medical directors, associate medical directors, clinical directors, and pharmacistsare the only plan representatives who can deny payment for a service based on medicalnecessity/appropriateness.Neither providers nor internal Paramount staff are financially or otherwise compensated toencourage underutilization and/or denials.Paramount works cooperatively with its participating providers to assure appropriatemanagement of all aspects of the members' health care.The primary care provider (PCP) is responsible for coordinating all aspects of themember's health care. Conversely, the member is responsible for coordinating his/her medicaland behavioral health care through their PCP. Although in-network specialist referrals are notrequired by Paramount for claim payment, members are encouraged to seek their PCP’s advicebefore seeking specialist consultation and treatment.CARE MANAGEMENT PROGRAMOur care management program identifies and manages members who are at high risk forcomplex, costly or long-term healthcare needs. Our care managers are registered nurses (RNs)or social workers who: Coordinate care for members who have both behavioral health and medical conditions,often working together to enhance the member’s outcome.Work 1:1 with members and their PCP to ensure that medically appropriate services areprovided in a supportive cost-effective environment.Follow members through the continuum of care from home to office, home health care,in-patient hospitalizations, rehabilitation, skilled nursing facility, and help them transitionhome again.Assist with utilization of participating providers.Care Management Goals 18Treat members in the least restrictive and most cost-effective setting and manner.Empower members to acquire knowledge, decision-making ability, and alteration inlifestyle to promote positive health outcomes.

Support the PCP/specialist by reinforcing the treatment plan.Avoid complications and multiple admissions by early identification of problems anddevelopment of goals.Identify members who are inappropriately over utilizing the emergency room andeducate them to utilize PCPs for care whenever possible.Foster communication between the PCP, specialists, and ancillary providers.Decrease premature delivery by promoting prenatal care.Reduce the cost of care.Coordinate the services of social and public health agencies when applicable.Role of the PhysicianAs the primary care provider (PCP), you are responsible for coordinating all aspects ofmembers’ healthcare needs. Our care managers will assist you with the process.Please help us identify members who: Are experiencing a complicated pregnancyAre at high risk for frequent hospitalizationsAre at high risk for complicated pregnanciesAre potential transplant casesAre oncology patients with complicationsAre medically unstable or complexDo not adhere to their treatment plan, are non-compliant with medication management,and/or miss appointmentsHave special healthcare needsHave drug-seeking behaviorHave behavioral health needsInappropriately utilize the ERNeed specialized careThe Ohio Department of Medicaid (ODM), Center of Medicare & Medicaid Services (CMS), andNational Committee for Quality Assurance (NCQA) expects the evidence-based collaborativeefforts between case management and the primary care physician to influence positively thehealth and well-being of our members.How to Make a Referral to Care Management For medical care management, please send information to:Paramount.CM@ProMedica.org.For behavioral health care management, please send information to:PHCBH@ProMedica.org.A care manager will contact you if more information is needed prior to connecting with themember.19

REFERRALSOutpatientSpecialist Referrals: The primary care provider (PCP) may request a consultation from aparticipating specialist at any time. A referral is not required from Paramount prior toconsultation with any participating specialist.Emergency Room Services: Referrals are not required for treatment of an emergency medicalcondition that manifests itself by such acute symptoms of sufficient severity, including severepain, that a prudent layperson with an average knowledge of health and medicine couldreasonably expect the absence of immediate medical attention to result in any of the following: Placing the health of the individual or, with respect to a pregnant woman, the health ofthe woman, or her unborn child, in serious jeopardy.Serious impairment to bodily functions.Serious dysfunction of any bodily organ or part.Emergency Room services are covered if referred by an authorized plan representative, PCP,or plan specialist. A referral is not required for payment of Emergency Room services for anemergency medical condition; the plan may do retrospective claim review to ensure theappropriate level of service is reimbursed.Out-of-Plan Referrals: These requests are reviewed individually, and determinations are madebased on the patient's medical needs and the availability of services within the Provider Networkto meet these needs.Tertiary Care Services: All referrals to tertiary care centers are reviewed on an individualbasis. The member's medical needs and the availability of the requested services within thenon-tertiary care network are taken into consideration.Predetermination of Benefits/Outpatient Certification: Certain services, procedures, durablemedical equipment, and injectable medications require prior authorization. Additionally,cosmetic surgery and other procedures may be reviewed prospectively, at the request ofproviders an

accordance with HIPAA privacy regulations and Paramount policies. Then, click "Next" 4. Enter your tax ID, your 5-digit Paramount provider ID or NPI number, and a recent claim number (for access to claims information). Then, click "Next" 5. Complete the registration instructions, and then click "Submit" 6.