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HEALTHSCRIPT
Table of Contents

It's HEDIS Time Again

HEDIS Monitors Minimum Standards of Care

Provider Education: HEDIS Measures

Medical Record Documentation

Change in Prior Approval Requirement

Clarification about Members Enrolled in PPO Plan

Proper RX Coding

RadMD Announcement

HealthScript Archives

for Members

for Providers

for Employers

for Brokers

A publication for HNE providers and their staff
April 2006

Clarification about Members Enrolled in PPO Plan:
Care from In-Network and Out-of Network Providers

At times, members may receive care from both an In-Network Provider and an Out-of- Network Provider for the same medical condition. The Plan will pay for the services that the member receives based on each provider's status. Here are some examples:

A member is admitted to an In-Network participating hospital. While there the member receives services from an ancillary provider working in that facility, such as an anesthesiologist, radiologist, or pathologist. These ancillary providers may not be participating providers. The Plan will pay the In-Network Hospital at the In-Network level, and the Out-Of-Network ancillary provider at the Out-Of-Network level.
A member is admitted to an In-Network Hospital by an Out-of-Network Doctor. The Plan will pay the In-Network Hospital at the In-Network level and the Out-of-Network Doctor at the Out-of-Network level.
A member has chosen to receive all of his/her primary care from an In-Network participating doctor. The doctor orders lab tests and sends the tests to an Out-of-Network lab. HNE will pay the In-Network doctor at the In-Network level and the Out-of-Network lab at the Out-of-Network level.

Unless being treated for an Emergency, members should verify that the providers who are treating them are In-Network Providers.

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