Changing GVHP Family Practice Offices

As a GVHP member, you choose a GVHP Family Practice Office. This is where you will receive your care. We ask you to do this because it is important that you receive your care from one GVHP Family Practice Office team. Consistent care allows you and your GVHP Family Practice Office team to develop a relationship. This can lead, to better care, satisfaction and communication. Also, your medical records are stored at your GVHP Family Practice Office.

We know, however, members from time to time may wish to change GVHP Family Practice Offices. If you do, just ask for a GVHP Family Practice Office Transfer Form at your current GVHP Family Practice Office. Or, call the GVHP Customer Service Team at 616-949-2410. The transfer of your medical records to your new GVHP Family Practice Office will begin with this process. You will be effective at your new GVHP Family Practice Office on the first of the month following your request for transfer.

Request For Your Medical Record

As a GVHP member, you may want a copy of your GVHP medical record. As a member, you are entitled to receive one (1) copy of your current medical record at no charge. If you want a second or additional copies, there will be a charge. For second or each additional copy of your GVHP medical record, you will be charged a $10.00 retrieval fee. This charge includes copying up to 25 pages of your medical record. Each additional page thereafter is $.50.

Copayments

What is a copayment? A copayment is a "fixed" amount you owe a GVHP Family Practice Office practitioner or provider for his/her service. A copayment is your responsibility. You owe a copayment at the time of service.

There are two types of copayments you could owe. One type is found in your GVHP Certificate of Coverage. The other type is found in a rider that is added to your certificate.

An office visit copayment is one type of copayment. Your employer may have chosen an office visit copayment to be part of your benefit package. This is found in a rider that is added to your GVHP Certificate of Coverage. If you do owe an office visit copayment, please see your rider for more details. However, in general, the following things apply to office copayments:

• It is owed at every GVHP Family Practice Office visit with a physician, mid-level practitioner, and Counseling and Wellness staff
• It is owed at every physical, occupational, and speech therapy session.
• It is owed at every specialist office visit.
• It is owed at every urgent care visit at our GVHP Urgent Care Center (UCC).

Other copayments you might owe under your GVHP Certificate of Coverage include the following:

Remember you are responsible for your copayments. They are owed at every visit or service.

Deductibles

Grand Valley Health Plan has many different plan designs. Plan designs are the different types of coverage available for an Employer Group to purchase for their employees. Some of these plan designs, but not all, have deductibles. Please check your New Member Packet or call Customer Services at 616-949-2410 to see if a deductible applies to your benefits with Grand Valley Health Plan.

What is a deductible? A deductible is a "fixed" amount of money that you must pay for health expenses before GVHP will begin to pay. For example, if you have a plan with a $500 deductible you would have to first pay $500 in addition to your premiums for the cost of your health care expenses. This would be before GVHP began to make payment for your health care expenses.

Not all services that you receive from Grand Valley Health Plan are subject to your deductible. The services not subject to your deductible are listed below:

• Services performed at a Grand Valley Health Plan Family Practice Office
• Services performed at the Grand Valley Health Plan Diagnostic Radiology Center
• Services performed at the Grand Valley Health Plan Urgent Care Center
• Authorized preventative healthcare services

All other covered services you receive are subject to your deductible. These include, but are not limited to, visits to a specialist office, emergency care services, hospitalizations and outpatient surgical center visits. Remember, except for emergency care services you must receive pre-authorization for these services to be covered. Even with pre-authorization from your GVHP Family Practice Office, your deductible still applies.

There are certain out-of-pocket cost that you will still have to pay that will not apply towards your deductible. These costs include copayments and non-covered medical services. This also includes a deductible met on a prior insurance plan and a deductible met on a previous contract with Grand Valley Health Plan.

Claims and Your Explanation of Benefits

As a GVHP member, you do not have to worry about a lot of "paperwork." This is especially true for authorized and covered benefits. Your GVHP Family Practice Office services are prepaid. You do not have to worry about a bill for these visits. (Though you may be billed for outstanding copayments.) Specialists will bill GVHP directly for their services. Other health care providers will also bill GVHP. Except for non-covered or non-authorized services or benefits, you should not receive "bills."

Sometimes, however, practitioners and providers will send you a "statement." This statement tells you GVHP is being billed. Look over all statements from practitioners and providers. If you have any questions about what you have received, call your GVHP Family Practice Office or the GVHP Customer Service Team at 616-949-2410.

Under ERISA (see Appendix A of your GVHP Certificate of Coverage), you are entitled to receive certain information. You should get information about money you owe for services, copayments, or deductibles. You also must receive information about claims that are denied. This information should be easy to read. You should be able to understand the information you get. You also have the right to appeal the denial of a claim. To appeal any denials, call your GVHP Family Practice Office or the Customer Service Team at 616-949-2410. See Member Grievances in this section of your handbook for additional information.

How do you get information about claims? This information is sent to you through the form. You receive an EOB when you owe money. You receive an EOB when a claim has been denied.

We want you to understand how to read the GVHP EXPLANATION OF BENEFITS (EOB) form. A copy of this form is shown below. Please remember that the GVHP EOB is not a bill. The GVHP EOB is a statement about a medical bill. It tells you GVHP has received this bill for services provided for you or your dependent. Your EOB explains what GVHP paid or did not pay.

For questions about your GVHP EXPLANATION OF BENEFITS (EOB) call your GVHP Family Practice Office or the GVHP Medical Accounts Payable Team at (616) 949-2410.

1. Date of Service: This field gives you the date of service. This should mean the date you received the service.
2. Diag. No: This field gives you the diagnosis code for the service being billed. This will be a five (5) digit number.
3. Proc. Code: This field gives you the procedure code being billed. This code could either be a three (3) digit code (usually for a hospital or inpatient bill). It could be a five (5) digit code (usually for a service performed by a physician).
4. Description of Services: This field tells you what the procedure code means (see field 3 above).
5. Fee Charged: This gives the amount the hospital, agency or practitioner is charging for the service.
6. Amount Not Allowed (CD): This field gives you the amount not being "allowed" under the GVHP fee schedule.
7. Allowed Amount: This field gives you the amount allowed under the GVHP fee schedule.
8. Deduct. Amount: This field gives you information about any deductible you might owe.
9. Copay %: This field gives you information about any co-insurance or copayment amount owed because your certificate requires that you pay a percentage (%) of the charge.
10. Copay Amount: This field tells you if you owe a copayment on the visit. This copayment could be for an office visit ($5, $10, $15), an urgent care visit ($25 if you did not use the GVHP Urgent Care Center) or $50 (ER copayment). You owe this amount to the "Provider."
11. Patient Pays: This field tells you if you owe anything You owe this amount to the "Provider."
12. GVHP Resp.: This field tells you what GVHP will be paying for the service being billed.

Requests for "Special Services": The GVHP Medical Opinion Process

There are "special services" that need to be reviewed. This review is done by the Vice President for Medical Affairs (VPMA). The VPMA is also known as the Medical Director. These "special services" are:

• Out-of-Area Care
• Cosmetic Procedures
• Investigational or Experimental Procedures
• Requests for New Technology

There is a process for looking at these requests. It is called the GVHP Medical Opinion Process. Your GVHP Family Practice Office Practitioner helps in this process. You only need to speak with him or her about treatment options. The GVHP Family Practice Office Practitioner makes the request. He or she completes the necessary "paperwork." The GVHP Family Practice Office then gives medical information to the Medical Director.

The Medical Director reviews the request. Sometimes more information is required. A GVHP Specialty Care Nurse might help get more information. A GVHP Family Practice Office team member might help in getting information. A Customer Service Representative might also gather other information. This could involve researching clinical studies. It can also include contacting medical experts. The Medical Director might also talk with treating physicians. We want you to know that we investigated each Medical Opinion thoroughly.

There are, however, time frames for the Medical Opinion Process. These are important in making sure we get an answer to you as soon as possible. These time frames include:

1. Non-Urgent Opinions: These are for requests that are not clinically urgent. That means you do not have a condition that requires immediate medical attention. A non-urgent decision must be made within one (1) working day of GVHP having necessary information to make a decision. You should get a verbal and written response within two (2) working days of the decision. If your request is denied, we offer you the GVHP grievance process. (See Member Grievances for additional information.)
2. Urgent Opinions: These are for requests that are clinically urgent. That means you have a condition that needs a quick answer. A decision must be made within one (1) day of GVHP having the necessary information to make a decision. You should get an oral response within one (1) working day of the decision. You should get a written response within two (2) working days of the decision. If your request is denied, we will offer you the GVHP expedited grievance process. (See Expedited Grievances for additional information.)
3. Concurrent Opinions: These are for requests that are being made at the time you are receiving care. A decision must be made within one (1) working day of GVHP having the information. You should get an oral and written response the same day as the decision. If your request is denied, we will offer you the GVHP expedited grievance process. (See Expedited Grievances for additional information.)
4. Retrospective Opinions: These are for requests that are made after a service has taken place. A decision must be made within thirty (30) days of receiving all information needed to make a decision. You should receive a written response within five (5) days of the decision. If your request is denied, we will offer the GVHP grievance process. (See Member Grievances for additional information.)

It is important to remember we must have all necessary information to make a decision. Sometimes the Medical Director finds that there is not enough information. At that point, our process allows us an additional thirty (30) calendar days to gather information. If there is a delay during this period, your GVHP Family Practice Office Practitioner will be notified. The GVHP Family Practice Office should then call you about the delay.

If you have any questions about the Medical Opinion Process, please call your GVHP Family Practice Office. You may also call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977. You may ask to speak to the person who made the decision about your request. We are always available to answer your questions.

New Technology and Treatment in Medical Care

New advances in health care happen every day. Technology is changing rapidly. And, new medical treatments appear quickly. While some of this is good, it is important to know what works. It is also important to know what does not. GVHP wants to be sure the new technology and care is safe.

GVHP covers "generally accepted medical care." This means there already is a body of scientific evidence that supports the care. If there is none, GVHP does not cover the care. We call this type of care experimental and investigational. That is, these are not considered "generally accepted" medical care. We also do not cover drugs and devices that are a part of experimental or investigational treatment. This also includes other procedures and services.

GVHP does, however, review new technology. It looks at investigational or experimental treatments. We research and review current medical literature. We consult with physicians and medical experts. We do this in the interest of knowing what is available. We do this to know what might help our members.

What kinds of things do we look for when reviewing new treatments? We use the GVHP Framework for Clinical Effectiveness. This acts as a guide in our decision-making. It asks the following questions:

• Is it recognized by a nationally recognized body such as the National Institute of Health (NIH), the National Cancer Institute (NCI), the Food and Drug Administration (FDA), Health Care Finance Administration (HCFA), etc.?
• Is it undergoing clinical trials or study?
• Can you only get it in an investigational setting?
• Is there published scientific evidence or peer review trials as to clinical effectiveness?

If we decide the new treatment or technology meets the GVHP standards, we give this information to our Board of Directors. We ask the Board of Directors to review and approve our findings. If the Board agrees, we then cover the treatment or technology. We let our members know of any benefit changes. We do this through HealthLine, the GVHP member newsletter.

For more information, see your Certificate of Coverage, Article II: Benefits Schedule (Section 17). You may also want to look at Article III: Definitions (1.22) for a definition. And, if you have any questions, call your GVHP Customer Service team at (616) 949-2410.

Benefit Limitations and Exclusions

GVHP offers you and your family a broad range of services. However, there are certain things that we do not pay. That means that something is not a covered benefit. There are some things that have "limits." This means there are conditions that must be met in order to have something covered. Or, it could mean that we cover things up to a certain point or "limit."

A summary of "exclusions" is provided. A summary of "limitations" is also given.

• Services that are not authorized by your GVHP Family Practice Office
• Services out-of-area that are not authorized by your GVHP Family Practice Office; this does not mean emergency care
• Investigational and experimental procedures
• Services, equipment, and supplies that go along with experimental or investigational procedures
• Services that are not medically necessary
• Services that are not considered generally accepted medical practice
• Office visits, examinations, treatment, tests and reports for are needed to document health or medical status for employment, insurance, travel, or legal proceedings
• Elective cosmetic surgery
• Comfort items and items not medical in nature
• Conditions covered by workerÕs compensation
• Conditions covered by military-connected disabilities
• Long term behavioral health counseling
• Court-related services
• Special elective procedures; some examples include voluntary pregnancy termination, radial keratotomies
• Services that go along with non-covered benefits
• Services of a dentist, oral surgeon, and orthodontist
• Dental implants and prosthesis
• Personal or donor blood storage
• Reproductive procedures; this includes in-vitro fertilization, GIFT and ZIFT
• Services to treat educational, developmental or learning disabilities
• Custodial care
• Eyeglasses, contact lenses, or hearing Aids
• Prescription drugs, devices, and medicines not a part of outpatient care
• Refraction after vision examination
• Rehabilitation services, cognitive therapy, vocational training and driverÕs training
• Deluxe durable medical equipment
• Coverage for services due to any illness or injury that was the result of illegal activity
• Lost wages
• Implantable hearing devices
• Food supplements and formula
• Routine foot care
• Obstetrical deliveries in a home.

For additional information see your GVHP Certificate of Coverage under ARTICLE II: BENEFITS SCHEDULE, Section 17.

• Office visits copayment if you have an office visit copayment rider; this includes visits to GVHP Urgent Care Center
• Infertility diagnostic work-up and treatment, 50% copayment limited to a specific amount outlined in your GVHP Certificate of Coverage under ARTICLE II: BENEFITS SCHEDULE, Section 17.
• Coverage for physical, occupational, and speech therapy limited to sixty (60) total visits per contract year
• Home health care services must be for skilled nursing care and instead of hospitalization
• Coverage for a private hospital room; this is limited to medical necessity
• Urgent care co-payment if you have not used the GVHP Urgent Care Center
• Emergency Room copayment for services if you are not admitted
• Ambulance copayment
• Coverage for substance abuse limited to annual state mandated dollar amount.
• Human organ or tissue transplants; this is subject to medical opinion review and pre-authorization by the Medical Director.
• Durable Medical Equipment covered at 50% or applicable rider
• Orthotics are covered at 50%
• Deductibles may apply if purchased by your employer

For additional information see your GVHP Certificate of Coverage under ARTICLE II: BENEFITS SCHEDULE, Section 17.

Member Complaints

GVHP wants you to be completely satisfied with your medical care and services. If you are not, you have the right to voice concerns about GVHP or the health care provided. You can do this in a number of ways.

You can discuss your concerns directly with your GVHP Family Practice Office. We encourage you to start the process there. GVHP Family Practice Office staff is very concerned about member satisfaction. They would like the opportunity to correct any service issue immediately. And, most questions and concerns can best be answered by your GVHP Family Practice Office.

If you are unable to get the information you need or you are not satisfied with the answer your GVHP Family Practice Office provides you, you can call the GVHP Customer Service Team at 616-949-2410.

The GVHP Customer Service Team will work with you to address your concern. We will investigate your complaint. This could mean that we will call your GVHP Family Practice Office or practitioner to discuss what happened. We will review your Certificate of Coverage. We will look at our procedures and processes. We will get other information as needed. We try to make our complaint review process as complete and thorough as possible. Our goal is to resolve all complaints within five (5) working days of contact with us.

When we complete our investigation, we will contact you and inform you of the decision. You will also be given information on what this decision was based. We will help you understand how GVHP works. If you are dissatisfied with a decision or information given you, you have the right to file a grievance. For further information about Member Grievances see the next section.

Member Grievances

As a member of GVHP, you have the right to file a formal grievance. This grievance process is provided to you at no cost. You or your authorized representative can request this by calling the GVHP Customer Service Team at (616) 949-2410.

How does the grievance process work? A summary of the GVHP Grievance Process is presented below.

If a member's request has been denied, he or she receives a written statement. This gives the reasons for this decision. A member or their authorized representative who wishes to contest this decision may request the grievance process. GVHP responds to member grievances either orally or in writing. A member or their authorized representative receives a grievance form and copy of the GVHP grievance procedure.

Members or their authorized representative do not have to submit a written response at any point in the grievance process.

Grievance requests remain open for two (2) years from the date the member or authorized representative asked to pursue a grievance. This is also called the "point of discovery."

GVHP sends a letter telling the member we have received his or her grievance request. The GVHP Customer Service Team investigates. The GVHP Customer Service Team arranges the first level grievance hearing. The President of GVHP hears the first level grievance.

The decision of the first level grievance hearing must be made within fifteen (15) calendar days after GVHP receives the memberÕs grievance. A letter to the member with the decision must also be done within the same time period. If there is a delay in the process, the member is told. The member also receives information in writing about the delay. This delay shall not exceed ten (10) business days and only if GVHP has not received requested information from a health care facility or health care professional.

If the member is not satisfied with the response of the first level grievance, he or she, or the authorized representative may orally inform the GVHP Customer Service Team to appeal the decision. A Customer Service Representative will arrange for the next appeal level (2^nd level). The appeal may be heard without the member or their authorized representative present. The member may also choose to have someone represent him or her. The member or his or her representative may make the appeal in person. It may also be done by "technological methods" such as a telephone conference call. The appeal is heard by the GVHP Grievance Committee. This committee is made up of GVHP Board members.

If the member or their authorized representative chooses not to attend or does not come to the second level grievance hearing, the GVHP Grievance Committee reserves the right to hear the grievance and make a decision.

The GVHP Grievance Committee hears the appeal. A response with the decision of the committee must be done within five (5) working days of a decision. The GVHP Grievance Committee's decision is the final decision of the Plan. If GVHP informs the member orally of the decision, a letter confirming it will be sent no later than two (2) business days after the oral notice.

The member or their authorized representative may appeal the GVHP Grievance Committee decision. GVHP will provide the member or authorized representative with the appropriate form to request an external review with the Commissioner of the Office of Financial and Insurance Services at the time we send our final determination. If you request an external review, you will be required to release any medical records required to be reviewed for the purpose of reaching a decision. The member can also inquire about the external review process by contacting the

Office of Financial and Insurance Services
Division of Insurance, Health Plans Divisions,
611 West Ottawa Second Floor, PO Box 30220
Lansing, MI 48909
1-877-999-6442.

Please note: The Commissioner of the Office of Financial Services will not hear your appeal until you have exhausted the internal GVHP grievance process unless GVHP did not complete their review within the required period of time.

The entire GVHP grievance process may not exceed thirty-five (35) calendar days (45 calendar days with an extension). The grievance process includes the 1^st and 2^nd levels of appeal. This time period does not count any "stops" or "delays" due to the member. For example, the member might be offered the second level appeal and not call us for thirty (30) days. This 30-day period is not part of the 35 calendar day total. For more information, please call the GVHP Customer Service Team at 616-949-2410. (See also your GVHP Certificate of Coverage, ARTICLE IV: General Provisions, Section 5.)

Expedited Grievances

You, your authorized representative, or your physician may want to file an expedited grievance. An "expedited" grievance is one that must be resolved quickly. An urgent condition means you and your physician believe your need is serious or life-threatening. You and your physician believe you are not getting the care you need.

Always discuss your medical needs with your GVHP Family Practice Office practitioner. If you think your condition is urgent, tell him or her. Your GVHP Family Practice Office practitioner can help you understand your medical needs. He or she can discuss treatment options. You can explore options with your GVHP Family Practice Office practitioner. If you are not satisfied with this information, you can file an expedited grievance. You may also file a grievance without talking to your GVHP Family Practice Office practitioner.

How does the process work? It begins when you, your authorized representative, or your physician calls the Medical Director. You may reach the Medical Director at 1-800-335-1977. Or you can call 1-616-949-2410. The Medical Director will need your medical information.

After getting your request, GVHP has 72 hours to resolve a clinically urgent grievance. The 72-hour period begins when we get your request.

If GVHP makes the determination orally, GVHP shall provide a written confirmation of the determination to the member no later than two (2) business days after the oral determination.

If you are not satisfied with GVHP's decision, within ten (10) days after receipt of a determination, you may request a determination of the matter by an independent review organization under the Patients Right to Independent Review Act. GVHP will provide the member with the appropriate form to request an external review. If you request an external review, you will be required to release any medical records required to be reviewed for the purposes of reaching a decision. If you have any questions regarding this process you can also contact the Office of Financial and Insurance Services, at the address and phone number listed below:

Office of Financial and Insurance Services
Division of Insurance, Health Plans Division
611 West Ottawa, Second Floor
P.O. Box 30220
Lansing, MI 48909-7720
Phone: 1-877-999-6442
http://www.cis.state.mi.us/ofis

For more information about this process, call your GVHP Customer Service Team at 616-949-2410.

Your Customer Service Team

For any questions, concerns or issues about GVHP, you can always call your GVHP Family Practice Office. Your Patient Care Coordinator is your supporter on the team. She or he is available to answer your questions. He or she can help you with any concerns. These can be about GVHP or your health care. It can be about the services you have received.

You may also call the GVHP Customer Service Team at 616-949-2410. The GVHP Customer Service Team works in support of your GVHP Family Practice Office. Located at the GVHP Corporate Office, the GVHP Customer Service Team helps you and your GVHP Family Practice Office by supplying these additional services:

• Information on how GVHP works including benefits, processes and procedures
• Information about GVHP eligibility requirements
• Information about federal and state laws that affect your health care or coverage such as HIPAA, COBRA, and other laws
• Handling and maintaining member application and change forms
• Verifying member status and other eligibility information
• Handling member grievances and complaints
• Supporting GVHP service needs

The GVHP Customer Service Team can be reached at 616-949-2410 during regular business hours of 8:00 AM - 5:00 PM (March - August); 8:00 AM - 5:30 PM (September - February).

How to Get Answers to Your Questions

Do you have any other questions? Are there still things you do not understand? There are places to get answers to your questions.

A great place to start is with the GVHP web page. Our web address is: www.gvhp.com.

If you have questions about your benefits, here are some places to get answers. Your GVHP Certificate of Coverage gives details about your benefits. You might have riders. These have other information about your benefits. For any questions about your coverage, call your GVHP Family Practice Office Specialty Care Coordinator. Or, call the GVHP Customer Service team at 616-949-2410.

If you have questions about how GVHP works, here are some places to get answers. Your Member Handbook gives you more information about how your plan works. You can call your GVHP Family Practice Office Patient Care Coordinator or Specialty Care Coordinator. Or you can always call the GVHP Customer Service Team at 616-949-2410.

If you have questions about claims, here are some places to get answers. Call your GVHP Family Practice Office Specialty Care Coordinator. Or, call the your GVHP Family Practice Office or the GVHP Customer Services Team at 616-949-2410.

If you have questions about preventive health or wellness, here are some places to get answers. Your Helping You Help Yourself is a great source of information. Your Member Handbook gives you information as well. The member newsletter, HealthLine, gives you information about our wellness classes. You may also call your GVHP Family Practice Office for health and wellness information.

Always remember your GVHP Family Practice Office or your GVHP Customer Service Team is available to help you with your questions or concerns.