At PARTNERS Medicare Choice,we are committed to the health,safety and wellness of ourmembers. Advancements inmedicine are helping people livelonger and experience animproved quality of life in theirsenior years. As a result, manyAmericans are now taking severaldifferent medications at the sametime to treat an illness or disease.

PARTNERS wants to ensure thatits members are well educatedabout their health care options andhealth safety. That’s why we arenow offering tips to members whomay be taking multiplemedications. This January, welaunched a medication awarenessinitiative designed to educatemembers about how to take theirmedications properly in order toavoid complications related tomedication therapy.

Select members received abrochure containing medicationsafety tips, a medication log, apillbox, and a bag for theirmedications. Members wereinstructed to take the log and allmedications (prescription, over-the-counter, vitamins, minerals andherbal supplements) with them onthe next visit to their physician.

Here is an example of theinformation we provided tomembers through this awareness program:

Medication Safety Tips• Keep a list of your medications

and supplements. Include thename of each one, how oftenyou take it, why you’re using it,and who prescribed it.

• Discuss your currentmedications with yourpharmacist or physician beforetaking any new medications(including vitamins, herbalsupplements, etc.).

• Try to use only one pharmacyfor all your medications.

• When you see multiplephysicians, let them know whenyou start or stop taking aparticular medication.

• Keep track of your medicationsby using a pillbox. Fill eachcompartment ahead of time foreach day of the week.

• Mark your calendar for whenyou need prescriptions refilled.

• Discard any medications that have expired.

The medication awarenessprogram will be expanded toinclude all PARTNERS members

Medication AwarenessProgram for Members

(Continued on page 2)

Referrals to

Specialists ..............................2

PARTNERS Formulary

Now Online ............................4

Prior Authorization

Guidelines ..............................6

Partnershealth.com Gets a

Makeover ................................7

Inside theSpring 2005 Issue:

Newsletter

2 The PARTNERS Provider Newsletter

Medication Awareness Program for Members(continued from page 1)

later this year. Continuing educationwill be achieved through a series ofmailings that will address topicssuch as Medication Compliance,Polypharmacia, Brand vs. GenericMedications, and Effects and Side

Effects of Medications. For more information about this membereducation program, please contactPARTNERS Provider Service at 1-888-296-9790 Monday throughFriday 8 a.m. to 5 p.m.

Referrals to Specialists The goal of the PARTNERS

Provider newsletter is toprovide you with health andbenefit information that willenable you to make informed

decisions regarding healthcare services for

our members.

This newsletter, unlessotherwise stated, applies toMedicare Choice members.

PARTNERS is committed to offering its health plans on a

nondiscriminatory basis.

PARTNERS does notdiscriminate based on color,religion, national origin, age,

race, disability, handicap,gender, or health status as

defined by CMS.

PARTNERS National HealthPlans of North Carolina, Inc.

PARTNERS Provider ServiceToll free 1-888-296-9790

or 1-336-774-5400

PARTNERS primary care physicians(PCPs) are responsible for providingor arranging for all appropriatemedical services for PARTNERSmembers, including referrals toparticipating specialists, whennecessary.

PARTNERS provides two referralforms – one for physical therapyservices and one for all otherspecialist services. When com-pleting the appropriate referral form, the PCP should reference thePhysician Referral Directory or ouronline provider directory to locate aparticipating PARTNERS specialist.

If services are not available from aPARTNERS participating specialist,the PCP must obtain prior approval

from PARTNERS to refer a memberto a nonparticipating specialist. Ifthis prior approval is not obtained,the services will not be covered.PCPs may seek this approval bycalling PARTNERS ProviderServices at 1-888-296-9790 andselecting the prompt for obtainingprior approval.

Please keep in mind that a referral isnot a guarantee of payment unlessthe service is a covered benefit.Additionally, if a member self-refersto a specialist and then contacts thePCP for a retrospective referral, thePCP should not comply with therequest, but instead direct themember to file an appeal withPARTNERS.

partnershealth.com 3

Questions About a Claim?Whenever you have a question about a particular claim,we encourage you to submit a written Provider ClaimInquiry form. The claim inquiry form can be found inSection 25, “Forms,” on page 7 of your PARTNERSProvider Manual. Use the Provider Claim Inquiry formin cases in which you are seeking:

• Reconsideration of paid or denied claims.

• Request for review of incorrectly paid claims.

• Request for information regarding denial of servicesnot included in member’s health benefit plan.

• Request for status of filed claims.

• Refund of overpayments.

The completed Provider Claim Inquiry form can befaxed to us at 1-336-659-2962 or mailed to us at:

PARTNERS National Health Plans of N.C., Inc.

P.O. Box 17268

Winston-Salem, NC 27116-7268

Telephone Numbers:

General Information: 1-800-942-5695 or 1-336-760-4822

PARTNERS Provider Service: 1-888-296-9790 or 1-336-774-5400

PARTNERS Medicare Choice Customer Service:

1-888-310-4110 or 1-336-774-5410

PARTNERS Disease Management: 1-336-774-5412

Fax Numbers:

Claims Department: 1-336-659-2962

Referrals: 1-336-659-2944

Customer Services: 1-336-659-2963

Precertification/Utilization Review:1-336-794-1556

Case Management: 1-336-659-2945

Disease Management: 1-336-794-1546

Mailing Addresses for Claims PARTNERS Central OfficeTelephone and Fax Numbers

Facility Claims:

P.O. Box 17368

Winston-Salem, NC 27116-7368

Physician Claims, Referrals and EOBs:

P.O. Box 17268

Winston-Salem, NC 27116-7268

Special Deliveries, FedEx or UPS:

5635 Hanes Mill Road

Winston-Salem, NC 27105

4 The PARTNERS Provider Newsletter

You can now access the PARTNERS formulary online via the Provider section of the PARTNERS Web site atpartnershealth.com. Drugs that require prior approval will be in bold and may include some nonformulary drugs.We encourage you to use the online formulary, as it will be more up-to-date than your printed formularies, whichyou should have received in February.

PARTNERS Formulary – Now Online

PARTNERS Medicare Choice has helped develop auniform Smoking Cessation Toolkit designed to assistour respective network primary care physicians (PCPs)identify, assess and support patients in smokingcessation efforts.

PARTNERS Medicare Choice (PMC) will provide atoolkit with 50 patient education packets to all PCPpractices participating with PMC. A mailer will be sentto your practice advising you of the availability of thetoolkit upon your request.

Quit Now NC! designed the toolkits and also providesthe program material online at quitnownc.org or throughNC Prevention Partners’ Web site atncpreventionpartners.org.

Medicare Plans Smoking CessationCounseling CoverageOn a related note, please read the following news releasefrom the Centers for Medicare and Medicaid Services(CMS). It should be of interest to your practice in

Smoking Cessation Toolkits Available

(Continued on page 5)

✓Description of procedure consistentwith CMS description

✓Language is compliant with the“Woman’s Health and Cancer RightsAct of 1998”

partnershealth.com 5

The following medical coverage policies have been reviewed and approved by the Quality Improvement Committeeand the PARTNERS Physician Advisory Group. The new policies were effective as of December 8, 2004. Pleasecontact PARTNERS Health Services if you need any additional information.

Rehabilitation Therapy ✓Clarified separate sections foroutpatient and inpatient therapy

✓Requires Prior Approval

✓Complies with Medicare coverageguidelines

Breast Reduction ✓Requires Prior Approval

✓Complies with current Medicare coverage guidelines

Physician Services in Long-Term Care Facility

✓Policy renamed to “PhysicianServices in Long-Term Care FacilityRoutine Services” to clarify this isnot for acute services

✓ Requires Prior Approval

✓Terminology clarified for “routine”evaluation and management ofmembers with additional note addedto address “acute” condition(s)

✓Referral to appropriate contractingprovider needed for acute condition

Durable Medical EquipmentPolicy

✓Consistent with CMS coveragedeterminations and DMERC RegionC Supplier Manual

✓Terminology consistent with CMScoverage guidelines

✓Please refer to Prior AuthorizationGuidelines for specific itemsrequiring prior approval

Policy Major Changes Additional Notes

Medical Coverage Policy Updates

considering reimbursement options for your Medicarepatients seeking smoking cessation counseling services.

CMS intends to provide new coverage allowing certainMedicare beneficiaries who smoke to receive counselingservices that will help them quit the habit, according toan announcement made by HHS Secretary Tommy G.Thompson. Medicare beneficiaries who have an illnesscaused or complicated by smoking, including heartdisease, cerebrovascular disease, lung disease, weakbones, blood clots, and cataracts will be eligible forcounseling coverage. The coverage also applies tobeneficiaries who take any of the many medications for

which effectiveness is complicated by smoking includinginsulins and medicines for high blood pressure, seizures,blood clots and depression.

In 1993, smoking cost the Medicare program about$14.2 billion, or approximately 10 percent of Medicare'stotal budget. On average, nonsmokers survived 1.6 to 3.9years longer than those who never smoked. The proposalto cover smoking cessation counseling is a response to aJune 2004 request from the Partnership for Prevention(PFP) that CMS open a national coverage decision toconsider coverage of tobacco cessation counseling.(HHS News Release, Dec. 23, 2004)

Smoking Cessation (continued from page 4)

6 The PARTNERS Provider Newsletter

Prior Authorization Guidelines Updates

Cosmetic Procedures (or those potentially cosmetic),such as, but not limited to:

• Abdominoplasty

• Blepharoplasty

• Breast Reduction

• Genioplasty/Sliding Osteotomy

• Rhinoplasty

• Strabismus Surgery

Dental Services for Accidental Injury

Diagnostic Testing• Neuropsychological Testing

• Psychological Evaluations for Medical Reasons

Durable Medical Equipment and Prosthetics • All Rental Items

• Items Greater Than $600 (purchase price)

• Penile Implants

External Counterpulsation

Home Health Agency Services

Hospice

Inpatient Admissions• Scheduled admissions, including acute hospital,

rehabilitation facility, hospice and skilled nursing facility

• NOTE: For urgent/emergency admits (including obstetric admits), prior authorization is NOTrequired. However, notification to PARTNERSof urgent/emergency admits (including obstetric admits) within 24-hours or the first business day after the admission is required.

Investigational Procedures (or those consideredpotentially investigational)

Nonparticipating Providers and Services

Pharmaceuticals (See also PARTNERS formulary)• Amevive (Alefacept)

• Cerezyme

Rehabilitation/Therapy• Biofeedback

• Cardiac Rehabilitation

• Pulmonary Rehabilitation

• Speech Therapy

• Wound Care Clinic

Surgery

• Capsulotomy (laser)

• Extracapsular Cataract Extraction With

Intraocular Lens

• Implantable Automatic Cardiac Defibrillators (ICDS)

• Lithotripsy, Extracorporeal for Orthopedic Problems

(plantar fasciitis and chronic lateral epicondylitis are

the two conditions considered for coverage)

• MOHS Surgery

• Refractive Surgical Procedures

• Retina, Central Photocoagulation (laser)

• Pan-Retinal Photocoagulation (PRP, laser)

• Photodynamic Therapy With Visudyne

• Spinal Neurostimulators

• Surgical Treatment of Morbid Obesity

• Surgical Treatment of Sleep Apnea

• Temporomandibular Joint Surgery

• Transplants, Bone Marrow and Organ

• Varicose Vein Treatment

• Vertebroplasty and Kyphoplasty, Percutaneous

Transportation (non-emergency)

Effective April 1, 2005, PARTNERS will require priorapproval for coverage of implantable automatic cardiacdefibrillators. A revised copy of the PARTNERS PriorAuthorization Guidelines is included below for your

reference. Please replace any previous copies of the PriorAuthorization Guidelines that you may have in yourPARTNERS Provider Manual with this revised version,which will become effective April 1, 2005.

Prior Authorization Guidelines

partnershealth.com 7

Partnershealth.com has a new look! With vibrantgraphics, adjustable text size, and easy-to-use portals,the new site has something for all PARTNERS visitors,including members, employers, providers andprospective members.

In the new Providers section, you’ll find an array ofvaluable information at your fingertips that will makeworking with PARTNERS even easier. With the click ofyour mouse, you can:

• Review the online Provider Manual

• Search the prescription drug formulary

• Read the latest PARTNERS Medicare ChoiceProvider Newsletter

• Learn about PARTNERS health programs

• Find contact information

And don’t forget to recommend the site to yourPARTNERS patients. PARTNERS members can use thenew site to:

• Find a doctor

• Find a drug

• Review benefits

• Research health management programs

Stop by and experience the new partnershealth.comtoday!

Partnershealth.com Gets a Makeover

8 The PARTNERS Provider Newsletter U3214

Editor: Susan LovettCorporate CommunicationsDurham, NC 27702-2291

Address Service Requested

PRSRT STDU.S. POSTAGE

PAIDRaleigh, NC

Permit No. 59

As part of it’s quality and compliance program TheCenters for Medicare & Medicaid Services (CMS)require that Medicare Advantage organizations (i.e.,PARTNERS) report HEDIS data annually. Collectingand reporting information for HEDIS is required forCMS certification and licensing.

Over the next several months, PARTNERS staff will becollecting information for the 2005 HEDIS report. Arandom sample of members that meet the eligibilityrequirements will be chosen in order to calculate therequired measures. Many of you will receive a calland/or visit from PARTNERS staff requesting access tomedical records on specific health issues such asCholesterol Management After Acute CardiovascularEvents, Comprehensive Diabetes Care, Beta BlockerTreatment After a Heart Attack, Colorectal Screeningand Controlling High Blood Pressure.

PARTNERS has reviewed the HIPAA Privacy regulationcarefully in regard to these activities. HIPAA allows the

disclosure, without an authorization, of protected healthinformation (PHI) for the purposes of treatment,payment and health care operations. In section 164.501and 164.506 of the Privacy Rule, the Department ofHealth and Human Services makes it clear that activitiesincluding evaluating health plan performance,certification and accreditation are defined as “HealthCare Operations” activities. Accordingly, a coveredentity may use or disclose PHI without an authorization,for its own health care operation activities or for certainhealth care operation activities of another covered entityincluding those listed above.

PARTNERS is a covered entity and requires thisinformation in order to meet CMS requirements, and,under the HIPAA Privacy Rule, you are allowed todisclose this information to us to perform these healthcare operations activities.

Your cooperation with our staff is greatly appreciated.

HEDIS Data Collecting to Begin