A: Health care practitioners gain access to CHN via membership in a participating CHN member organization's physician hospital organization (PHO) or employment by a member facility. CHN does not contract directly/independently with individual practitioners. Once a practitioner has been credentialed by a participating member organization, the appropriate information is forwarded to CHN. Practitioners must meet or exceed established CHN credentialing criteria and be accepted by the CHN Credentialing Committee.

A: CHN ancillary services are either:

• Provided directly by a CHN network facility
  
• Owned by a participating hospital or
  
• Contracted directly with CHN

A: CHN has participating organizations in the following Ohio counties: Cuyahoga, Summit, Lorain, Mahoning, Trumbull, Erie, Wayne, Medina, Stark and Ashtabula and one in Erie, Pennsylvania.

A: A member organization is an entity that consists of a hospital or system of hospitals, ancillary providers and an affiliated practitioner network. The affiliated practitioner network can be a Physician Hospital Organization (PHO), Contracting Organization (CO) and/or employed practitioner panel (staff model).

A: These are legal organizations that bond hospitals and the attending medical staff. PHOs are frequently developed for the purpose of contracting with managed care plans. Source

A: CHN has established credentialing criteria for all practitioners included in our contracts. Qualifications for specific practitioner types are developed by the CHN Credentialing Committee and are annually reviewed.

A: Practitioners must first be credentialed and approved by a participating CHN member organization. The practitioner must then be submitted to CHN for an additional review of qualifications. The entire process should take no longer than six months or 180 days, contingent on receiving complete information. The National Committee for Quality Assurance (NCQA) determined this time frame. Once approved by the CHN Credentialing Committee, practitioners become effective the 1st day of the following month.

A: A contracted payor is an insurance company, self-funded employer group or third party administrator that contracts with CHN to provide access to our practitioner network. For additional information on CHN contracted payors, please refer to the CHN Payor Fact Sheets.

A: Definitions from Source.

Health Maintenance Organization (HMO)-- A type of plan that controls health care expenses by making cost-saving arrangements with physicians, hospitals and other health care practitioners. Usually, HMOs offer reduced out-of-pocket costs to members who have their care coordinated by a primary care physician who participates in their network.

Point-of-Service Plan(POS)-- A commercial insurance plan which combines elements of HMOs and PPOs to balance cost controls with the enrollee's freedom of choice. Enrollees select a primary care physician from a network of physicians contracted to the plan. The cost to the enrollee for care provided by a network practitioner is very low or nothing. Enrollees may obtain care from out-of-plan practitioners but at a significantly higher cost share.

Preferred Provider Organization (PPO)-– A managed care plan in which you use doctors, hospitals, and providers that belong to the network. The practitioner agrees to accept negotiated fees in return for prompt payment and a certain volume of patients. Members may seek care from non-participating practitioners but generally are financially penalized for doing so by the loss of discounted fees and may be subject to co-payments and deductibles.

A: When a managed care organization such as CHN is "at risk" it means that the organization accepts responsibility for the financial risk and rewards in the cost for effectively caring for members enrolled in a health plan. A non-risk contract is a contract in which the payor is responsible for the health care costs of members enrolled in their health plan.

A: Practitioners should verify the patient’s eligibility through the Member Services department of the health plan.

A: All medical care must be coordinated through the patient’s primary care physician. However, if a PCP refers a patient to a specialist and the specialist needs to provide a service which requires additional authorization, the specialist could request the authorization for continued care. CHN expects the specialist to communicate the need for additional services or treatment back to the patient's PCP.

A: In general, laboratory and/or radiology services can be provided in any in-network physician office. Laboratory and/or radiology services can also be provided in hospital laboratories, in addition to hospital affiliated- laboratories or radiology centers. Please verify with the health plan when authorizing or precertifying these type of services. Physicians can also refer patients to any CHN hospital-affiliated laboratories or radiology centers.

A: In general, laboratory and/or radiology services can be provided in any in-network physician office. Laboratory and/or radiology services can also be provided in hospital laboratories, in addition to hospital affiliated- laboratories or radiology centers. Please verify with the health plan when authorizing or precertifying these type of services. Physicians can also refer patients to any CHN hospital-affiliated laboratories or radiology centers.

A: Physicians are reimbursed on a fee-for-service basis directly by the CHN contracted payors. For non-risk contracts, fee schedules are negotiated via a messenger model process that allows the PHO and the payor to establish rates. After the rates are agreed to, they are used by the payors so that reimbursement is made according to the negotiated fee schedule. The CHN risk contracts (HMO and POS) reimburse practitioners according to a fee schedule negotiated between CHN and the member organizations. Practitioners are NOT capitated by CHN.

A: Not necessarily. A provider has the option to choose in which contracts he/she will participate. The best way to know if a provider participates in a particular contract is to reference the payor’s website.

A: There are a number of ways to determine if your physician is participating in CHN:

• Ask your physician is s/he is participating in CHN.
  
• The most current information should be accessible from the payor's Member Services department. Please refer to your membership identification card for the appropriate phone number.
  
• CHN contracted payors publish a practitioner directory which is periodically updated. Obtain a current copy of the payor’s Practitioner Directory from your respective payor’s Member Services Department.
  
• Query the CHN practitioner directory on our Web site (www.chnetwork.com) to locate a practitioner participating in CHN, and to find out the hospital(s) where s/he has admitting privileges.
  

A: CHN does not pay claims to practitioners, therefore any claims questions should be directed to the Member Services department of the respective payor. The Member Services department typically requires the following information in order to answer your questions:

• Patient name
  
• Patient or member identification number
  
• Practitioner name
  
• Date of service
  

A: Incorrect claims questions and issues should be forwarded to the Member Services department of your respective payor.

A: Each health plan has their own practitioner appeal process. Please refer to the plan’s practitioner manual. In the case of those plans for whom CHN has medical management responsibilities, please refer to the CHN Practitioner Manual Appeals Process and Procedures.