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2015

eviCore healthcare Provider Manual

TRIAD Healthcare IPA, Inc., dba eviCore healthcare IPA, Inc. (collectively “eviCore”).

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TABLE OF CONTENTS

Welcome to eviCore hhealthcare ................................................................................................................... 3

eviCore Provider Manual ............................................................................................................................... 4

eviCore’s Responsibility to You .................................................................................................................... 5

Your Responsibility to eviCore ...................................................................................................................... 6

Quick Reference Contact Information ........................................................................................................... 7

Network Participation .................................................................................................................................... 8

Utilization Review and Quality Management ................................................................................................ 9

Peer-To-Peer (P2P) ...................................................................................................................................... 11

Claims Processing ........................................................................................................................................ 13

Appeals and Grievances ............................................................................................................................... 17

Discrimination .............................................................................................................................................. 18

Privacy.......................................................................................................................................................... 19

Plan Specific Addendum .............................................................................................................................. 20

Aetna (New Jersey) ...................................................................................................................................... 21

WellCare (Medicare Advantage) ................................................................................................................. 24

WellCare New Jersey Medicaid ................................................................................................................... 28

Visiting Nurses Service New York Choice (VNSNY CHOICE) -Chiropractic .......................................... 30

Visiting Nurse Services New York Choice (VNSNY CHOICE) -Acupuncture ......................................... 33

© 2015 eviCore healthcare

All Rights Reserved. This document is an unpublished proprietary work of eviCore healthcare. This document contains certain information as to the methods, processes, procedures, and other confidential information proprietary to eviCore healthcare and may not be copied or disclosed, whole or in part, without the prior written consent of eviCore healthcare. Any copies made of this documentation shall contain eviCore healthcare’s copyright notice and any and all proprietary marking or confidential legends, including this paragraph and the two above. Printed in the USA. All trademarks and registered trademarks used herein are the property of their respective owners.

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Welcome to eviCore hhealthcare TRIAD Healthcare IPA, Inc., dba eviCore healthcare IPA, Inc. (collectively “eviCore”) is a leading musculoskeletal service company focused on the unique needs of the patient with painful spine and joint conditions. We work with providers, patients, health plans and employers to ensure the person with musculoskeletal pain complaints receives care that is safe, efficient and likely to produce a favorable outcome. eviCore offers programs that identify and promote the delivery of quality, evidence-based care to musculoskeletal patients in the following areas and specialties:

Physical Medicine Chiropractic Physical Therapy Occupational Therapy

Pain Management Interventional Anesthesiology Physiatry (PM&R) Neurology Musculoskeletal Surgery Orthopedic Surgery Neurosurgery Primary Care management support for musculoskeletal patients Internal Medicine Family Practice General Medicine

Participating providers are selected on the basis of an ongoing credentialing review process based upon standards established by accreditation organizations for managed care companies. eviCore will encourage, support and facilitate all participating providers in their

pursuit of evidence-based care. We welcome your participation under each of eviCore’s client plans and value your contributions in meeting our shared goal of ensuring the delivery of the highest quality care. This manual was prepared to assist you and your office staff in administering the health care services to your patients as a participating provider in one of our programs. It includes information about eviCore's operations, network and plan participation requirements, claims submission, utilization review and network communication. As we add new clients or revise policies and procedures, you will receive updated information in a timely manner. If you have any questions, please contact our Customer Service Department. Toll free numbers are listed in each plan specific addendum.

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eviCore Provider Manual This Provider Manual is an extension of your eviCore1 Participating Provider Agreement (“Agreement”). As such, it is referenced multiple times within that “Agreement”. The information and instructions contained within this Manual are designed to assist you in maintaining compliance with your “Agreement”. Please note, where referenced within the “Agreement”, the information contained within this Manual is intended to be equally binding as the language within your “Agreement”. To facilitate your use of this Manual, we have referenced the “Agreement” throughout, by section, to relate the explanations and detailed information contained within the Manual to your “Agreement”. Below is a bulleted summary of those areas of the “Agreement” that are detailed within this Manual. This summary is not intended to be a substitute for the “Agreement” itself, which we recommend you review in detail prior to using this Manual.

1 eviCore healthcare: formerly known as CareCore, MedSolutions and Triad Healthcare, Inc.

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eviCore’s Responsibility to You

• Section 2.1 – eviCore is responsible to obtain and monitor your professional credentials and communicate these accurately to its Plans and other authorized recipients.

• Section 2.2 – eviCore is responsible to notify you of any new contract with a Health Plan and to provide you with complete information about that contract so you can make an informed decision to participate.

• Section 2.3 – eviCore is responsible to notify you when entering into an agreement with a

Health Plan where there is an administrative fee, charged to you.

• Section 2.4 – eviCore is responsible to accept your claims, process and pay them to the terms negotiated with the Plan and in compliance with State and Federal claims payment regulations.

• Section 2.5 – eviCore is responsible to make reasonable efforts to secure Health Plan contracts for your participation.

• Section 4.1 – eviCore is responsible to develop and maintain utilization and quality management programs that ensure that care delivered to Plan Enrollees is safe and compliant with current evidenced based medicine.

• eviCore is responsible to communicate to you, through this provider manual and periodic additions and deletions to it, all the information necessary for you to comply with your obligations under the eviCore Participating Provider Agreement.

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Your Responsibility to eviCore

• Section 1.2 – You are responsible to accept Plan Enrollees as patients unless you notify eviCore that your practice is closed to new patients. You may not discriminate against any Plan Enrollee.

• Section 1.4 – You are responsible, when contemplating a referral to another provider, to utilize a participating provider of your patient’s health plan.

• Section 1.5 – You are responsible to create and maintain adequate medical records on your patients and share them with eviCore upon our request. Provider shall furnish such records at no charge to eviCore, upon reasonable notice during reasonable business hours, to the extent necessary for utilization review activities, claims processing and payment, and for the purpose of inspection.

• Section 1.6 – You may not engage in discussions with other Participating Providers about refusing to deal with any proposed or active Plan contracts entered into by eviCore.

• Section 1.10 – You are responsible to verify if your patient is eligible for coverage under the applicable Health Plan. Please note eviCore has developed an easy to use online tool for you to verify member status. Please access eviCore’s public website, http://www.triadhealthcareinc.com, and select “Provider Portal” from the Provider drop-down menu to register.

• Section 1.13 – You may not engage in any activity designed to encourage a patient or an employer to terminate their coverage with a Plan or their participation with an eviCore program.

• Section 5.4 – You are responsible to accept payment for your claims under the terms of the eviCore Participating Provider Agreement and the Plan contract, as payment in full. You may not collect additional fees from your patient unless a waiver has been obtained under the terms of this agreement.

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Quick Reference Contact Information

Credentialing Please fax all credentialing documentation to 888-844-6645 or you can mail to: eviCore healthcare Attn: Credentialing Department 80 Spring Lane Plainville, CT 06062

Medical Policies Please access eviCore’s Medical Policies at the below link: http://www.triadhealthcareinc.com/providers/policies.aspx

Claims eviCore electronic claims submission is available through MD On-Line, payor id (39181). Please submit your paper claims to: eviCore healthcare Attn: Claims Department 80 Spring Lane Plainville, CT 06062

Utilization Review You can fax approval forms and/or medical records to 1-866-225-1033 For all general Utilization Management inquiries please call number listed in each plan specific addendum.

Eligibility To verify patient eligibility please contact the patient’s health plan directly, access eviCore’s provider portal or call eviCore’s Customer service Department. Toll free numbers are listed in each plan specific addendum.

P2P (Peer–to-Peer) If you wish to speak with a Clinical Peer please call eviCore’s Customer Service Department. Toll free numbers are listed in each plan specific addendum.

For additional support, please access eviCore’s public website, http://www.triadhealthcareinc.com, and select “Provider Portal” from the

Provider drop-down menu.

eviCore’s Customer Service Department is accessible Mon. through Fri. from 8:00 AM to 6:00 PM. Please note: Times may vary depending on plans.

Please refer to plan specific addendums for hours of operation.

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Network Participation eviCore’s Participating Provider Network represents providers who meet minimal health care industry criteria for educational and professional quality standards as well as eviCore established criteria for patient accessibility, and clinical performance. The network participation process includes both initial credentialing and periodic re-credentialing activities. Healthcare providers who participate in eviCore’s Networks are eligible to provide healthcare services to eviCore’s Health Plan clients as well as serve on eviCore’s Quality Committees and Clinical Staff. eviCore healthcare is a member of the Council of Affordable Quality Healthcare, Universal credentialing application data source (CAQH). You may access a CAQH Universal Credentialing Application on-line at https://upd.caqh.org/oas/ eviCore’s Credentialing and Re-credentialing Programs are currently accredited by both NCQA and URAC. All providers billing under the same Tax ID as you, must be credentialed with eviCore. Call the number listed in each plan specific addendum to request applications for new associates.

The following is required for network participation. • A fully executed eviCore Participating

Provider Agreement. • A current unrestricted license to practice in

the state of practice location. • You must NOT be restricted from

participating in any Medicare/Medicaid programs or any other third party reimbursement programs.

• You must NOT be subject to disciplinary action by any state or territorial board of medical examiners.

• You must NOT have been convicted of a felony.

• You must be in good physical and mental health.

• You must carry a minimum of one Million/three million claims made or occurrence professional liability insurance.

• You must provide a minimum of 20 patient contact hours per week.

• You must provide covered services for members within the scope of your license. You must provide coverage 24 hours per day, 7 days a week, and 52 weeks a year.

• You must meet OSHA standards and maintain compliance with all federal and state health and safety regulations.

• In addition, upon re-credentialing eviCore may require you to meet certain quality standards as established annually based on: o Member complaints or grievances o Utilization performance. o Member satisfaction survey results

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Utilization Review and Quality Management eviCore commonly provides utilization review and quality management programs to Health Plans. These programs are designed to ensure that the delivery of health care services to Health Plan Enrollees is safe, effective and consistent with evidenced based medicine and to collect the data necessary to report this information to authorized stakeholders. Generally, these programs apply to both participating and non-participating providers who treat Health Plan Enrollees. eviCore Participating Providers may elect to utilize voluntary prior approval processes that eviCore does not make available to non-participating providers. For each Health Plan, there may be slightly different utilization and/or quality management processes that you must follow. The UR/QM process is defined specific to each Health Plan under the section of this Manual called PLAN SPECIFIC ADDENDUM.

All of eviCore’s utilization review decisions will be communicated to you and to your patient in either written or verbal format as required by law. Unless otherwise required, eviCore will provide you with a utilization review determination in the same format as you used to submit a claim or request for prior approval. For example, if you fax your prior authorization form, you will receive our response by fax. All utilization review determinations sent to your patients by eviCore, will be sent by standard U.S. Postal Mail. eviCore collects information from health plans, providers and members through claims forms, medical records, surveys and other sources that are used to manage the cost and quality of care, process claims and generate reports. We strive to collect this information as efficiently as possible. Prior Authorization Forms eviCore administers prior approval using standardized authorization forms – Physical Medicine Authorization & Musculoskeletal Services Authorization. eviCore’s authorization forms include provider and patient demographics only. Medical Records must accompany the authorization form. Forms with records can be submitted to eviCore via dedicated fax lines, postal mail, and customized web interfaces (eviCore’s Provider Portal). eviCore will use these forms, and any accompanying medical documentation, to determine medical necessity and notify you of such determination. The information on this form is used by eviCore to identify you and the member for whom you are requesting prior authorization. While we can accept these forms telephonically, medical records must be sent via fax or web. Physical Medicine Authorization Forms are available on eviCore’s website: http://www.triadhealthcareinc.com/providers/forms.aspx Medical Records

Medical Records should always be submitted with your prior authorization form. If you choose not to prior approve care, eviCore’s clinical staff will review your claims as they are received. If additional clinical information is required to make a determination of medical necessity, medical records will be requested of you at that time. Medical records may also be requested of you following a Peer-to-Peer call to document any verbal information you have provided. eviCore will request only that information necessary for the review. The medical records you provide to eviCore should contain

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your clinical records for all dates of service for the submitted claim or prior authorization request including but not limited to: exam narrative, office notes, diagnostic tests and/or any equivalent notes which demonstrate your patient’s condition and/or progress to date. Use black ink for clarity and quality of copying. If handwriting is not legible, records should be typed. Notes should be timely, brief, and include all pertinent data. Standard accepted medical abbreviations are suitable. Copies of all correspondence regarding a case, including return-to-work notes, referral letters, reports, telephone communication, written authorization to release information, consent to treat forms, etc. should be maintained.

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Peer-To-Peer (P2P) eviCore recognizes that most of our Participating Providers also participate with other UR/QM programs. In addition, not all of our Participating Providers approach patient care from exactly the same perspective or use the same scope of services. These factors, in combination with the rapidly evolving medical evidence base, can make understanding and complying with UR/QM programs more difficult than it should be.

One of the more important aspects of our program involves the understanding of eviCore’s clinical rationale language and the clinical logic and medical evidence used to make clinical determinations.

eviCore engages only experienced, actively practicing health care providers to serve as Peer Reviewers for our UR/QM programs. We define “Peer” to mean a healthcare professional with the same educational credentials and professional degree as you, who may also practice within a similar geographic region (state or locality). Our goal is to ensure when clinical judgment is required to make a determination of medical necessity, it is done by someone who is treating patients like yours every day, just like you.

We appreciate that it may be difficult to find a Peer who is exactly like you with a practice that is exactly like yours, but we take special efforts to get it as close as possible.

In addition to their clinical experience, eviCore’s clinical staff is trained in four primary areas:

1. Medical policy and evidence based literature.

2. NCQA and URAC accreditation standards

3. eviCore’s Care Management Process

4. Conducting Peer-to-Peer dialogue

Each of our clinical staff, in addition any committee duties they volunteer for, has two primary responsibilities, the first is to perform utilization review, the second is to respond to telephonic requests for additional discussion from our Participating Providers, something we call Peer-to-Peer Dialogue or P2P.

Anytime eviCore receives a request for information that involves further explanation of a utilization management determination, review of medical policy or the medical evidence behind the medical policy, the understanding of eviCore clinical rationale language or an understanding of the UR/QM process itself, the caller is provided access to an eviCore Clinical Peer for that discussion.

We make every effort to accommodate you immediately with a clinical Peer; however, because our Peers are in their offices, just like you, sometimes these calls have to be scheduled at a later time that is convenient for you.

Our Peers are authorized to do the following with you by telephone:

1. Review clinical determinations and any related correspondence sent to you from eviCore.

2. Accept additional clinical information that may not have been included in your original clinical documentation.

3. Discuss specific aspects of an individual case to best understand its unique aspects, directly from you.

4. Review current eviCore medical policy and clinical criteria.

5. Approve services that were initially denied.

We strongly recommend that you take advantage of this service to streamline the UR/QM process and get accurate, direct answers to your clinical questions. If you wish to speak with a Clinical Peer

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please call eviCore’s Customer Service Department. Toll free numbers are listed in each plan specific addendum.

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Claims Processing

eviCore commonly processes healthcare claims for Health Plans. We strive to exceed industry standards for processing turnaround time and payment accuracy. Generally, there is little variation in the claims submission process from one Health Plan to another, but occasionally there is. The claims process is defined specific to each Health Plan under the section of this Manual called PLAN SPECIFIC ADDENDUM. Claims Processing Methodology eviCore currently employs two claims processing methodologies. Each methodology is offered to Health Plans as options for Claims Processing. Consequently, the methodology may vary from one Health Plan to another. Please refer to the PLAN SPECIFIC ADDENDUM to this Manual to determine which methodology described below is being utilized with which Health Plan.

1. Fee for Service (FFS)

This methodology applies coverage determinations based on benefits and medical necessity determinations across each service (CPT code) that you bill and reimburses for each service.

2. Bundled Encounter (BE)

This methodology applies coverage determinations and medical necessity determinations across only the service date (encounter) that you bill and reimburses one rate per covered encounter.

Claim Submission • Electronic Submission: eviCore healthcare

has partnered with MD On-line for electronic claim submission. Claims can be individually entered free of charge. To

access this benefit, log on to www.triadhealthcareinc.com/providers and click the “Submit” button under Online Solutions. This will route you to MD On-line’s portal for eviCore’s providers. Please include eviCore’s address (see below) and electronic payer ID #39181. To learn more about MD On-line’s products for submitting eviCore claims electronically free of charge, please call: 1-888-499-5465

• Paper claims can be submitted directly to eviCore at: eviCore healthcare Attn: Claims 80 spring Lane Plainville, CT 06062

Time Frame for Claim Submission Unless otherwise specified in a PLAN SPECIFIC ADDENDUM (Claims Filing Deadlines) to this manual, Participating Provider claims must be received by eviCore no later than 180 days from the date services are rendered (claims filing deadline). Claims submitted to eviCore after the claims filing deadline will be denied due to late submission. Submissions received by eviCore outside of business hours shall be considered as received the following business day. Clean Claims Claims will be processed in accordance with all state and federal guidelines. A “clean” claim will have no defect or lack of required substantiating documentation. Documents required for the claim to be considered clean include medical documentation (initial exam narrative, re-evaluations and daily treatment records) in addition to any pertinent information that detail the member’s presenting condition, the member’s progress/response to treatment as compared to the member’s initial evaluation baseline and the member’s expected prognosis/outcome to treatment for the date(s) of service submitted. Please refer to the information outlined in the Required Information for all Claim Submission

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section of the Provider Manual for required fields on “clean” claims. “Non-clean” claims are incomplete claims, claims that are missing required data as outlined by eviCore or a claim that requires additional information from the provider. eviCore applies all state and federal guidelines to determine if a claim is considered “non-clean”. Paper Claims Guidelines – Effective October 28, 2010 • Submit “clean claims” using CMS-1500

claim forms. For complete, detailed information about paper claim submissions refer to the National Uniform Claim Committee (NUCC) – CMS1500 forms. Refer to the 837 Institutional Implementation Guide by Washington Publishing Company (March 2003) for any EDI-related issues.

• Paper claims must only be submitted on original (red ink on white paper) claim forms.

• Paper claim forms must not be handwritten or have any extraneous data printed or stamped on them except handwritten information that may be at the top of the original claim form indicating “Corrected Claim” in the instance of a re-submission. In the instance of an encounter submission, “Encounter” may be written or stamped in red on the paper claim, only if it does not obscure any of the claim’s information. o Any missing, incomplete or invalid

information in any field will cause the claim to be rejected.

o The font should be: legible; typed in black ink; in large, dark font in capital letters. The font should not have: broken characters; script, italics or stylized font; red ink; mini font; or dot matrix font.

Required information for all claim submission Claims submission Guidelines are posted on eviCore’s website: www.triadhealthcareinc.com/providers/claim.aspx . If any required field is omitted, or otherwise illegible, you will receive notice that you have failed to follow the proper procedure

for filing a clean claim. Such notice shall be provided to you within statutory time frames and shall include a description of the failure and the proper procedures to follow in order to rectify and re-submit the claim. Remittance Advice Once a claim has been adjudicated, providers will receive a Remittance Advice via US postal mail. The Claims Payment System assigns applicable payment/non-payment codes and descriptions for all billed services. Provider Remittance Advice notices contain payment/non-payment descriptions listed in the provider payment description table. In compliance with applicable federal and state regulations, Provider Remittance Advice notices provide: (1) instructions for filing a grievance and appeal, including timeframes for filing; and (2) CMS appeals language, including time frames for filing, as applicable. Providers are afforded a right to appeal an adverse claim decision. Additional days may be afforded as allowed by state. Member Explanation of Benefit (EOB) notices are also generated and mailed for members with Medicare or Commercial plan benefits upon claim adjudication. Member EOB notices contain payment/non-payment descriptions listed in the member payment description table. Reimbursement Unless otherwise specified in a PLAN SPECIFIC ADDENDUM of this manual, both electronic and paper claims identified as “clean” will be paid within 30 calendar days after receipt. If additional information is needed, eviCore will request from the insured/provider within 30 days of receipt of claim. Once additional information is received, the claim will be paid within 30 days of the receipt of the additional information. Fee Schedules eviCore has developed competitive fee schedules for participating providers for each of our programs. Fee schedules may vary depending on client, state and region. All of our fee schedules are made available to our providers upon request and in advance of changes or new programs. You can request a

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copy of a fee schedule by calling eviCore’s Customer Service Department. Toll free numbers are listed in each PLAN SPECIFIC ADDENDUM. Eligibility and Benefit Verification Your office staff may contact eviCore, or access eviCore’s Provider Portal, to verify member eligibility and inclusion in each of our clients’ programs. Coverage for each client, plan and member may vary; therefore, it is important to verify coverage for certain procedures by reviewing eviCore’s Plan Specific Addendums and Covered Services Sections of our client’s website prior to rendering services. Claims for members not effective on the date of service rendered or not included in an eviCore program will be denied. Balance Billing: The non-payment of services for any reason resulting in member responsibility for Commercial and Medicare claims are processed according to CMS guidelines, state mandated requirements, and health plan delegation agreements, as applicable. Providers cannot bill the patient for any covered services deemed not medically necessary by eviCore unless they have obtained a written agreement to do so from the patient prior to rendering services. In addition, per eviCore’s Participating Provider Agreement, the provider will agree not to bill the patient for any amount above the negotiated fee schedule for covered services unless otherwise specified by plan contract. Overpayment eviCore shall request (in writing) any amount deemed “overpaid” to a participating provider. Coordination of Benefits (COB)

Coordination of Benefits (COB) is a provision which establishes the order in which insurance plans pay claims when an individual has coverage under more than one plan. The concept of COB is to make the member “whole”, meaning that payment is calculated to reimburse up to the allowed amount, eliminating the member's responsibility or cost

share for services that are coordinated as long as the paid amount does not exceed the normal benefit. The Primary Insurer Plans certificates of coverage contain COB provisions and eviCore will coordinate those benefits with those available from other Commercial insurance plans, Federal Medicare, motor vehicle insurance plans, worker's compensation issues, third party insurance plans and multiple Primary Insurer Plans'. Primary Insurer Plans’ COB department determines which plan is primary and which is secondary (or tertiary (third), etc.). The client’s COB department uses standard industry rules to determine the order of payment and will update the member's eligibility record accordingly. This is referred to as the order of benefit determination or the order of payment determination. Things to remember when submitting claims to eviCore:

1. Verify patient eligibility.

2. Verify patient inclusion in an eviCore program.

3. Verify covered services, limits or exclusions.

4. Verify claim submission process in the plan specific addendum.

5. Collect applicable copayments from your patients.

6. Include all pertinent medical records.

7. Submit current year CPT and ICD codes.

For more detail please refer to the PLAN SPECIFIC ADDENDUM

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Required fields for claims submission (HCFA 1500)

Please note: medical records must be submitted with a claim in order for the claim to be considered clean.

Field 1 Medicare/Medicaid/CHAMPUS/CHAMPVA/Group Health

Plan/FECA/other 1a Insured’s ID Number 2 Patient’s Name 3 Patient’s DOB 4 Insured’s name 5 Patient’s Address/City/State/Zip Code/Phone# 6 Patient Relationship to Insured (Self /Spouse/ Child/Other 8 Patient Status- Check either- Single, Married/Other. Employed/FT/PT

9,9a-d Other Insured’s Name/Other Insured’s Policy#/DOB/Gender/Employer’s Name/Insurance Plan

10 a-c Is the patient’s condition related to: Employment, Auto or Other? Place?

11 Insured’s Policy Group or FECA Number 11d Is there another Health Benefit Plan? 12 Patient’s or authorized person’s signature 13 Insured’s or authorized person’s signature 21 Diagnosis Codes 24a Date of Service 24b Place of Service 24d Procedure Codes 24e Diagnosis Codes 24f Charge Amounts 24g Days or Units 24i ID. Quality 24j Rendering Provider ID # 24k Rendering Provider’s ID as assigned by payer 25 Federal Tax ID Number, SSN, EIN 26 Patient’s Account # 27 Accept Assignments 28 Total Charge 29 Amount Paid 30 Balance Due 31 Signature of Physicians or supplier and date 32 Name and Address of Facility where services were rendered 32a NPI 33 Physician’s, Supplier’s Billing Name, Zip Code and Phone # 33a NPI

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Appeals and Grievances

APPEALS You may appeal any adverse determination issued by eviCore. eviCore will process and respond to your appeal as described in the PLAN SPECIFIC ADDENDUM. In some cases, eviCore may not be delegated to administer all levels of appeals. In instances where eviCore is not delegated, eviCore will immediately forward your appeal to the Health Plan for processing and consideration. Please refer to the PLAN SPECIFIC ADDENDUM to this Manual for the correct appeals process for each Health Plan. eviCore shall include an explanation of the relevant appeals process with all adverse determinations to the provider, member and/or their designee. When delegated, appeals must be submitted in writing and must be received by eviCore within 90 days of receipt of an adverse determination. All written comments, documents, records and other information submitted to support the appeal will be reviewed and considered in a timely manner without regard to whether those documents or materials in making the initial determination. GRIEVANCES eviCore encourages open communication with our provider community. A grievance or complaint can be expressed in writing at the address below or by calling eviCore’s Customer Services Department. Toll free numbers are listed in each plan specific addendum. All grievances and complaints will be researched and responded to in a timely manner, in accordance with state and federal regulations as applicable. Once received, your complaint or grievance is logged by eviCore’s Quality Management (QM) staff. You will receive a written acknowledgement within five (5) days. The complaint or grievance will be evaluated for urgency, categorized and researched. The complaint or grievance with accompanying research is presented to the complaint committee for review and then sent to QM for the creation and distribution of the final response. All complaints and grievances are reported to MQIC and are reviewed for potential opportunities for quality improvement or corrective action. Written grievances and complaints: eviCore healthcare Complaint Department 80 Spring Lane Plainville, CT 06062

Forms can be found at http://triadhealthcareinc.com/providers/forms.aspx

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Discrimination Section 1.3 of the eviCore Participating Provider Agreement states: Non-Discrimination. Provider shall, and shall require Associated Providers to, perform healthcare services for all patients in the same manner, and in accordance with the same standards. Provider shall, and shall require Associated Providers to, treat Enrollees on at least the same basis as other patients. Provider shall not, nor shall Provider allow Associated Providers to, discriminate or differentiate with respect to the treatment, or quality of services, provided to Enrollees on the basis of race, sex, age, religion, sexual orientation, handicap, place of residence, or health status. Understanding discrimination is necessary before you can effectively comply with the terms of your agreement with eviCore. Below is a summary of non-discrimination language offered by CMS referencing Title VI of the Civil Rights Act of 1964. You are responsible to ensure that you and those you employ are aware of and compliant with the non-discrimination provisions of this law.

“As a recipient of Medicare, Medicaid or other federal funds, Providers cannot exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by the Provider directly or through a contractor or any other entity with which the Provider arranges to carry out its programs and activities.

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.”

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Privacy

Section 1.6 of the eviCore Participating Provider Agreement reminds you, among other things, to be aware and comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Among HIPAA’s many important provisions are those that expressly relate to the privacy of protected health information (PHI). You are responsible to ensure that the PHI you obtain from your patients and share with authorized parties is protected from unauthorized access. Below is a summary of the Privacy Rule issued by the U.S. Department of Health and Human Service (“HHS”) which should guide your efforts at compliance. You are responsible to take the necessary measures to ensure that your practice is in compliance with HIPAA and the Privacy Rule. “The U.S. Department of Health and Human Services (“HHS”) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). 1 The Privacy Rule standards address the use and disclosure of individuals’ health information—called “protected health information” by organizations subject to the Privacy Rule — called “covered entities,” as well as standards for individuals' privacy rights to understand and control how their health information is used. Within HHS, the Office for Civil Rights (“OCR”) has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties. A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.”

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Plan Specific Addendum The PLAN SPECIFIC ADDENDUM outlines the details of each program you may have elected to participate with through your eviCore Participating Provider Agreement. The forms for each program can be found under the forms section on the eviCore website www.triadhealthcareinc.com. If you should have any questions pertaining to these programs please call eviCore’s Customer Service Department. Toll free numbers are listed in each plan specific addendum.

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Aetna (New Jersey)

Type of Business Aetna HMO-based, Health Network Option/Only and Medicare Advantage plans

eviCore Program Chiropractic Benefit Management including Network Participation, UR/QM and Claims Processing

Summary Aetna has delegated the administration of chiropractic benefits to eviCore healthcare for their HMO-based (including Health Network Option/Only and Medicare Advantage plans) members in New Jersey. This delegation includes network contracting, utilization management and claims payment. You should contact eviCore at 1-800-409-9081 to verify member inclusion in this program or you may go on-line at http://www.triadhealthcareinc.com/providers/providers.aspx

Effective Date HMO Northern New Jersey members – 10/1/06

HMO Southern New Jersey members – 7/15/10

UR/QM eviCore’s 10 visit UM Threshold

The members first 10 visits of therapeutic care will be adjudicated and reimbursed without utilization review. In addition, the first 10 visits of therapeutic care for any established patient who presents with a new condition will also be adjudicated and reimbursed without utilization review. eviCore will use the CMS definition for a “new patient” as a reference for “new condition”, therefore, a patient with a new condition will be defined as:

“Any established patient with a diagnosed condition for which the treating provider or another provider within the same practice has not provided care for that condition within the last three years.”

The following conditions apply to the 10 visit UM threshold:

Any concurrent evaluation/management, preventative medicine, radiology or electrodiagnostic service will be reviewed for medical necessity.

For treatment plans extending beyond the 10 visits, participating providers may elect to prior authorize the 11th and subsequent visits or may provide care and eviCore may review the 11th and subsequent visits retrospectively.

Physical Medicine Authorization forms are available in this section, below or on eviCore’s website: (http://www.triadhealthcareinc.com/providers/providers.aspx).

Please note, medical records are required to be submitted with the Physical Medicine Authorization form.

Physical Medicine Authorizations will be valid for six (6) months from the

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date of the determination.

Prior approval is required for Medicare members ONLY.

Voluntary prior approval for Commercial and Self Insured members may be requested after the patient’s tenth encounter (visit).

Claims Methodology

Fee for Service (FFS)

Claims Submission Participating providers will need to submit all claims for Aetna HMO-based members (including Health Network Option/Only and Medicare Advantage plans) members in New Jersey directly to eviCore. Participating provider claims submitted directly to Aetna for HMO members will be denied by Aetna and will have to be re-submitted to eviCore.

Claims filing Deadline

Providers have 180 days to submit claims from the date of rendered services

Fee Schedule Claims are adjudicated according to the eviCore/Aetna fee schedule. The fee schedule is subject to a Maximum Daily Allowed Amount per date of service for new patients, established patients with evaluation service(s) and established patient routine visit. You can request a copy of the eviCore/Aetna fee schedule, by calling eviCore’s Customer Service Department.

Administrative Fee There is no administrative fee applied to claims for the HMO program with Aetna.

Appeals NJ Prompt Pay/Administrative Denial Appeals All providers may initiate an administrative claim appeal on or before the 90th calendar day following receipt of the claims determination. These Appeals should be completed using the Health Care Provider Application to Appeal a Claims Determination Form (NJ Only) and mailed or faxed to eviCore (see below). This Form can be found on-line at our website www.triadhealthcareinc.com under the Forms & Instructions section.

Claims appeals should be sent directly to eviCore at: eviCore healthcare Appeals Department 80 Spring Lane Plainville, CT 06062 Fax: 860-793-3317 If you disagree with eviCore’s administrative claim appeal decision, you may obtain an external review by initiating an arbitration proceeding within 90 calendar days of receipt of an uphold notice. The New Jersey Department of Banking & Insurance has contracted with MAXIMUS, Inc. as the Arbitration Organization (AO) to operate the Program for Independent

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Claims Payment Arbitration (PICPA). Health care providers may submit an Application for Arbitration online at https://njpicpa.maximus.com. For more information, please contact MAXIMUS by phone, fax or mail at: MAXIMUS, Inc. Attn: New Jersey PICPA 50 Square Dr., Suite 210 Victor, NY 14564 P#: (585) 425-5326 F#: (585) 425-5296 UR appeals should be sent to:

Medicare Aetna Medicare Advantage Grievances and Appeals PO Box 14067 Lexington, KY 40512

Commercial Aetna Health, Inc. Customer Resolution Team PO Box 14625 Lexington, KY 40512

Benefit Limitations Maintenance Care, Wellness Care and Scheduled Supportive Care are not covered.

P2P If you wish to speak with a Clinical Peer at any time, please call eviCore’s Customer Service at 1-800-409-9081 and a Representative can assist you.

Complaints and Grievances

A grievance is a complaint expressing dissatisfaction. eviCore healthcare encourages open communication; a complaint can be made by calling eviCore’s Customer Service Center at 1-800-409-9081 or in writing at the address below. All complaints are researched and resolved in a timely manner. eviCore healthcare Complaint Department 80 Spring Lane Plainville, CT 06062

Primary Care Referral

eviCore’s programs do not require a PCP referral for chiropractic; however any Aetna plans that currently require a PCP referral will continue to do so. Please contact Aetna to determine if your patient requires a referral.

Customer Service Contact eviCore’s Customer Service Department at 1-800-409-9081, Monday-Friday from 8:00 AM to 6:00 PM EST.

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WellCare (Medicare Advantage) Type of Business Medicare Advantage in the State of New York & New Jersey.

eviCore Program Chiropractic Benefit Management for Medicare Advantage Members in New York and New Jersey. Chiropractic Benefit Management includes Network Participation, UR/QM and Claims Processing

Summary eviCore will assist WellCare in delivering a chiropractic benefit to their Medicare Advantage members in New York and New Jersey. Chiropractic Benefit Management includes clinical data collection, care planning, healthcare coaching, provider network management, and claims administration.

***NY State Program

Individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit are often referred to as “dual-eligible members.” These benefits are sometimes referred to as Medicare Savings Programs (MSPs). Dual eligible members are eligible for some form of Medicaid benefit, whether that Medicaid coverage is limited to certain costs, such as Medicare premiums, or the full benefits covered under the state Medicaid plan. States administer MSPs for Medicare and Medicaid eligible members with limited income and resources to help pay for their Medicare cost-sharing. There are multiple MSP categories and the categories are based upon the beneficiary’s income and asset levels as well as “medically needy” status. Members learn of their MSP assistance from an award letter they receive from the state Medicaid agency.

Please see the chart below for the different categories of dual-eligible members:

Medicare Savings (MSP) Assistance

Fee-for-Service Part A Premium Covered?

Fee-for-Service Part B Covered?

Part A and B Cost-Sharing Covered?

Full Medicaid Benefits Provided?

Qualified Medicare Beneficiary (QMB)

Yes Yes Yes No

QMB Plus (QMB+)

Yes Yes Yes Yes

Specified Low Income Medicare Beneficiary (SLMB)

No Yes No No

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SLMB Plus (SLMB+)

No Yes Yes Yes

Qualifying Individual (QI)

No Yes No No

Qualified Disabled Working Individual (QDWI)

Yes No No No

Full Benefit Dual-Eligible Members (FBDE)

Yes Yes Yes Yes

In general, QMB, QMB+, SLMB+, and FBDE beneficiaries are considered “zero cost-share” dual-eligible members since they pay no Part A or Part B cost share. Please note, the state Medicaid agency defines all state optional MSP levels and those levels may vary among states. Please contact the state Medicaid agency for full MSP information.

Effective Date Medicare Advantage members in New York- May 7, 2007.

Medicare Advantage members in New Jersey - January 1, 2008.

UR/QM Prior approval is required after the 1st date of service (encounter). You can request prior approval of services by submitting the Physical Medicine Authorization form.

Physical Medicine Authorization forms are available on eviCore’s website: (http://www.triadhealthcareinc.com/providers/providers.aspx).

Please note, medical records are required to be submitted with the Physical Medicine Authorization form.

Claims Methodology

Fee for Service

Claims Submission Participating providers will need to submit all claims directly to eviCore.

***NY State Program Providers

Please continue to submit claims to eviCore. If the member is a Dual Special Needs Plans eligible member you will receive an Explanation of Payment (EOP). Some DSNP Plans will have a Part B deductible amount applied prior to payment similar to how Medicare operates today. The amount for the 2014 is $147.00. This deductible is considered a cost sharing amount and covered by the state Medicaid agency or designee if they have Managed Medicaid. Providers will bill eviCore as they do today and submit the EOP provided by eviCore to the state for payment.

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Claims Filing Deadline

Providers have 180 days to submit claims from the date of rendered services

Fee Schedule Claims are adjudicated and reimbursed at the eviCore/WellCare fee schedule. You can request a copy of the eviCore/WellCare fee schedule, by calling eviCore’s Customer Service Department.

The fee schedule represents the Allowed Amount. Member cost share (copay, coinsurance, deductible) will be deducted from the Allowed Amount when final payment is issued by eviCore. The member cost share (copay, coinsurance and deductible) portion of the Allowed Amount will be identified on the Explanation of Payment and should be collected directly from the member.

***NY State Program

The filed cost-sharing amounts related to supplemental benefits are the responsibility of the member. Provider may not “balance bill” these members. This means providers may not bill these members for either the balance of the Medicare rate or the providers’ customary charges for Part A or Part B services. The member is protected from liability for Part A and Part B charges, even when the amounts the provider receives from eviCore are less than the Medicare rate or less then the providers’ customary charges. Providers who bill these members for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing) are subject to sanctions.

** Please note as stated above for some Dual Special Needs Plans the members cost share will be reimbursed by the state.

Administrative Fee None

Appeals All Participating Provider Claims, Administrative, and Retrospective (UR) denial of treatment should be mailed to: eviCore healthcare Appeals Department 80 Spring Lane Plainville, CT 06062 Fax to 860-793-3317 All Member Appeals and Provider Prospective (UR) denial of treatment should be mail to: New York Members: WellCare Attn: New York Appeals Department PO Box 31368 Tampa, FL 33631-3368 New Jersey Members: WellCare Attn: New Jersey Appeals Department PO Box 31368 Tampa, FL 33631-3368

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For a Fast Appeal you or your representative should contact WellCare by telephone or fax: Toll Free: 1-800-278-5155 TTY/TTD: 1-877-247-6272 Fax: 1-866-201-0657 For additional information about the appeal process please refer to the denial letter. You may request another copy of the denial letter by calling eviCore’s Customer Service Center at 1-800-409-9081.

Benefit Limitations Chiropractic Manipulative Therapy (CMT) is the ONLY covered service under this benefit.

P2P If you wish to speak with a Clinical Peer at any time please call eviCore’s Customer Service at 1-800-409-9081 and a Representative can assist you.

Complaints and Grievances

A grievance is a complaint expressing dissatisfaction. eviCore healthcare encourages open communication; a complaint can be done by calling eviCore’s Customer Service Center 1-800-409-9081 or in writing at the address below. All complaints are researched and resolved in a timely manner. eviCore healthcare Complaint Department 80 Spring Lane Plainville, CT 06062

Primary Care Referral

eviCore’s programs do not require a PCP referral for chiropractic care.

Customer Service Contact eviCore’s Customer Service Department at 1-800-409-9081.

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WellCare New Jersey Medicaid Type of Business Medicaid in the State of New Jersey.

eviCore Program Chiropractic Benefit Management for Medicaid Members in New Jersey. Chiropractic Benefit Management includes Network Participation, UR/QM and Claims Processing

Summary eviCore will assist WellCare in delivering a chiropractic benefit to their Medicaid members in the following New Jersey counties: Essex, Hudson, Middlesex, Passaic, and Union.

Chiropractic Benefit Management includes clinical data collection, care planning, healthcare coaching, provider network management, and claims administration.

Effective Date Medicaid members in New Jersey – April 1, 2014.

UR/QM Prior approval is voluntary; therefore, you do not need to prior approve services. eviCore reserves the right under your provider agreement and WellCare’s member Certificate of Coverage to review billed services for medical necessity at the time of claim submission if prior approval has not been elected. If you elect to prior authorize care, you must submit the Physical Medicine Authorization Form to eviCore before the patient’s second visit, or within fourteen (14) days of the initial visit, whichever occurs first. The Physical Medicine Authorization form requests that medical records be submitted with the form to eviCore healthcare for review. Physical Medicine Authorization forms are available on eviCore’s website: (http://www.triadhealthcareinc.com/providers/providers.aspx).

Please note, medical records are required to be submitted with the Physical Medicine Authorization form.

Claims Methodology Fee for Service

Claims Submission Participating providers will need to submit all claims directly to eviCore.

Claims Filing Deadline

Providers have 180 days to submit claims from the date of rendered services

Fee Schedule Claims are adjudicated and reimbursed at the eviCore/WellCare fee schedule. You can request a copy of the eviCore/WellCare fee schedule, by calling eviCore’s Customer Service Department.

Administrative Fee None

Appeals All Participating Provider Claims and Administrative appeals should be mailed to: eviCore healthcare Appeals Department 80 Spring Lane Plainville, CT 06062

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Fax to 860-793-3317 All Member Appeals, Provider Prospective (UR) denial of treatment and Retrospective (UR) denial of treatment should be mail to: New Jersey Members: WellCare Attn: New Jersey Appeals Department P.O. Box 31368 Tampa, FL 33631-3368 For a Fast Appeal you or your representative should contact WellCare by telephone or fax: Toll Free: 1-800-278-5155 TTY/TTD: 1-877-247-6272 Fax: 1-866-201-0657 For additional information about the appeal process, please refer to the denial letter. You may request another copy of the denial letter by calling eviCore’s Customer Service Center at 1-800-409-9081.

Benefit Limitations Chiropractic Spinal Manipulative Therapy (SCMT) is the ONLY covered service under this benefit.

P2P If you wish to speak with a Clinical Peer at any time, please call eviCore’s Customer Service at 1-800-409-9081 and a Representative can assist you.

Complaints and Grievances

A grievance is a complaint expressing dissatisfaction. eviCore healthcare encourages open communication; a complaint can be done by calling eviCore’s Customer Service Center at 1-800-409-9081 or in writing at the address below. All complaints are researched and resolved in a timely manner. eviCore healthcare Complaint Department 80 Spring Lane Plainville, CT 06062

Primary Care Referral

eviCore’s programs do not require a PCP referral for chiropractic care.

Customer Service Contact eviCore’s Customer Service Department at 1-800-409-9081.

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Visiting Nurses Service New York Choice (VNSNY CHOICE) -Chiropractic

Type of Business Medicare Advantage

eviCore Program Chiropractic benefit for Medicare Advantage Members in New York. Chiropractic Benefit Management includes clinical data collection, utilization management, healthcare coaching, provider network management, and claims administration.

Summary eviCore assists VNSNY Choice deliver its chiropractic benefit to VNSNY Choice Medicare Advantage members in the following New York counties: Bronx, Brooklyn, New York, Queens, Richmond, Nassau, Suffolk, Westchester, Saratoga, Albany, Schenectady, and Rensselaer. Covered chiropractic services for VNS’s New York Medicare Advantage members are only available through eviCore’s network of participating providers who also participate with Medicare. VNSNY Choice offers several tiers of benefits to its members. Please verify covered services for your patients prior to rendering services.

eviCore is expanding the current VNSNY CHOICE chiropractic program to include FIDA membership effective 1/1/2015 in the following New York counties only: Bronx, Kings, Queens, New York, Nassau, and Richmond.

Effective Date Original program start date: 6/21/2007

FIDA membership implementation date: 1/1/2015

UR/QM Prior approval is required after the 1st date of service (encounter). You can request prior approval of services by submitting a Physical Medicine Authorization form. Physical Medicine Authorization forms are available on eviCore’s website: (http://www.triadhealthcareinc.com/providers/providers.aspx).

Please note, medical records are required to be submitted with the Physical Medicine Authorization form.

Claims Methodology

Fee for Service

Claims Submission

Participating providers will need to submit all claims for dates of service from June 21, 2007 forward for VNSNY Choice Medicare Advantage members directly to eviCore. Participating provider claims submitted directly to VNS will be denied by VNS and will have to be re-submitted to eviCore.

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Claims Filing Deadline

Providers have 180 days to submit claims from the date of rendered services.

Fee Schedule Claims are adjudicated and reimbursed at the eviCore/VNS fee schedule. You can request a copy of the eviCore/VNS fee schedule, by calling eviCore’s Customer Service Department.

The fee schedule represents the Allowed Amount. Member cost share (copay, coinsurance, deductible) will be deducted from the Allowed Amount when final payment is issued by eviCore. The member cost share (copay, coinsurance and deductible) portion of the Allowed Amount will be identified on the Explanation of Payment and should be collected directly from the member.

Administrative Fee

None

Appeals All Participating Provider Claims and Administrative appeals should be mailed to: eviCore healthcare Appeals Department 80 Spring Lane Plainville, CT 06062 Fax to 860-793-3317 Utilization Review and Member Appeals: VNS Choice Select Grievance and Appeal Department 1250 Broadway 3rd Floor New York, NY 10001 For additional information about the appeal process please refer to the denial letter. You may request another copy of the denial letter by calling eviCore’s Customer Service Center at 1-800-409-9081.

Benefit Limitations

Chiropractic Manipulative Therapy (CMT) is ONLY covered service under this benefit.

P2P If you wish to speak with a Clinical Peer at any time please call eviCore’s Customer Service at 1-800-409-9081 and a Representative can assist you.

Complaints and Grievances

A grievance is a complaint expressing dissatisfaction. eviCore healthcare encourages open communication; a complaint can be done by calling eviCore’s Customer Service Center 1-800-409-9081 or in writing at the address below. All complaints are researched and resolved in a timely manner. eviCore healthcare Complaint Department

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80 Spring Lane Plainville, CT 06062

Primary Care Referral

eviCore’s programs do not require a PCP referral for chiropractic care.

Customer Service Contact eviCore’s Customer Service Department at 1-800-409-9081.

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Visiting Nurse Services New York Choice (VNSNY CHOICE) -Acupuncture

Type of Business

Medicare Advantage

eviCore Program

Acupuncture benefit for Medicare Advantage Members in New York.

Summary eviCore has been selected to administer an Acupuncture program for VNSNY CHOICE Medicare Preferred (HMO SNP) and VNSNY CHOICE Medicare Maximum (HMO SNP) members (only) in the following New York counties: Bronx, Brooklyn, New York, Queens, Richmond, Nassau, Suffolk, Westchester, Saratoga, Albany, Schenectady, and Rensselaer. eviCore will provide administrative services including; network contracting, credentialing and claims payment. The program will allow VNSNY members the opportunity to receive Acupuncture services from an eviCore participating provider based on members benefit.

eviCore has expanded the current VNSNY CHOICE Acupuncture program to include FIDA membership effective 1/1/2015 in the following New York counties (only): Bronx, Kings, Queens, New York, Nassau, and Richmond.

Effective Date Original Program Start Date: 1/1/2013

FIDA membership implementation date: 1/1/2015 for counties listed above.

UR/QM Prior Authorization is not required for this program. Only the following Acupuncture services are included and covered under this program. All other services provided will not be covered under this program.

• 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.

• 97811: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles. 97811 cannot be performed without 97810.

• 97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient. 97814: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles. 97814 cannot be performed without 97813.

Claims Methodology

Fee for Service

Claims Submission

Participating providers will need to submit all claims directly to eviCore for dates of service January, 1 2013 forward for VNSNY CHOICE Medicare Preferred (HMO SNP) and VNSNY CHOICE Medicare

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Maximum (HMO SNP) members (only) in New York.

Claims Filing Deadline

Providers have 180 days to submit claims from the date of rendered services

Fee Schedule Claims are adjudicated and reimbursed at the eviCore/VNS fee schedule. You can request a copy of the eviCore/VNS fee schedule, by calling eviCore’s Customer Service Department.

Administrative Fee

None

Appeals All Participating Provider Claims and Administrative appeals should be mailed to: eviCore healthcare Appeals Department 80 Spring Lane Plainville, CT 06062 Fax to 860-793-3317 Utilization Review and Member Appeals: VNSNY CHOICE Appeals and Grievance Department 1250 Broadway 3rd Floor New York, NY 10001 For additional information about the appeal process please refer to the denial letter. You may request another copy of the denial letter by calling eviCore’s Customer Service Center at 1-800-409-9081.

Benefit Limitations

Limited to 12 visits per calendar year

Complaints and Grievances

A grievance is a complaint expressing dissatisfaction. eviCore healthcare encourages open communication; a complaint can be done by calling eviCore’s Customer Service Center 1-800-409-9081 or in writing at the address below. All complaints are researched and resolved in a timely manner. eviCore healthcare Complaint Department 80 Spring Lane Plainville, CT 06062

Primary Care Referral

eviCore’s programs do not require a PCP referral for acupuncture services.

Customer Service

Contact eviCore’s Customer Service Department at 1-800-409-9081, Monday- Friday from 8:00 AM to 6:00 PM EST.