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HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITSSLOANs LAKE MANAGED CARE ma �. $LOANS LAKE MANAGED CARE 1355 S. Colorado Blvd. Suite 902 - Denver, Colorado 80222 - 303/691-2200 General Questions to be Answered by All Proposers for CITY OF FORT COLLINS Administration ALYreements and General Information 1. It is the intention of the City that the master contract reflect the elimination of the actively -at -work restriction or deferred effective date for all initially enrolled active or inactive employees and dependents. This will include only initial eligibles (those eligible on the effective date of the contract) including COBRA continuees. Please indicate your acceptance to this requirement. Sloans Lake Managed Care agrees. 2. It is required that proposals assume that all participants (including COBRA) presently covered will be covered under a successor plan regardless of medical condition, disabled status, or whether they are actively -at -work or on a no -loss no -gain basis for both the City and the participant. Is your proposal written in accordance with this requirement? Not applicable. 3. If your company is awarded this business, how soon after notification of the award would you be able to have a draft of the contract? A draft of the contract will be available within one day after notification of the award. 4. If the services furnished by your company differ in any respect from those described, please indicate where such differences exist. If you do not indicate any differences, it will be assumed that the services included in your proposal do, in fact, exactly match those described. Sloans Lake Managed Care agrees. 5. Provide a sample contract similar to the one that would be used for the City. City Standard Services Agreement is enclosed as Exhibit "A" , note specific exception or changes requested. Sloans Lake Managed Care 1 City of Fort Collins July, 98 C Attachment F Provider Directory i SLOANs LAKE MANAGED CARE Directory of Participating Providers ACCREDITED Health a Network w�. Standards Fall 1997 k Requested Attachment Concurrent Review Requested Attachment Concurrent Review /./ r LeIILI L \BP _'�-SELECT PRECERT -EADNEXT SLOA.NS LAKE MANAGED CARE 1355 S. COLORADO BLVD., SUITE 902 DENVER, COLORADO 80222 -D -I SUB.FIRST -I SUB.LAST -I SUB.ADD1 --I SUB.ADD2 -I SUB.ADD3 -I SUB.. ZIP PATIENT: -I PAT.FNAME -I PAT.LNAME INSURED NAME: -I SUB.FIRST -I SUB.LAST INSURED SSN: -I SUB.SSNO INSURANCE: -I GROUP.NAME NON -AUTHORIZATION #: -I CHID POLICY #: -I POLICY.NO _. FACILITY: -I FAC.NAME DATE OF PROCEDURE: -I ADMIT.DATE ANTICIPATED PROCEDURE: -I PROC.DESC The review for the above -referenced procedure is complete. After . careful review of the clinical information given to us, it had been determined that the procedure does not meet medical criteria for authorization. Please contact your physician regarding further treatment and/or clarification of rationale for non -authorization. THIS REVIEW DETERMINATION ADDRESSES MEDICAL APPROPRIATENESS ONLY. BENEFITS PAYABLE ARE DETERMINED BY THE *INSURANCE COMPANY SUBJECT TO THE HEALTH CARE COVERAGE IN EFFECT AT THE TIME OF SERVICE. THIS INCLUDES CONTRACTUAL LIMITATIONS, ELIGIBILITY REQUIREMENTS, COORDINATION OF BENEFITS, AND ANY OTHER POLICY LIMITATIONS IN EFFECT WHEN SERVICE IS RENDERED. The provider has been informed of copy of the Appeals Process. You decision by submitting a written - Group Health at the above address please call 1-800-850-1899. Sincerely, Robert P. Faraci, Medical Director \CE:kIN LETTERS.TEXT M.D. DGHSI our decision, and has been given a may appeal the non -authorization request to the Clinical Manager of If you need further assistance, !A 1 - / Requested Attachment Preservice Denial/Nonconfirmation Letter, - Y . _ I. (I i i. L, I _ f L \BP .."-SELECT PRECERT =..EADNEXT �7 T SLOAINS LAKE MANAGED CA -RE 1355 S. COLOPADO BLVD., SUITE 902 DENVER, COLORADO 80222 --I SUB.FIRST -I SUB.LAST -I SUB.ADDI -I SUB.ADD2 -I SUB.ADD3 -I SUB.ZIP CERTIFICATION NUMBER: -I CHID CERTIFICATION DATE: -I ENTRY.DATE PATIENT: -I PAT.FNAME -I PAT.LNAME INSURED: -I SUB.FIRST -I SUB.LAST INSURED SSN: -I SUB.SSNO INSURANCE: -I GROUP.NAME POLICY #: -I POLICY.NO DOCTOR: -I DOC.FNAME -I DOC.LNAME FACILITY: -I FAC.NAME ADMITTED: -I ADMIT.DATE NEXT REVIEW DATE: -I FOLLOW.UP.DATE We have reviewed the above named patient's admission to the hospital. Based on the information provided to us, the above hospital admission meets the guidelines for inpatient care and has been certified. THIS CERTIFICATION CONFIRMS THE MEDICAL NECESSITY OF INPATIENT CARE ONLY. PLEASE CONTACT YOUR BENEFITS OFFICE TO 'VERIFY THESE SERVICES ARE A COVERED BENEFIT. Per our utilization review process, these stays must be reviewed on an ongoing basis. Additional days or extended stays are authorized based on the reviews conducted with the admitting doctor's office. THE ADMISSION CERTIFICATION DOES NOT VERIFY ELIGIBILITY OF INSUR.n.NCE BENEFITS. BENEFITS PAYABLE FOR THIS ADMISSION ARE DETERMINED BY TH INSURANCE COMPANY SUBJECT TO THE HEALTH CARE COVERAGE IN EFFECT AT THE TIME. SERVICES ARE RENDERED. THIS INCLUDES CONTRACT LIMITATIONS, ELIGIBILITY REQUIREMENTS, COORDINATION OF BENEFITS, AND, ANY OTHER POLICY LIMITATIONS OR EXCLUSIONS. If I may be of further sere -ice to vou, please cont,ct me at 1-800-850-18?9 'Xt. --I EXT . Sincerely, 9 l i REQUESTED ATTACHMENTS REQUESTED ATTACHMENTS Please provide the following: 1. PRESERVICE REVIEW a. Include a sample preservice confkmation/approval notice/letter. b. Include a preservice denial/nonconfirmation notice/letter. 2. CONCURRENT REVIEW a. Provide a sample letter indicating that continued stay is longer able to be certified/approved. 3. CASE MANAGEMENT a. Include a sample case management summary report with savings analysis. (Do not identify the patient or providers of service.) b. Include a sample bill which this client could expect to receive for a case management patient. 4. REPORTS a. Include a sample standard report package with an explanation of abbreviations and categories of data. b. Include samples of customized report capabilities. 5. APPEAL PROCESS a. Attach a copy of the detailed appeal process a patient, physician or provider would need to follow in the resolution of a complaint/disagreement including key timeframes. b. Attach a sample appeal closure letter which would be forwarded to a physician. 6. ADMINISTRATIVE a. Include sample education material which informs enrollees regarding your Utilization Review fum's overall services. b. Include a sample Utilization Review contract. Nob aoa%1WV\e., .9 i Requested Attachment Preservice Confirmation/Approval Letter, C. Briefly describe a Utilization Management program/process/tool developed by your firm which you believe is innovative in controlling or measuring health care costs. d. Does your organization offer disease management programs? If so, describe including chronic conditions evaluated, length of program, savings and associated costs. Are the costs included in your quotation or are they additional? NA e. Complete the grid regarding your fi m's Utilization Management services. Type of Client Check (X) the Type of Service Number of Firms Number of Participants General Medical Worker's Compensation Taft -Hartley Trusts X 3 Single employer corporate x 9 Lo Government (State/Fed) X (CUKIQ Municipalities (city/county) r-El Schools X I Associations Other X TOTAL Sloans Lgk'zCggn40-d (:�4t`t UPI 4-;1I ZAZ -61 �alleu�nc� S �pr i cR-SS ILD G nA::r o \ lrt 4_MSk r ¢. �'1 a a 11r1� caa-v CAS • Q T(TLL-na\ Q%Acki C.�r,�*; � - c'��, v to CM*.b rn%-r S¢.h1,C.E. lelFar 30 S2CArA:S . ® C10%irnS 15PR�WarQ. CQ-u��� CDc�aS. rtiar,�S 1� s U-;: \� ZaA a 5 a GW1Irr%S otssaS5r' col o\ . © q tJar�hovS�n� 5 -�s� a55i5ir in 61 Not available, proprietary information. However, if submitted in writing, Sloans Lake Managed Care will consider any specific questions you may have about the contract. 6. Commissions or fees of any type are not to be paid to any entity as part of the cost of the services requested in this specifications letter. Is your proposal written in accordance with this provision? Sloans Lake Managed Care will not include commissions or fees. 7. Please provide at least three Colorado (preferably municipality plans with at least 500 employees) references (not current Segal Company clients) for each service you are proposing. List the name of the organization, address, telephone number, and contact person's name and title. If your company is quoting all or a portion of the benefits included in this Request for Proposal, please provide references for each benefit you are proposing. Also, provide the name and telephone numbers of any clients you are not now serving that you were serving three years ago. Why are you not providing service to these clients? PPO REFERENCES: NAME CONTACT EFFECTIVE DATE NUMBER OF MEMBERS Key Corp. Irene Immerman January 1, 1996 223 127 Public Square (216) 689-4667 Cleveland, OH 44114-1306 Promise Keepers Robert Borkovec April 1, 1995 287 PO Box 18376 (303) 456-7282 Boulder, CO 80308 Colorado Counties Cindy Downey January 1, 1996 2113 Cooperative (303)861-0507 1177 Grant Street, Ste.200 Ext. III Denver, CO 80203 UM REFERENCES: NAME CONTACT EFFECTIVE DATE NUMBER OF MEMBERS Adams County Bennie Muniz, January, 1990 258 Government450 S. 4 h Ave. (303) 659-2120 Brighton, CO 80601 Colorado Painters Industry Everett Clark, September, 1980 172 Health Benefits Fundl (303) 777-2244 16 Inverness Dr., E, Ste. 108 Englewood, CO 80112 TERMINATED UM & PPO GROUPS: NAME CONTACT TERMINATION REASON Sloans Lake Managed Care 2 City of Fort Collins July, 98 L /0 k I r \BP x<..;ELECT PRECERT '<EADNEXT 67 -I DOC.FNAME ,-I DOC.ADD1 -:I DOC.ADD2 SLOANS LAKE MANAGED CARE 1355 S. COLORADO BLVD., SUITE 902 DENVER, COLORADO 80222 -I DOC.LNAME --I RPOST PATIENT: - -I PAT.FNAME -I PAT.LNAME INSURED NAME: -I SUB.FIRST -I SUB.LAST INSURED SSN: -I SUB.SSNO INSURANCE: -I GROUP.NAME POLICY #: -I POLICY.NO FACILITY: -I FAC.NAME ADMISSION DATE: -I ADMIT.DATE NONAUTHORIZATION#: -I @ID 5�t-y R After careful review of the provided clinical information, we can recommend certification for only -I DAYS.CERTIFIED day(s). The last certified day is -I SCHED.DISCH.DATE . Upon written request, clinical rationale for non -authorization decisions will be provided. THIS REVIEW. DETERMINATION ADDRESSES MEDICAL APPROPRIATENESS ONLY. BENEFITS PAYABLE FOR THIS ADMISSION ARE DETERMINED BY THE INSURANCE COMPANY SUBJECT TO THE HEALTH CARE COVERAGE IN EFFECT AT THE TIME OF SERVICE. THIS INCLUDES CONTRACTUAL LIMITATIONS, ELIGIBILITY REQUIREMENTS, COORDINATION OF BENEFITS, AND ANY OTHER POLICY LIMITATIONS IN EFFECT WHEN SERVICE IS RENDERED. Please refer to Reconsideration for review. If 1-800-850-1899. Sincerely, the enclosure for an explanation of the or Appeal Process and clinical information necessary you need further assistance, please call Robert P. Faraci, M.D. Medical Director _iAIN LETTERS.TEXT DGHCSP 0 -Requested Attachment Case Management Summary Report n F.� 6w „J i-I r� 1 f� C ?/ N Ql C1 c C C N U x 2 N C m nn ca i� cn �i IF U 9 i l• N i v Y Y A < N m R T O P w P O N O C 2 Z p. O m P O ^ � n 9 O n �� � <' t• O n n N m h O n n N N M1 T n M1 N h m g g m P 07 C. S m• p• T f; m n m P N N A T N N m n H p n n ti m m O n n a n II m n n n^ a n t M1 c n n �e - .n n h m n e o m a e• o u+ m f a o m e N N R n n n a P e T- m m � e n n e -• M1 = T- m p p P ;� e o � r O n R N m n N n n m n N �• � p m n n e ei m^ n T n N c a c= c p a T T� 2f a ri n a e g O e m n n N n n M1 c 8 t tJ II O p N n T l+ n O m M1 �• O h O p a a n 0 T m C m m T n C ` I p p' 8 a n n m m N ^• a f: n n N a m- P p p T `J n '• T O n � Q M1 _ _ 3 3 i - _ _ -- N C p C O E O P a C n r N O U H N C1 O •U U m U u i p U p C n N Q H tL L . U c m > O c1 u O N N L_ �J L J J - u` L ,j - C _ u J l u j J .1 r� U r� N Q C m C7 c ca zcc C r QU to R U 1 r y C7 O^ C C O �1 �i �1 C7 i N N T n N O T T N O O tl N O N b N n N T n N n N 3 I. 3 m 21 r N m 4+. n N O O N O N N P � a rN.• n T n tl S m a. n I V U U U U U .. � N m m L C NC C C cm N O � r - ? m U E a - C a m '• u C n l m y C C - N a C N C ur - '> v u m - ra u N C 6'7 - j _ V N J - t � U , Regjuested Attachment Case Management Sample Bill 0 Regjuested Attachment Case Management Sample Bill 0 SLOF.NS LACE MANAGED CARE 1355 S. COLORADO BLVD. #502 DENVER, CO 80222 (303) 691-2200 SLOANS LAKE HEALTH PLANS 1355 S COLORADO BLVD #902 DENVER, CO 80222 #0006273 DAN YOUNG SLMC FOR PROFESSIONAL SERVICES RENDERED: 0025292-IN 01/30/98 HOURS AMOUNT 01/12/98 Medical Record Review .50 45.00 01/12/98 Telephone call from Spalding Rehab CM .20 01/12/98 Telephone call to Spalding Rehab -CM .20 .18.00 18.00 01/13/98 Telephone call from Spalding CM .20 18.00 01/13/98 Telephone call to Spalding CM .20 18.00 01/13/98 Telephone call from Spalding-outpt coord .20 18.00 01/13/98 Research contract w/Spalding 1.00 90.00 01/22/98 Telephone call to UR w/Spalding ,20 18.00 01/22/98 Telephone call from Aurora MRI .20 18.00 01/22/98 Telephone call from Aurora MRI .20 18.00 01/23/98 Treatment Plan Assessment .30 27.00 01/26/98 Telephone call to CM w/Spalding Hosp .30 27.00 TOTAL: ------------ 3.70 333.00 ------------ AMOUNT DUE: 333.00 TA.Y ID #84-0969104 P YNLIENT DUE UPON RECEIPT CURRENT OVER 30 OVER 60 OVER 90 OVER 120 BALANCE . r Requested Attachment Sample Reports O O O O O O O O G N QI N ^ M J O ^ cc •O P O •O 7 I IO U 6 to 10 O 10 yl N O O I IN 9L d 6 O �O N 2 • C • W F� N• W Cf N G N W I N > I •N H N N O 7 W� m W 11 v II C N O O O O O O O N C •• ii y o�G P W I J N 11 u WO V W C OG O W f OC W N N 1- •O d r• M M I� .- � h 2 U I � C W u W C a Cl J Y• i U U O W O m v a 7 O C W 4l W 4a1 � W N u W O W C W O W • 11 m '- ). u s s s s w u u w w w w u w ' L II u u = u u u w u II s m s s s x s N M O u o . W . 7 . • a ` a . • 1 1 a 2 . ` m T W 1 m . M N 'O L . 2 O C N O W P V ova a O J Op V 1-• ^ N m . M 2 S Y > C. W F W O <awa 0'. • J 1 J 1 6 W 09 6 K y u w s _ ! u J a W • O � U K N F U = S O C Iteguested Attachment Appeal Process n Founders Asset Management, Inc. Dyanne Dambold, Terminated to go 2930 E. 3rd Avenue (303) 394-4404 fully insured. Denver, CO 80206 Belle Bonfils Blood Center Jackie Campeau Terminated to go 717 Yosemite Circle (303) 355-7366 fully insured. Denver, CO 80220 8 Provide samples of any communication materials that would be provided by your company to the City at no additional cost. What customized materials are available? Please identify the retention costs associated with these communication materials. Samples of our communication materials are included in the requested attachments of this proposal. The initial supply is provided at no cost. Sloans Lake Managed Care is willing to discuss customized materials at a negotiated additional fee. 9. Would you agree to contractual performance guarantees regarding telephone calls, referrals, access standards, W. cards, NCQA accreditation? Please provide the specific standards and examples of similar arrangements with other clients. Sloans Lake Managed Care agrees. 10. The City will require that contracts include language that any data associated with the City's plan is the property of the City and, as such, must be available to the City (e.g., when changing vendors). Please indicate your acceptance of this requirement. Sloans Lake Managed Care agrees. 11. Record keeping: a. Discuss how participant and dependent records are maintained. Sloans Lake Managed Care does not keep track of participant and dependent records. b. Indicate your data needs from the City in order to administer this program? Data needed would come from the providers on a case by case basis. c. How will your organization verify eligibility? Sloans Lake Managed Care will coordinate with the providers to verify benefits and eligibility with the TPA. 12. Confirm that you will be Year 2000 compliant, and describe your procedures to become compliant. Sloans Lake Managed Care 3 City of Fort Collins July, 98 CSLOP.NS LAKE MANAGED CARE MEDICAL MANAGEMENT (MM):APPE1L PROCESS Subject: Medical Management (MM) Appeal Process Policy No.: 90060.001 Scope: All Parties Responsible Dept.: Medical Management - Group Health Effective Date: October 1995 Revision Date: W96, 6/96, 1/97, 12/97, 1/98 Approval: -e FEB 11 1998 Vice Pres ent Date FEB 1 1 1998 D'recto Date 7 UQI',,,0- 7 1 �958 Manager Date Policy: To ensure consistency m handling iequests fur re�iecv of a decision not to authorize/certtify treatment, a --'fission, or other heal_=* care service. (Provider includes both health care professionals as weL as heal__ care fac ties.) Procedure: I. The Utilization Manager,_ent (UNf) nurse confers vide t_He Medical Director when the case does not meet criteria for medical necessi�y and/or appropriateness. The UiVI nurse will elicit from the provider why certain criteria has not been met. II. The Medical Director may pero= the reoievv or refer to a Specialty Peer Reviewer, the review dote: -lines medical necessity. III. When a decision not to autal!orize/certify has been de,e.—i= ed, tt-le pro�,1der rnay invoke the Reconsideration and :appeal Process. (AopenD) IV. The patient or patient representa five may initiate aun. a_veal process. V. All W 1cc-a responses irO the %ledical N(ar!a,gem.1-inc l OT —'tl'' �o ll be !n!L2Ced V by the Ci:?_rperson of C.: COM- icc-e and Wilt be :n cl- - W;C I CO time Cr-=.-s as stated i^ Aeoerd,--,: D. 11�Ir ll;rphexld;hhnwpR; ..�� !I. is being cone the nett working day If the request is for aeiectivc procedure that n and does not meet criteria, the UM nurse needs to advise the office that all efforts vrill be made to complete the Medical Director re-rievr that day, but it may not occur until the ne t world.rig day. A. The Team Coordinator or manager must be ad�sed of the urgent request. I �jlrl�;rphcll t�,hhnmpR; :�< '_ REQUESTED ATTACHMENTS Please provide the following: 1. PRESERVICE REVIEW a. Include a sample preservice confirmation/approval notice/letter. b. Include a preservice denial/nonconfirmation notice/letter. 2. CONCURRENT REVIEW a. Provide a sample letter indicating that continued stay is longer able to be certified/approved. 3. CASE MANAGEMENT a. Include a sample case management summary report with savings analysis. (Do not identify the patient or providers of service.) b. Include a sample bill which this client could expect to receive for a case management patient. 4. REPORTS a. Include a sample standard report package with an explanation of abbreviations and categories of data. b. Include samples of customized report capabilities. 5. APPEAL PROCESS a. Attach a copy of the detailed appeal process a patient, physician or provider would need to follow in the resolution of a complaint/disagreement including key timeframes. b. Attach a sample appeal closure letter which would be forwarded to a physician. 6. ADMINISTRATIVE a. Include sample education material which informs enrollees regarding your Utilization Review firm's overall services. b. Include a sample Utilization Review contract. 14. Will a U.M. representative be assigned solely to the City? If not, what will the arrangement be? No lkhu-4 1S S"FRuu^t g=f� .� hctr"k\Q- GnM issgas -611t }ems. 15. What organization would provide the utilization review services, where is its headquarters and where will the utilization review services be provided? S1-MC- pt ore%% UP\ an -Sid e-) '\R �)sfw r,CD. 16. Will your firm agree to modify procedures to meet the needs of the City? PJO 17. The City is considering the addition of an Employee Advocacy Program which would provide assistance to employees regarding self care, general medical care, second opinions, selection of providers, etc. This program would be accessible to employees through a WATS telephone service during normal business hours. This service would be provided by personnel with the appropriate medical background to accurately answer questions. If the City were to add an Employee Advocacy Program: a) What type of personnel would provide these services? What of credentials would these individuals possess? SO4c-be %A '6—> type ba-hao+zml Vt-t.1�,-h, b) How would quality be assured and measured through this program? :5a)Jam,.,naS+r•s c) How many hours per day would this service be accessible through a live attendant? Daysperweek? OiHhm/dq-j �'?days(,ak d) Have you implemented a similar program for any other clients? If so, what were the financial impacts on the Plan compared to the investment? legs 18. Describe how psychiatric/substance abuse reviews will differ from other utilization services. Are these services subcontracted or provided within your organization? If done within, what are the credentials of the individuals performing this service? S a b cow &% A {'.a p&u Qe)tQ�'\ VA^tkh J:vlX�, dgAari;+atllwck �Ot��ySiOrlo)iS 19. Are there any other services that are subcontracted? Nanc 20. Are there or have there been any lawsuits brought against your company? Please describe in detail. 0;) c1 Q, 59 and negative areas of the working relationship? If yes, consider this cost in your proposed fees. (n9) [�(] a. Yes [ ] b. No 7. Indicate your firm's per occurrence liability INSURANCE LIMIT with regard to errors, omission, negligence, malpractice. (CHECK ONE ONLY) (n10) (] a. < $1,000,000 (] d. $5,000,000 [] b. $1,000,000 [] e. > $5,000,000 but < $10,000,000 �j C. > $1M but < $5M [ ] f. >=$10,000,000 8. On cases where any adverse decision has been rendered, are you willing to retain hard copy U.R. and medical information files for a period of one year POST contract termination? (CHECK ONE ONLY) (n15) a. Yes, at no added cost [ ] b. Yes, with an added cost $ [ ] c. No, explain: 9. Do you have educational material which informs enrollees regarding your U.R. services and Procedures? (CHECK ONE ONLY) (nl8) [ a. Yes, available for this client at no added cost [ ] b. Yes, available for this client with an added cost of $, [ ] c. No, but can develop at no added cost [ ] d. No, but can develop with an added cost of $ [ ] e. No, not available 10. Is your firm willing to assist this client if a dispute arises over payment/nonpayment for healt h care services which your firm recommended were not medically necessary, appropriate and/or reasonable? (CHECK ONE ONLY) I (n20) a. Yes, within our proposed fees [ ] b. Yes, for an added cost $ [ ] c. No, explain: 11. Is your firm willing to assist the City with medical appeals when special questions or situations arise? 25 12. What is your response time for returning phone calls/messages? W;6vi, N 4LJ tioMrs. ( basl nQSsdgb) 13. When approval or denial is granted for a procedure, what is the procedure for notification, who is contacted and what is the timeline? PI a cu¢ s e lA�:i 1; zQt o n P tan 58 GENERAL QUESTIONS How long has your organization been performing Utilization Management services? (CHECK ONE ONLY) (nl) [ ] a. Less than 1 year [ J b. 1 - 3 years [ j C. 4 - 6 years d. 7 - 9 years [ ] e. 10 or more years 2. Are your services local, national, or international? (CHECK ONE ONLY) (n2) [ ] a. Local only [ ] b. National, some states* [� C. National, all states [ ] d. National, all states plus international I * Indicate the states you SERVE or DO NOT SERVE (whichever is shorter). 3. What percent of your primary operational staff involved in preservice, concurrent and case management review have been with your firm for ONE YEAR OR LONGER? Q5 % 4. Are there any specific reporting or administrative procedures you would require of this client prior to implementation of your program? (n4) a. Yes, explain: b. No 5. Considering this client's START DATE for U.R. SERVICES, do you foresee any difficulty in the installation of your program? Give timeline proposed. (n5) �j a. No [ ] b. Yes, explain: 6. Would you be agreeable to a periodic (e.g., quarterly) "round table" meeting with the client, Utilization Management firm, claims payor and consulting organization to discuss both positive 57 QUALITY CONTROL 1. Do you have a mechanism to ensure that data entry is ACCURATE and COMPLETE? 01) (] a. No [ b. Yes, explain: 2. Do you have a mechanism to ensure the consistent application of written screening criteria by your nurse reviewers? 02) [] a. No b. Yes, explain: 1 hs- Cernt,isslbn I/UR C 3. When reviewing a case for which no specific written criteria exists, is the case AUTOMATICALLY referred to a physician advisor? 07) [ ] a. No (Describe your protocol) b. Yes 4. Do you have a mechanism to monitor whether your PHYSICIAN ADVISOR REVIEW DECISIONS are reasonable and cost effective? 03) [ ] a. No �(] b. Yes, explain: 5. Does your Utilization Management firm maintain PRODUCTIVITY STANDARDS for nurse reviewers (e.g.. "X number of reviews must be completed each day", etc.)? 04) a. No ] b. Yes, describe: 6. Do you monitor to assure that reviews are completed in a TIMELY manner? 05) [� a. No �N b. Yes, explain how: 56 5. Indicate your STANDARD METHOD OF REPORTING SAVINGS from review of ' INPATIENT hospitalization. (CHECK ONE ONLY) (g6) 1. 7. [ ] a. Inpatient hospital savings reports not available. Q(j b. Basically as the difference between days requested and days approved/certified. (] c.* Basically as'a comparison of days or length of stay utilized versus normative or case mix adjusted days or length of stay. [ ] d. Other: Describe: Indicate the STANDARD METHOD OF REPORTING SAVINGS from review of OUTPATIENT surgery. (CHECK ONE ONLY) (g7) [ ] a. Outpatient surgical review not available. [ ] b. Outpatient surgical review available but specific reporting not delineated. [ ] c. Dollar value times the number of cases determined not to be medically necessary. �] d. Other: Describe: 'the (lum)Nv Ckppra'ima is 1 ins nur,ti,.r d ¢.t1i ad . Indicate if the outcome of your review activities in the following categories is able to be provided on client reports. (CHECK ONLY THOSE WHICH CAN BE PROVIDED.) (g8) a. Number of cases determined to be medically necessary. b. Number of cases determined to be NOT medically necessary. C. Number of cases diverted from inpatient to outpatient. d. Number of cases where requested assistant surgeon was approved. e. Number of cases where requested assistant surgeon was NOT approved. f. Number of cases where a proposed preop day was approved. g. Number of cases where a proposed preop day was NOT approved. (J(j h. Number of cases where a proposed 23 hour observation stay following outpatient surgery was approved. i. Number of cases where a proposed 23 hour observation stay following outpatient surgery was NOT approved. oa j. Number of cases where outpatient surgery was approved. W k. Number of cases where outpatient surgery was NOT approved. 55 GRID 2* The cases which were (a) avoided, (d) denied and (w) waived are to be specifically recorded and provided as an attachment to the Utilization Management Grid #1 to include: Enrollee Sex Original Requesting Date Review Rationale Age Request Dr of Status: for: Service (a) (a) (d) (d) (w) W X X GRID 3 Concurrent/Continued Stay Number of Cases Total Length of Stay Average Length of Stay Inpatient medical Inpatient surgical Iage `� z . a Maternity/obstetrics 3 Psychiatric 39 c,4 4 l b • 1$ Substance abuse I 3 &. la 3 TOTAL 3`� 4 Lv �-I Olg a. 01'n 3. How often should the client expect to receive a ROUTINE report from your firm indicating overall utilization and savings? (CHECK ONE ONLY) (g4) [ ] a. Weekly [ b. Monthly [ C. Quarterly [ ] d. Semi-annually (every 6 months) [ ] e. Annually 4. Are you able to provide an annual summary of the client's utilization statistics and your firm' s overall savings? (g5) �] a. Yes [ ] b. - No 54 2. If the following information (3 grids) was needed from your Utilization Management firm at least quarterly, indicate your firm's ability to provide this required information. (CHECK ONE ONLY) (g3) ] a. Yes, capable of providing the information contained in the three grids on a quarterly basis at NO additional cost. [ ] b. Yes, capable of providing the information contained in the three grids on a quarterly basis WITH additional cost. [ ] c. No, unable. GRID 1 Original Precertification Cases Number Approved Number Avoided* Number Denied* Number Waived* Inpatient medical/surgical 301.4 1 50 O Outpatient surgery of O p [ 0 Inpatient psychiatric/J0 substance abuse �r 6) Outpatient psychiatric/ substance abuse Outpatient services (e.g. doctor office, PT, OT, chiropractic, etc.) 0 Equipmendappli=es Diagnostic tests TOTAL * Definitions of terms in preceding grid: AVOIDED = cases where your firm's staff persuaded physician to seek an alternate more cost effective routelservice than had been called into certify without having to issue a denial (e.g., physician concurred with your Utilization Management firm's recommendation). WAIVED = cases where client overturned Utilization Management firm's recommendation for denial/noncertification. DENIED = cases where your firm issued a letter of noncertification (e.g., denied necessity for service). 53 Sloans bake Managed Care hereby represents and warrants that it shall use best efforts to ensure that services and products provided by Sloans Lake which are affected by the year 2000 issue will continue to operate at the same level of functionality as prior to the year 2000 date change. Sloans Lake has budgeted 1,800 hours in 1998 to review and correct any possible year 2000 issues. 13. How does your organization handle the surcharge requirements of New York and Massachusetts? What impact do these surcharges have on your clients (e.g., describe charges, if applicable)? Not applicable. Fees and Rate Guarantees 1. These specifications require that any rates quoted in your proposal be firm and guaranteed for a minimum of 12 months and cannot be changed by recalculation based on actual enrollment. Please indicate your agreement to this requirement. Is your organization willing to provide a multiple year guarantee or a second year cap on fees? Please specify separately for each service. Sloans Lake Managed Care will guarantee fees for a minimum of 12 months and has in the past offered multiple year guarantees or a second year cap on fees. 2. The City is requesting that formal renewal notice for all services be received no later than four months or 120 days prior to the renewal date of the program. Please indicate your agreement to this stipulation. Sloans Lake Managed Care agrees that formal renewal notice for all services be received no later than four months or 120 days prior to the renewal date of the program. 3. When are fees due and what is the grace period for payment of fees under your policy? If fees are paid subsequently, is a penalty and/or interest charge assessed? If yes, please explain in detail. Fees are based on the number of employees covered on the I" day of each month and due no later than the last day of the month. Late payment charges will be computed at the rate of one and one half percent (1.5%) of the overdue amount per month or the maximum lawful amount, whichever is less. 4. Are any options available with respect to the grace period? If so, please explain the option(s) and any charge that is made for them. Sloans Lake Managed Care is flexible with respect to the grace period. For example, we would be willing to change the day of the month you are required to pay us, or the Sloans Lake Managed Care 4 City of Fort Collins July, 98 (Continued .....) Can Can . Provide at ': '.Provide at Not Yes, Js Special Special ..'. Routinely . Rouhnely Request. at .: Request Provided Provided no adds '9VII'EC Data Elements tional Cost :` Additional Cost o. Length of stay by employee a. b. c. X d. vs. dependent P. Number of pre -certified cases a. b. C. X d. by procedure name or ICD-9 q. Admit and discharge date by a. b. C. d. patient name or ID/SS# J� r. Length of stay by patient a. b. C. d. - name or ID/SS# s. Number and name of cases a. b. c. d. receiving a second surgical opinion t. Admits by physician name a. b. C. d. u. Bed days by physician name a. b. C. d. v. Average length of stay by a. b. C. d. physician name 52 STATISTICAL REPORTING 1. Indicate your firm's ability to provide the following data for this client: (gl) Can Can is ' Provtde af:' : Provide at' Not Yes, is : Special Special Routinely' Routinely Request at Request Provided Provided;: no Addi- WFTH Data Elements:' tionaI Cost:;; Additional :. Cost, a. Total number admissions or a. b. c. d. discharges b. Total number of bed days a. b. X c. d. c. Total length of stay a. b. c. d. d. Admissions per thousand a. b. C. X d. e. Bed days per thousand a. b. c. d. f. Average length of stay a. b. C. d. g. Admissions by service type a. b. C. d. or major diagnostic category or DRG h. Bed days by service type or a. b. C. d. major diagnostic category or DRG j. Length of stay by service a. b. c, d. type or major diagnostic category or DRG j. Admits by facility name a. b. c. d. k. Bed days by facility name a. b. C. d. 1. Length of stay by facility a. b. C. d. name m. Admits by employee vs a. b. C. d. dependent n. Bed days by employee vs a. b. C. d. dependent 51 TOTAL 1 100% 6. What is the AVERAGE amount of time (billable hours) this client should expect that your Utilization Management firm spends on a TYPICAL case management case from initiation to closure? (CHECK ONE ONLY) (fl1) [ ] a. 0 - 1.5 hours [ J b. greater than 1.5 - 4 hours C. greater than 4 - 7 hours [ ] d. greater than 7 - 10 hours [ ] e. greater than 10 - 15 hours [ ] f. greater than 15 hours (specify) hrs. 50 2 3 a. Yes [ ] b. No (Proceed to Next Section) For the most current one year period, indicate the number of COMPLETED AND BILLED case management cases. (CHECK ONE ONLY) [ J a. 0 [] b. 1-40 [ j c. 41 - 80 [j d. 81-120 e. If greater than 120 cases, indicate: aVo /year. During case management, does your staff NEGOTIATE FEE REDUCTIONS with provider) and vendors? (CHECK ONE ONLY) a. Yes [ ] b. No [ j c. No, but willing to develop for this client. 4. What is the AVERAGE percent fee discount this client could expect your firm to negotiate for service/equipment, etc.? (CHECK ONE ONLY) (f4) [ ] a. Fees not typically negotiated- b. 1-5% [] c. 6-10% [] d. 11-14% [ e. 15-20% f. 21-25% [ g. 26 - 30% [ j h. More than 30% 5. Given your firm's average case management scenario, indicate the percent of total savings g) attributed to the following three categories: Percent o[ Savutgs Case Management: Service Savings FiaNegotiated fee savings % intervention to alter patient care plan C. Potential savin s 5% 49 5. Check the category of staff who MOST FREQUENTLY perform telephonic concurrent review. (CHECK ONE ONLY) (0) a. Not applicable (Concurrent review performed only onsite.) [ ] b. LPN/LVN [ ] c. Trained clerical (� d. RN [ ] e. Physician [ ] f. Other: 6. Average number of concurrent reviews performed PER STAFF PER DAY: (CHECK ONE ONLY) (d8) [] a. 1-10 [� b. 11 - 20 t ] C. 21 - 30 [ ] d. 31 - 40 [ ] e. 41 - 50 [ ] f. 51 - 60 [ ] g. More than 60 7. What percent of concurrent case reviews require your physician advisor intervention/feview decision? (CHECK ONE ONLY) I , (0) [ ] a. 0 % [] b. 1-10% C. 11 -20% [ J d. 21 - 30% [] e. 31 -40% [ ] f. 41 - 50 % [ ] g. 51 - 60% [ ] g. More than 60% 8. Is discharge planning an integral part of your concurrent review process and included in the fee for this program? (CHECK ONE ONLY) (d15) [� a. Yes [ ] b. Yes, but separate fee for discharge planning services. [ ] c. No, discharge planning not part of concurrent review process or the fee. [ ] d. Other: CASE MANAGEMENT 1. Does your firm have an ACTIVE case management program? (fl) 48 3. 9 �] a. Yes ] b. No In the last 12 months, considering 100% of your firm's appealed PRESERVICE review denials, whhat% of these UPHELD upon completion of the appeal? (b7) p 9_% In the last 12 months, considering 100% of your frrm's appealed CONCURRENT review denials, what % of these were UPHELD upon completion of the appeal? (M) % 5L.MC, has ck�%Qk5 , baX non' ta+r r - "PPL012J4 CONCURRENT/CONTINUED STAY REVIEW Does your firm perform concurrent review services? a. Yes [ ] b. No (Proceed to next Section) 2. Indicate the locations which are reviewed under your concurrent review program. (d2) a. Review of cases in acute medical/surgical facilities b. Review of cases in long term rehabilitation facilities C. Review of cases in skilled nursing facilities d. Review of cases in acute psychiatric facilities e. Review of cases in substance abuse rehabilitation facilities 3. Concurrent Review is performed: (CHECK ONE ONLY) (0) [ ] a. Telephonically for all cases. b. Telephonically in MOST cases with occasional onsite review needed. [ ] c. Onsite in all cases. [ ] d. Onsite in MOST cases and telephonically where staff not available for onsite record review. [ ] e. Other: 4. Concurrent review staff are: (d4) a. IDo % Full-time employees of the Utilization Management firm. b. _% Part-time employees of the Utilization Management firm. C. _% . Subcontracted/consulting reviewers (e.g., on -call only, registry, home health agency personnel). 100% TOTAL 47 13. Do you have a toll -free (1-800) telephone number for receipt of patient/provider calls? (CHECK ONE ONLY) (a27) [ ] a. No (� b. Will add prior to this client's implementation date. C. Yes (Indicate): 1-800- g 0 •.9V49 / &AiM.1 mg.5,..*+b M. kq,-4 ' 14. Considering the size of the proposed client and possible volume of incoming phone calls, indicate your telephone system capabilities. (Check one.) (a31) �(J a. Present system clearly adequate to manage the anticipated volume of calls. [ ] b. Present system will need to be expanded, which will occur PRIOR TO the implementation date for Utilization Management services. [ ] c. Present system will need to be expanded, which will occur SHORTLY AFTER the implementation date for Utilization Management services. 15. 'What type of system is available for receipt of preservice calls BEFORE/AFTER your normal working hours? (Check one.) (a32) [ ] a. Answering machine with recorded message given. (] b. Answering machine will accept receipt of messages. c. Answering service to receive messages. [ ] d. Open 24 hours a day. [ ] e. No provisions, except during normal business hours. 16. If a client wanted OUTPATIENT SURGERIES precertified, what specific services would you include in the presurgical review? (May check more than one.) (a33) [ ] a. We do not offer outpatient surgery precertification. b. Medical necessity for the surgery. c. Necessity for an assistant surgeon. d. Necessity for a 23 hour/observation overnight stay. [ ] e. Necessity for a post -op recovery center. [� L Other:�1,c ck* cap6wkie- 5t64n5s �Jr suraarJv APPEAL/GRIEVANCE/RECONSIDERATION PROCESS 1. Do you have a formal written appeal/grievance/reconsideration process? (b1) j a. Yes [ ] b. No 2. Is there information regarding the option for an appeal, the timeframe and the mailing address in the body of any denial notification letter? (W) IR 8. For your non -worker's compensation clients, in the past 12 months, what percent of your preservice calls were classified as EMERGENT? (a13) [ ] a. Info not Available [ ]g.51-60% [ ] b. 0-10% [ ] h.61-70% " .:. c. 11-20% [ ] i. 71-80,7 [ ] d. 21-30% [ ]j.81-90% [ ] e. 3140% [ ] k. 91-100% [ ] f. 41-50% 9. Indicate the category of staff who can make final DISAPPROVAL for a preservice request (may check more than one). [ J a. Clerical [ J b. LPN/LVN c. RN d. Physician 10. Are there precertification cases which could be approved by your non -RN personnel? j a. Yes, describe (] b. No 11. What percentage of ALL preservice reviews require your physician advisor review for decision making? (Check one) (ail) [ ] a. Less than 1 % L l b. 1 - 10% C. 11 19 % Ll d. 20-30% 31 - 40 % is , [J f. 41-50% [ ] g. Greater than 50% 12. Indicate the MINIMUM number of hours your normal "business day" switchboard operation would coincide with an 8:00 a.m to 5:00 p.m. "business day" in ALL FOUR of the continental U.S. time zones (e.g., switchboard hours 8:00 a.m. to 5:00 p.m. Eastern time would coincide with a call availability olIf��6 hours Pacific time). (a26) tY hours 45 e. Pre -op day(s) determined a. Yes a. Daily a. [ Phone call not to be medically b. [ ] No b. (] Weekly b.] Phone call plus necessary c. [ ] N/A c. [ J 2x/month written followup d. [ ] Monthly c. [ ] Letter or e. [ ] > Monthly computer report d. [ ] Magnetic tape e. [ ] Combination of a+c, d or e 5. Indicate the primary method for determining the appropriate length of stay for a hospital admission. (CHECK ONE ONLY) (a5) a. HCIA/PAS book for Region 'Percentile [ ] b. [ ] c. [ ] d. [ ] e. Year Internally developed written LOS table Length of stay not preassigned Other purchased written LOS table (specify) Other: 6. Within the past twelve months, in what percent of all precertification cases was a letter of noncertification (denial) for MEDICAL NECESSITY/APPROPRIATENESS for the procedure/service issued? (Answer may require specific justification at a future date.) (CHECK ONE ONLY) (a6) [ ] a. less than 1 % [ ] b. 1-2% [ ] c. 3-4% �(J d. 5-6 % [ ] e. 7-8 % [ ] f. more than 8 % [ ] g. not applicable 7. What key written clinical criteria are utilized to determine the MEDICAL NECESSITY for a SURGICAL procedure. (CHECK ONE ONLY) (a8) [ ] a. We do not review medical necessity during presurgical review. [ ] b. Milliman & Robertson. J C. Suns (Internual). [ ] d. No written criteria utilized. Case information individually reviewed by Utilizatio n Management staff nurse or physician reviewer. [ ] e. Internally developed written criteria set. [ ] f. Other purchased criteria: (Specify) [ ] g. Other: 44 Other: Explain 4. Indicate the type of review information which is communicated to the claims payor by your firm: (a4) Approximate ivlethod of :Notification i Claims Pay 1lohiied ;<! Frequency (CHECK O� i (CCK ONE) HE (.CHECK:ONE) a. Appropriate level of care a. Yes a. Daily a. [ ] Phone call (e.g. outpatient) b. [ ] No b. [ ] Weekly b. Phone call plus c. [ ] N/A c. [ ] 2x/month written followup d. [ ] Monthly c. [ ] Letter or e. ( ] > Monthly computer report d. (] Magnetic tape e. [ J Combination of a+c, d or e b. Certified Length of stay a. Yes a. [ Daily a. [ ] Phone call b. [ ] No b. [ ] Weekly. b. Phone call plus c. [ ] N/A c. [ ] 2x/month written followup I d. [ ] Monthly c. [ ] Letter or _ e. [ ] > Monthly computer report d. [ ] Magnetic tape e. [ ] Combination of a+c, d or e C. Procedure/service a. jA Yes a. Daily a. [ ] Phone call determined NOT to be b. [ ] No b. (] Weekly b. Phone call plus medically necessary c. (] NIA c. [ ] 2x/month written followup d. [ ] Monthly c. [ ] Letter or e. [ ] > Monthly computer report d. [ ] Magnetic tape e. [ ] Combination of a+c, d or e d. Procedures where assistant a. [4 Yes a. Daily a. [ Phone call surgeon determined not to b. [ ] No b. (] Weekly b.] Phone call plus be medically necessary c. [ ] N/A c. (] 2x/month written followup d. [ ] Monthly c. [ ] Letter or e. [ ] > Monthly computer report d. [ ] Magnetic tape e. [ ] Combination of a+c, d or e 43 calculation of the number of employees could be calculated on the I" of the month or the 15'hof the month. 5. The contracts are to provide that a change in fees can only be instituted on January 1. Please indicate whether your company is willing to issue master contracts reflecting this provision. Sloans Lake Managed Care agrees to include in the contract that a change in premium can only be instituted on January 1 st. 6. Can the individual services proposed by your company be purchased separately or are they interdependent upon each other? Please be specific and elaborate on any fee consideration. Sloans Lake Managed Care access and repricing may be purchased separately from the utilization management and vice versa. The CCM fee is interdependent and includes access, repricing, UM and gatekeeper. The PRO Behavioral Health network may be purchased separately with any of the Sloans Lake networks. Fee considerations can be found in section 1- Rate Quotes. Orizanization Issues 1. Please describe your organization addressing the following items: a. Ownership; Sloans Lake Managed Care is owned by Centura Health. b. Length of time in business; Sloans Lake Managed Care has been in business for 20 years. c. affiliated organizations; Sloans Lake Managed Care contracts with Pro -Behavioral Health for Mental Health and Substance Abuse. d. Include a copy of you most recent audited financial statement. Please see Attachment A -Financial Statement. 2. Provide a statement, signed by an officer of your company, that your firm has adequate personnel and financial resources to provide the services indicated in this RFP. Sloans Lake Managed Care 5 City of Fort Collins July, 98 UTILIZATION MANAGEMENT QUESTIONNAIRE NOTE: PLEASE READ QUESTIONS CAREFULLY. While some questions may allow for multiple responses, those annotated with 'CHECK ONE ONLY' MUST be answered with only 0 NE response option. PRESERVICE REVIEW 1. Does your firm perform preservice review (also known as precertification, prior authorization) of proposed elective health care services? (al) a. Yes [ ] b. No (Proceed to next Section) 2. Indicate which services are reviewed under your preservice review program (check all applicable Lo your program): (a2) [ a. Elective inpatient medical/surgical admissions [ b. Elective outpatient surgery M C. Diagnostic services d. Durable medical equipment e. Corrective appliances/prosthetics [ f. Skilled nursing facility W g. Home health/home enteral/parenteral therapy h. Musculoskeletal services (e.g., chiropractic) i. Medical services (e.g., physical therapy, Dr office visits) Rogllgryy Jarv;vos 40i, p(] j. Psychiatric admissions (acute and residential) uf{; %q, v+s --. k. Psychiatric outpatient therapy services 1. Substance abuse (e.g., detoxification, rehabilitation) [ ] m. Other: 3. Precertification includes the analysis and determination of which of the following (may check more than one): (0) a. Eligibility of coverage. [ b. Appropriate use of Plan (e.g. work -related injury which is excluded from the plan) (XJ C. Appropriate LEVEL OF CARE (e.g., inpatient versus outpatient). [ d. Reasonable LENGTH OF STAY for inpatient confinement. RQ . e. Actual MEDICAL NECESSITY and appropriateness of the surgery or service being requested (e.g., does service require performance). [14 f. Necessity for the services of an ASSISTANT SURGEON with each operative procedure analysis. g. Necessity for a proposed PREOPERATIVE hospital day. h. Necessity for a proposed 23 hour observation stay following outpatient surgery. INSTRUCTIONS FOR COMPLETION OF UR RFP QUESTIONS These UR RFP questions have been created to help the City determine which organizations can offer both the TYPE of review services desired as well as EFFECTIVE PERFORMANCE of those services. 1. Answers may be handwritten ON the RFP questionnaire form. Explanations can be attached or added onto the back of the questionnaire as desired. Questions, answers and additional information must be identified by question number. 2. Some of the UR questions prompt you to provide multiple answers; however, several questions ask for ONLY ONE response to be marked. UR vendors will not be contacted to clarify why multiple answers are marked to a "check one only" type of question. If you check one answer but wish to add an explanation/rationale then please do so by providing a written attachment to that question. 3. Please proof your answers before submitting the RFP response to ensure completeness. A UR vendor will also NOT be contacted to query as to why a question was NOT answered. . 4. A UR firm will be held accountable for all answers. You may be asked to substantiate a response during the interview, onsite evaluation or through a formal UR audit process. 5. Reporting of basic utilization statistics as well as the effectiveness of the UR fi m's services will be important to this client. 6. Please note that a vendor's proposal responses will become part of the contract between the client and the UR organization if and when the proposal is accepted by the client and accompanied by a separate formal written contract document. 7. Submit separate responses if your answers differ for the plans you propose to administer. 41 Attachment G 0 GeoAccess Analysis 0 Sloans Lake PPO Network Colorado Zip code access standard detail information A la 3�R i:,rp �! BRA, .+y� aiiYw"."{`a�'x'I', xm as ,.,.„�nixw�.�. m*'. .. .a a §C a """ ,:. fd i t el gar: IR t t vi 4J'� yyi r: S`" wa.i ,� +rill,{ qR wI K( MA;'; F. al �� �Emplayee�ccess't 7s i&I R xc aiv rorider4 3,ru: i•,t' k S s m F �1 } T m4�� law '..b ld rv1v"a �xM�>�'� bRa �'� 7 &a 4"i, b s f•' �k b giN^s k l "P�iL Q� e�IOyeeS'Wlth R fl `- R > >F r 2�p nu{tuber o "nu mwPilers ber o r ��erage provid"ers within z miles, ��°odes mloeexrcdistance ARVADA 80003 1 9 0.8 100 AULT :�r �� ,� ; m 100 aarcx� { : a u,'�" d ""� U2 .0:.a l-, ro �U� Y NIV",T i3 Ngkl�,a ^ aae5' sx exu im s'� a m 1 u`s�,] i' 'i .`l,u:. i Pi AURORA 80014 1 23 0 5 100 BEL1�lUE" ;,{�"?8t��z{�I1 R�� 400� 'k sw. :: ..r{r w,u ';„ 'a ; ; 3441 s . ,� x: a »�a.:. x'.�ow '7'�!�M"; rdiE' ' i .w � 1 u��'. BERTHOUD 80513 1 3 2.6 100 BOULDER,,,,,.. » ZM 803Q16 , z 100 80304 2 19 0.2 100 BRQQ FIELD"I3'•'�' 8002d�FE 2 14 w 100 6d 80234 1 14 0.5 100 w ?490.w W' ai` mow" x� 1..5'� Mal IG::=x'd'iu"'t �dl$'birtr,c, .��'�W=,ca�r 4pi+,�'M Wi`51V0� DENVER ESS .., . , '' Aw �;�+ 0 8 100 M ."VId" , ,' i' 'a��v- 0L7� 4 �i I� ire7.'' .r''A'"� , �:a.�,s.all. „,::i' �"..u.�3..,s:..,_..,,." .,.. _.:..t i'r''°,., x 0100m,�,z �. 80252 3 0 0.0 100n 19R n(, iht'�"w� ri �� ! :v u�wr W , awk,.. a iv �», . �: ....,. 'we.'Pjg is ��al + :a EATON 80615 5 1 4.3 100 ST ARK a '8L1 � � r /{ { fix , 100 n acraw sms:ia, s,a?..»s $nh�' '41'J., x wi'nV ...i`rF EVANS 80620 2 0 1.5 100 >APP8 2 . '•a 100� 80522 11 0 2.0 100 80524 . ,'m180 "'" �� 8' 0.9 100 80525 243 13 1.4 100 13r, i ,; 100 80527 7 0 2 5 100 4?R EY i, ��,w Nlik'Ra'iPx,y ia.z'a, 8�6�s �:�,cai'� Ma8i�P�., 100 ^�w nvry a t it .ireS al." ® '!�':,aS:9'. .,ua +..k. xary S7 q 3 ra? ced'Yl,''i �. U%. 80634 4 1 17 10r) �I JQH, STOWN 0 9.:_ y ,, 100 LAFAYETTE 80026 1 10 14 100 805 u" OR LIVERMORE 80536 8 0 31.0 0 rraxrs It �,®. r~ r:am �"x ,,,.s m o^ �: n 'iw-^r y� �` �I � , 8 4 "" 3345 - r ��® ., LONGMONT 80501 2 29 1.0 100 L a It RA '51 i ` 80538 41 14 2.0 100 x /y ryry i :n :. 2� �' �`j, b '�"}4R'ti+K�;�6i� �k >«'ixi'M , M I .' �VV� ySk� r q% ,CF 166ll :�� LYONS 80540 1 2 0.6 100 e.:, .vc iM+ON a.,�`�„,li -wxi 2sx{ Qr• ,.:1 ft a �;100,'", PIERCE 80650 .i 2I 0 7.9 � 50 P L=VfLLE � � ,806 31 z —i '-MUM (� � � 5 . _•.,.. a ., xwW S.ao-a�� "e'...: w 6'.�4 �:''"�1a.o- �i "t'.;a,ErcuOm saec ed' wmnrw uw� aW.n�Y.u& TIMNATH 80547 3 0 2.8 100 Provider group: Family Practice Sloans Lake PPO Network Colorado Zip code access standard detail information j�'1�ii3:3 si: r%; ,� A ir.{IP w0'� 9i ���� `aAli i nunbb�eO� a� n �nr�tf�in 'miles �'j+ ��� �"��P mbero Average v,.Prov�ders WELLINGTON 80549 29 0 4.9 100 VVl 1aSOR � 80550 � " 28 `'R"N is R,7 I 100 TOTALS 1,203 349 1.9 99 iv.luc' yivuN. call Oly rldlA0.Jtl Sloans Lake PPO Network Colorado Zip code access standard detail information I 1 1 7'V�'W /6 12, (�IR4a�pq"WS��aµiki $ 'L w �i.l�l Y Fla NW v'a' S ON ; N,54't l�{G 03�i1 Ail R 9 it i:�%dR�''31+: $v�"➢M ���i�"Y1��#!i 1L� r FQ S 1'ki iri 1 YY�ff MLIIi, binFF^^ R 1'4 k i� hn'�$ m dv4"x 'v. kW R '� �`'V•v sl % 3 W "�, �aa'.: i 4 FS wl yIVL :»-1 "'. „ u S�� ".1 3. -� _. 1 w �reiN 1�3 Y s Ivi i°1kaV ti - Ir w'I'NkoNl�!��+r 3 �y i "� t�iw =r p:i. 9 AWN H A �kl al F Wai `�»�„ $B ♦uti"ilk'� �� $ yqa F' iayeeaccesskto>2prouiders p 'Fi [I': - . ypA S �'7 'i �5�� : Nam'"� s�1W3 a 1'�i>`n •il i 0 � _0.& H•L 'L�Yz`, � RIla4 �"'� Y''y{i $��. .�.Ii��4�1'dicaik: �3✓ n iiti� #a'# ,i .. y •Pct ofi employees 2 ; with ��� E 1 Ili 'UaU 4' �" Y ilH%k Ny'kf ,,,p eF CtyW �I Zip �A •� numgerYo 9kl'3. "Y "dWlw^ inpi0yee rtambe o iv+ a /►verage Pr,'oviders within x mites; F- =' f+,,.� IB....�� coded F..��� provide 1 �. dtsiance'10 !"L'W I' FIB A :y u { ✓: �I ARVADA 1 1 2.0 100 A80`1{000`33, F,F _� " "N :L+ S .M "'w SHI� ' k 4"`3�Ic:Hi� � AURORA 80014 Ni �:s,3�OW'j+.:a3eB? 1 �.. u4; 12 m:.n. ibu ,'4 0.9 100 Y WB� , 1 Bil1UE M� ,k _r 805t2 gal ''i.,115 l z "ifl BERTHOUD 80513 1 0 5.3 100 ,BOU fWDER :_ A' - �Ai 3 W '�`� �, z3 3 '� mNX a n R M �1'b'"B 1 qq*,. w•,wS-: 80304 b 2 .n .,� 21 , »Y, . 0.4 s^' A 100 BRO"?tVIF{ELDIIW,�I� �i �� �_ _FI a . . , � 0020 � �1ry IIIII„ �� 'F A „ 5 r �� I yy �I I„ k q,`.yy 80234 1 PW 0 2.5 .°1-4 I F IY: 100 �p WA�RY� �FWA„bF yF 3jvB '� I'R 1✓i`B' J' � .iuv Y av{IMI W k r ,� ��uni'At DENVER is 80215 a1:l �. 1 3 B+Rl l lry inn ..,.:A 1.1 s S't t i IMMIM'"'� �'u:I,.i U, Wes:. "" _ ttan , r 1 ' es 100 a ^ta. , 2f .Vry ItillW+ SB3WIX�1M.,i .:wxi o.i-YAYx�I�:pP !I�Xqfr, 80252 3 0 0.0 100 7 v�"„�JIBrY �a&Hi4'I{i®SPro`�IW' �1 it 36EEAkF`GTTpOtiKNYWb3�i:vn Al:-�?ICB WWilz ia:DLL,a$-,17F,xir�,mlii�O33blwi� {�'y{ Ili q'¢�wP'I1Fg�A }� .."gWil..I�+v � i'�iF)r�I 9 : �:.' ..aF8H 80615 Jis I 6NINE $rt ts3l%E4tl � 1 EVANS 80620 2 t0 0 .6apA'M'1 15 :BIA'"P�YYi3jRfi 1Y�"i` g0gJ'0 ( i w2 � 171 ,W3 i &Bn� $.tT�"°Rl:q B O ^I COifS �A� 051 �R, �!01 A ��W�� to ��x,� a 100 80522 11 0 2.0 100 80524 -ir' _"180 16 2;0 100'" ' 80525 243 3 2.9 100 13 �S9 a*ni Itl%U 0521 z�, �'. �!�3 aW F� i� 3 ':i .•wl MW 80527 7 0 5 00 E i^j" � i � � ]NSilW' 4:yi&•kd:31llR a B�'i`P..:$+"�"n,. 91:5.„-x.'.® 6H' :•.'� 80631 E'w63&llLi " y �i?'q $1.j I� H�i''i� ��g0iilm?kif ` 80634 .�l��y,a 4 .IiYF.�I I�,Ldd�:AW 0 27 2$ W `A n R..Sn,JNw tlW'I w :uwl a 100 O TOUVNi 8Q534I II 1 3,g 0 LAFAYETTE 80026 1 1 30 �ZICI ,a 1(0�(00 ym1y RE Emil�} LIVERMORE 80536 8 0 32 5 „ q a r gig LONGMONT 80501 2 15 0.8 100 pR uw�dvPq sr„,73 acW1"3- -.plsb rxN�Y 4a .'.YH6,. +etlLm11, ag xB3k. etial 0kY 1 80538 41 sakY-a. 3 :a ,.. 4.0 iA�1wraKa e 100 NE11m, LYONS 80540 1 0 9.8 N a, Wae.cY,�n,.As �,�.wii �� am@- .wr ��/{° � mom ' �: � �p10yy0 _:. " icua: POV IERCE 80650 2 0 +.:. 11.5 aid,.;.;>,Yii 50 s... mi 1�r a:,iau i�i:ii lz;:: aI_: 9F3': m -` i 6 £.. ��i�l Y • TIMNATH 80547 3 0 _ Fvm: _ 3.5 �.i:...,:.»,v:u:'� 100 Ivvlucl klivuF!. 1II1011101 IvIvau Sloans Lake PPO Network Colorado Zip code access standard detail information a All{Employe>es�IN�{ �a�' Rp � ��, 3� s»�`wi'"fi" Wyy a� , Y'x" "a', �jFvl �Wi�+i `?.l Y N r'.§kE S P a{ts� �� .{' gMi '� W .1'�i. 2 IDI ,.. y � �� �' �`y '� 1, �`daxi�' l`^' �.,W iYi'' �1"11 .. R6 "^i.'41 �, 13 ""`iW�.l ��iY� i ?I g� iyy�:k. as 'x,N}L'V,yW � $'I• -} ab-3�w'M$•e��WI I�",d���k�pplf'i�lrjj�d` ti' eik�'' y � v, .t i ui^ W ��gP � 5.�y �at !.- ar a' ': 2 I � "A`., iJ:l�^� � ai`{"?+��'^7!I'w i Mia I~' alb.+ pp���� 4 4 iJa� ;W71Nh i PI'. I� � M�Y✓..1{ WWhi � "« �Ri4ti � 3r �y�1�1•� ���yyy ;;;�������.. 'P. 9 � , i ' P'�! � ��M"�i�i z' 3ya�l, a5�ryp �3 I'=i T_ " EcriCo K' {R4wlxi y +I 4 L >,y.. h.3' � a acce�� iQ 2[�ra�ritl�rs '�{' '�1'M!S+ �"'Wai' «+ • a i ,'a $� `u�. I 4�8i%!.: { `P' M' p '!R 51 !$ t31 Y. IK 4 �„� j" i z'W'x `bi I'W 3ii6 3 Wr='�13'xafi:, �I U 1 i ^rclYa IaF Y9� !:i I" „'Pine �Id�Zip W e � riu[pbeQ gurnb �A�rerage :. providers•�nr�ithin x miles y. eCOCi WELLINGTON 80549 29 0 6.7 100 11S7fCDSOFti :" .'� �t�. 8Q5�4�s,` °'. 0.1„ a 00 TOTALS 1,203 104 3.5 . J 99 . .yl WMv. 11 ILGl IIQ# IVIVU Sloans Lake PPO Network Colorado Zip code access standard detail information Yw ltl a&w I #i A '1 biL f 11� jR 'A:Y '- ,W Ak .w91. 34'A✓',w ui 3.11 M ��t yi W}jja m ��li•. ,a"w 33-;;.� �y�i�k , d'1g, NEV i5a}r i,: �,,Mryd ryrc�,I �TMA �I ���,A� EmPloyeeaaccs terry �iro�rd���. i31' Wig rc i �t i'av_ Sy' Av"Y ej I'i' I'^k.S i�, o�a(I, : IaA M i �I�Nib' : Otal u1,i ?% ^§? N fi .:W+"{I h"ril !"' L,`U":�i�wo, h P VR. i PC7 0 @Cn i eS✓v[th' , 3i :� � VA :W3g+S� F � ' W „� A�: '>,. �, .23� zp6, ndifib rb, nntnhe �o I Ar►erage 1' ;pro ideiswthinxmile .„ y� Ctyr . 'nor rri tO eet �tlistance �� ✓ .�✓�.I'.,�,y,. AjR�VADA 80003 1 0 A�:i:?tR3,a i'Y �] eislrA 4"' 3'�ri e ''' d5 }�;, a, ix2 a,"U" rLk; ' �06"0. ..w .�ui..s..:9: � ..niiliA '` air1. Ma','w� n ,il i.bYM s R P�- ie w..�Wi sr y:. yid a,'w hW" yypw��{I 5�, Yi ryO 80014 1 L 0 7 i uwwlk�hla1 Cw ,'gR' 0 pAURORA BLLIU: x sw E<a A . ,Iy M!ffid kY»dV:Yk ^uem A.IW ,4-Y �,K 805,2�"15� ��lQ �I;r' v31x v,3,x�-i a'3.v:bLF�T'�$.eiiWxRWiK.mo»a'H`vileai'viu+l BERTHOUD 80513 1 .v.N�:4,�r�r.SB vi4xYH'Y: 0 0 BQ J DER; ., � �F �. x:: ,rcP,. 803d2 a 80304 2 0 tu p Rh@ N.n ii� vales e 8Q()st�113 ["=N ii Ih xV uw I¢'' ��I� c��l AI YU'-U x,,I #0�,0'&' 80234 1 0 p ' I�1 !E �PIL3d�.SNP � DENVER .tu 80215 1 Pri. 0 _ _ :, .: '. y: �°` 1° , 'q # A� r�'v�y '' 'i _ �i `,1 E++ 7�11'a.�.L,m,.'�a?m,' t"§u @'..w p/ y Qtf2 G' r, ava x ux i� E°" . s5a,MRSaaVni"t':c ng 80252 3 0 0 y P ® ✓'",A Ni, 7 5y i lfE a �rw y.u,w.4 br,,,.,.. 8Q5t 3 ,� is" m Q31 BOais Y WiR ��Jy� .,m EATON 80615 5 0 .a.."_wM✓V wi.:c! "�i I�P"z„„muh'L�`}L'a� 0 �iI x 805 , 1 �� ,a,� �' N ,e �r4�T����'�a €e:'k re Om S EVANS 80620 2 0 0 FOF27C© tIV t , i, ;� g... 2 6 a x YI 5j� I i 3.+'e...xna 80522 11 0 0 86524 180 0.,- 0_ 80525 243 0 0 y , r y� � � 641, _ „ , � . w r�.,: ia„ u 'a� 80527 7 0 0 ud<Mtlis ... .....wi$.wubUA :3......'Li ',v� :�U11rl� gµ�z a e1ilE,✓' -'ml'. M MOP i:L �'ffid"^3�y'"iW i"".�tszq�i.:. 80634 .i' 4 . bDit^iq 0 z. .S.'iS.a1L'`,�W 0 .IOtITOUVtV ". 8Q_53!t LAFAYETTE 80026 1 0 0 "Jig ti ''. 80,535i „ KO3$ c y- ,reN e:H� LIVERMORE 80536 8 0 0 �W ��� Iw,I OEM LONGMONT 80501 2 0� MOM_ 'Ell 80538 41 A Uv0 , , I ,MA 4,'> 80M , LYONS 880540 1 0 y . "sua°i 'aww.,w-'.m';..eras:u�iwcoa.:..awe:wv�uusm,a;a�» Ida': r'1211 PIERCE 80650 :.�u b 2 0 v, 0 !Mom h 0 TIMNATH 80547 3 0 0 Drr,�.irler err.....• C...r.:l.. n_�_a:__ Sloans Lake PPO Network Colorado Zip code access standard detail information � 1� �',u��i��,r���,�,:. P' �r4� �iw tea' ��' '� k:5 � 'A�,ri�av�k /� "'N .?il�i{� i"1 �"�AI��A.rui�� Pi,!9 sG �,� k� ».�.� � ���.ve roi t ` � x �:� ((, i �R�;v i• ^,n.4�'.:�:�3 1.0 �IX�„azla MCI ,dw :xuJ. ;I::,t r� �. .a mMt o- o"u�I,5�irovit�ers �4empployvee inrith-2 .. ai�� vil, Octal �«x =1� 7 PiWA,�'.+ Y:z number�orovidersw�thmxm�les. rk mire o Average , I I: � CitS! coda mplax a pro�+�d'e""rs 'distan c0 j: I 'him j :r � '�W{�E�L"LIIN' GTON 80549 2a9 0 l 0 ",�( Y 11YI�\iQ��i` M 4N, t�°'i t �.a '.. } „Y �'i.: 3�+'m s+3li 8�5� � " [T �s �4 . ,. a w �-"v _ „"n' - �.. 1.,' _ TOTALS 1,203 0 0.0 p Provider group: Family Practice Sloans Lake PPO Network Colorado Zip code access standard detail information �,re• ,i �i t "ati.ii'>3tE tro�.9 �r ploya fi sx aii P Tk"` a R pLc b 12,E d- �.yx %""'+-.'''`�'I"�. :,�+ :1'�.I '.��' M X Nli?i: �N "�ilo� ij+^A^��,, � �ih�+," � ' ��P'� '��:1 �� ra{I`F""q Yk+.R "s C �� '..�.. �iiTsi IR.'iuiN:: t!�roY���+"p i:Mlw 11'irdlA. yy �� pro, '�a �� ��mp� i 1!F� ( 3 Y.i :'��1 �. t i i i 1 1`� Ib itAR�dv:tag � ogee kn W%w'iil"i i lri. A wwsf'R I Irl� xY i access,g�i �T pradvi'ders� �9 MI :. E ,•3 2:: 3 S'Y. i dill Till! '" ,.. - I PHp w :NWJ MI. ry lug Pct em � Num er o 4 moe�o 'rovidersdistance10 Average: of to ees with � � , ARVADA 80003 1 0 0 �'JWNc14'x 'tm� 806102J0 , a0',r 0 YeY�.�v 1� .w. WIY'Wxi�"i.v.xm waAeF'. b'v�.i1 .:..5.,.sr J1 AURORA iav 80014 [w. uvw.$I. a, n... 1 .'r�i h..a8m3a. ust @. sn:LvN'1 vv. .. .'..:.vXwYtl. wvil.S:..:�:�:�.3. 1Y ✓:Y� a J bJa 0 0 Bcc [(� +T' Cpb a3`k ��3.+ R9 2"" :'firv^ 3.i. .i :5'k "! &&Y' , 4r {�Y UL n iit r a t " $.': �'43 $5ilipl Yi 3�y1q'.t.,,.x. F wp r xy 8Q512 'i lR� 2.� i gpw i f'ai'�i'rrAat'i5 -: xM%A4i:N BERTHOUD 86513 1 0 m 0 BOUDER yy H °F,, aL.>I..: '.k'Jiv'fl A%3 3yw N-0'WJW 91'%P "dj,'YM .� 'W lr$iM: '5, �<� y-i'lim ..�RvII�XInTlllls] 9'4 s 80304 ?X 2 rz4�K' 0 .... alxXl4'J a .'itl: IXYi'Sfi. iry9— 0 R Q F1EL`C1'' AcfleA aSu eU'rz ., amass M i.ila w, ii t0020,,�� i�a 1� (i :.caioek�. 'I �.� s'°- "�T� .. , W a� 1 7 11 : �k!,U81Ix 80234 1 �. Or, _ SG`� " 0, `b i�ELAVgaggi�,n�, 3ZRM all".w ^.R"'�'4 �x �� �%tFII �' t5.:�vk gy �1$i ' .M DENVER 80215 i M91il:ry 1 :;}!t I!Ifi 0 iwt,! v ��Y � WaY$Ili)t KP ihJjlbPke4 '. 0 'T�r<' 4 ( s,..i i..r �.a"a. a'u�;.,6.:..'T.w'a'?i"IM�-r:.' (r Fi r36Ei'¢a j&" La it.. �I F4't -�iYK �ry iYim 80252 3 z;:d.1,Q:R.�`''ra,n¢� 0 w:. �r'.', tr.,l^��'�" mwcM�C.wil�:; 0' LQ5'15' Jg ��"��, EATON 80615 5 0 0 E z S SIR �, �- wI�I 0 EVANS 80620 2 0 0 5 FO bLL NS w, a �rww: :M:S6Arz tsu l?31:�r� i'a'fili '805120 o- .i.m 80522 11 'P,.4`IB)k: 0 gy 0 - 80524 0 0 80525 243 0 0 M Ellft ,�e 1, li,.', a »,aus 8052 '+12 �a O r '�' �9 k> � �"� 5i0, xn .. v.�anu3'..,: t':a,.d uu., a,w�:: 80527 7 lr_ ni„r L a �.„w,� .,,„ <. � xizr;ti ��a aim �. ,:, i s','e9l.il6n 'LqP-E IL RI. .� �II 80634 4 0 ��s m. 0 �:fOliW S'IOWNm r x� M„s 80534'ell .� O.i LAFAYETTE 80026VMS 1 0 0 OEM MMMIZ, LIVERMORE 80536 8 0 0 -00 LONGMONT 80501 2 0 0 w.. IM-1uC 14.: .1:9fN��A4�'[#' t ��' ..1 wMF. a i L a`.' '.. ''i �� 80538 .... 41 A uSX 0 ,d C brt" I4�9 0` a053' = It LYONS 80540 1 0 0 8054M11 MOM PIERCE 80650 2 0 0 n:. "E"I l ;�k 0' • TIMNATH P J 80547 3 0 _ � �p ,V9„VO, l,,Vup. I,IIG,,l= Iv16U Please see Attachment B-Statement of Organizational Resources. 3. If applicable, indicate the location of the claims office where claims would be processed and/or member services is handled. Is a toll -free phone number available for member inquiries? What are the hours? If a toll -free number is not available, will you establish one at no additional charge? Include a description of your member services. The claims mailing address is: 1355 S. Colorado Blvd., Suite 902 Denver, CO 80222 Member services toll -free phone number is:1-800-850-2249 and can be reached from 7:30 am to 5:00 pm, MST, Monday through Friday. Customer Service Representatives are equipped to handle a full range of calls including but not limited to provider inquiries, claim issues, and complaints. 4. Is your firm licensed in the state of Colorado (if applicable)? Please confirm that your proposal and/or plan design offered is in compliance with all federal an state laws and regulations that pertain to employee benefit programs, relevant state insurance regulations and other related laws. State licensure is not necessary for PPO however, Sloans Lake has achieved the broadest scope of accreditation from the American Accreditation HealthCare Commission /URAC (The Commission/URAC). Sloans Lake is the first managed care organization in the country to receive full accreditation for its PPO network, HMO network, and utilization management program. 5. Please identify the individual responsible for the account in the event of claim disputes, service problems, etc. Kelly Redpath will be responsible for the account in the event of claim disputes, service problems, etc. and can be reached at (303)504-5303. 6. In the event the City desires employee meeting to present your proposed plan, are representatives from your company available to make presentations? If "yes", are there any additional costs associated with these services? When given two weeks notice, Sloans Lake Health Plan representatives will be available for employee meetings at a no additional cost to the City of Fort Collins. 7. Do you agree that if this proposal results in your company being awarded a contract and if, in the preparation of that contract, there are inconsistencies between what was proposed and accepted versus the contract language that has been generated and executed, that any controversy arising over such discrepancy Sloans Lake Managed Care 6 City of Fort Collins July, 98 Sloans Lake PPO Network Colorado Zip code access standard detail information a ryfi m� i? u %G""", �iT�N'PF3ry��¢ app AAAaiI�'hk�$Y , N;.Mw '; k'qw,`3{ >p .�[,s�„p �iip:I� nA •d(�'NSy;e.y ex'-�aA,' m ^kY 9. "Er, rv" Ia IP e .��� �. ": M 9 M&!3 a 4 � -�„i �3�. numl eub r mplayee pm A�,,1' Y � Ys .cep�i y+S��� P ', ,I500 Tota: number o , providers a ti. ,,s...i�`s,' nPa Wy„q;NJ—.%?� �xF Em to «P4 TE!. ll llverage $h d "bita „ i A $ilP, Divas t�il''"y ke ii- .rx �ih�°ll t�`( ,n`.,Y4'. ee access to 2 viciem r A"f".. 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NU'$' ^�^ fe':P+rt•'� y y+: �..,,YV 8052S 00 „a -, 1 .:, .« �' i.'k 80527 7 0 2.2 100 'i%a�F :g6i"w55. 6' ; 3s1p aM 100 . m 80634 4 0 3 8 100 JCH, ,; -OW,... 6,0534 LAFAYETTE 80026 1 0 3.5 100 �d, • '� ^�%"'idd7' ,a ��5d i::ai"P Ii � .i� Z�I z'1L LIVERMORE u,.. 80536 .. 8 aa.Iwia�rw 0 38 5 0 8d85 2, l=A 403" '0w' LONGMONT 80501 2 7 2.0 100 p �" 'ami yams,1. i, s= rt rili 8(1537 '.ar8fiuLLy veRgr 13i 80538 41 0 9.2 73 Ig LYONS 80540 1 0 9.0 100 M ?q t­42 WWI PIERCE 80650 2 Win 0 117 0 ' -, 0 TIMNATH ��"Cfi"2 80547 3 0 2.5 M. 100 ..�...... W.....r........".. Sloans Lake PPO Network Colorado Zip code access standard detail information ,- +' ei h" :� �' n aw u.�a� tiYYii: EV F kN n'" wi -. � I�i i g �'ai zi� 1+d : xi v� fi� �� c_ x�� C%�:m '§ Ai° � AI IM = gg�� '";fl1:11-1�+ Till �. N, t.ip cadet ww,"�i -nl m 5.;�lo ppl�y pS R� "W Tofa�Pcoijern" d4 r�Q num6eco N YP.'."d S rnpl0ya$ '.�M� SI ! ees� � � adoH R`k9iM 2d mil. numbecoAYerage 4 �' 'Sv IN l �r6V i�ler� r ;a., 4 �.,�l � `,"d, sx by, d�sta ced i 3:'.q fl fit �_���� n � � "� „ n y, it �`i Y'� w ^£�Wi.,&1� k it u :j11 'b "v+ i access to 2„'provi�lers� � , to ees�w[th"2; eP"wx+ :. p�ovTersiwrthin�xmi(as�, r J � '_ � � 10 ,—..:,.. et r ,d p� il�!'f1 ,., 5/9� WELLINGTON 80549 29 0 9.8 iilrtbSOFam, 80550 �in��dl, :. U. >�do.n TOTALS 1,203 48 :. 5.5 90 r IUVIUVi V1 UUP. vo—vrry Sloans Lake PPO Network Colorado Zip code access standard detail information R".r..0 e'e`.,: i to a 'iii �2i3 `.%3'd. ream a„y -a'` �s9°Q' 'd }^S,'��i�.a Em fo � ?3, lxr`m ,� 1€ rya I�� 4�.. :V,i ,16 ^sS- u,�.. �I �M ; h x a. S �' *` .,: wWal la 1�1 >,��o ,yes m 'k �ih'1 jM, rq' rc �Iuk "'" .'�Ia�:wuLiRn lalls3ii''��:qu"'.aYmi,Np%�GS''a k rcm�vi�ai'�S I dWil:: K+ pd 9 ",44 M I&f'":Lsd.1- i lWOE, ��i ff vs, ✓ �Hi }'l.ki v,Afz IIW e'I�'I�'k..z :�� 'fl" [n�l�o�/ee :a'.-.. 'R }JM?91IR4y^VY. 46cbse',to proyl S .g" i�N�'£31G* v a A Y �' ^k'Yt 1�.d , Pct �1�"�ff��'',-h�y^{�=. �}{qq(F�'w P3?b IE l �R Tota{,am% 3�T+a »;j,S3 of erriployees nrith` 2; rdl'M+ kJ A+l rj4 AW ykt Y'N�X�'i•��'; i +Y a T i V'� Pi:Jtiim. % tl j l a m, Jt iin Zips°„num4eo - 1 k'^ k>•ras• iv .+a., °�' , .4.'W ni�mbe"��Nio "iN" k 5'".A A�eage d - ,providers with ln�x'Imiles;. 11 z , gm, a 1 �y¢k dell'�Aa.,e^.'affi.,"RnV�Y;x,.F4.v�aa. .,VG mpibiee' prYttlei's �tlistairce.��,.Il�p41 '11-- m ...� -t 4AKKi, I.W.-41-- 11, AW�+Y+ "mom cA; ...... ARVADA 80003 1 0 1.4 100 M t T 8.61'IM i ^Y" Ma Sax AURORA 80014 �� 1 3 1.5 100 ;p LL{{,1 1wU1 ry 'p7 M" s N� z'?llN 4 A 4A.m$$q!'` ae9MTx u"?.R E4 VV✓ �l"m� AQp "s . W 5m' u BERTHOUD 80513 1 0 6.8 1001"�� �BOI>�lER��y�� v A,k, ,4 "'v=jM,1Xmrc^il Wi.i o$ 80802 s `�� 1s d 01 pp�������1��. ,fl zW A"Re :Y [IAF,1 2 10 0.7 1d Maw BT'.il� - 100 & 1 -�`80304 ^.1 6J zC% "i "' xi ^ 't �a� ��. �: VQQGa ' . I;�m 1 1 diC'^ 1 � �liv 13 , 5 324e ;1ao ��- 'la '':', $3��t 1 Il - AI �fie, � ����� 80234 .���� Ire 1 .��'� ".a.� 0 b_.. 3.1 100 0112 1� m � IJJ �k• 5 a. :.,,o ff 81 6 w WS R iLailsu r ?PII ' � �u'Iti ira �' Q , ' �;. n .y ^. �, ;? x -a tm Y �:�'� '.. DENVER 80215 m 1 4 � 1.2 ... �1 4�„^r' 100 aw`ds".," �"8Q23 71 9 y "'� ��y��yYY' �'�i his �' 0 ,+d4w a ;21 ^r 4`s*' tlm'"' �F w,l @ g, +aL� us 80252 YMYla�i 3 s'4n 0 '��ks�n,�:u fin 0.0 wl.'A��ii'i''"I.1 #�unlim!''."l is 100 4'lep1�.' �ai`'aa ewa -�M 80a�5,a„ eli � i g sm �� 45 s �, i00'.,1 1:..�' m�� ;�rcl EATON 80615 �. .a m.,,__ 5 0 8.0 100 " Si1= ARK''. I� y „g, �m l`'^a w�'i a3 a` ice, Y �..m,La s euais,.,. ' ' ! e/�yy��^ y 8y.71 N' s'M �K;;,7 ml l r '� p 9Q '� °'' ' � 0 ,� ..RJ ..aw wu` i s,. - .a EVANS mess, 80620 ,:11 s sa. ra m" 2 � �' 0 .. a IIus,-.rc...a, . 3.4 sr .�A� ':1.€mmM.. •1-, Ix 100 y`:�,. IW 1 G AY➢'il° $S'f91k1 da ���L"i'� Y. �i"%.... SM'G'.nm.:MWI',Al:aiil3l :i^4,._rv` 'aS �{ 31f" .y VT ^^.#, '� /+�{ 3i Y�IT 4� M'R "�i z �4 " %W ...:TaHIM a .k.ICa v, 80522 I4nm'ilYIM1Az 11 0 .l 3.3 100 8524' �a'180" 10- 2.4 100'r 80525 243 2 3.7 100 m il ���� ° fi ',,m'.m�#�1� it aa'i« '& $0526 �3� ,,gm,tt �1.43su; �� il;1. 100" up�kt ,idm MY,.„p r,s c a«,' , 80527 ail"*s la 7 �.�.-ISw.aumr:�ik` 0 a.�n'g. 4i ,$d ..'. :,,m ArimI. 100 All.2 7.......L. +v£m.am. (S,Z1..sn"ahYyt 91, .x t,rG; i Y 80634 4 0 5.4 100 OCJST01iVN °rcI i�aimmml.; gym.. 80534 1 rl5''L,Q,125a�a�ymmw" m LAFAYETTE 80026 1 0 4.4 100 1 a Qs, ions; LIVERMORE 80536 8 0 34.2 0 lk LONGMONT 80501 2 4 3.1 100 fit WH'li gWikG. 5 3211 kl of ? QQ ya a�,w, m`, 8,0y538 41 9 2.5 IV:— 00 I m g ! 1y�."+� - i$,`w^'d 1$' 1 id. is.} s4. $fi r ll�z i1 °�5,7� aul wcea'w4 LYONS . 80540 1 0 .^. wwMxx 12.2 C'�a�i v'. Y��Nti: 0 !K S1 PIERCE 80650 2 0 12.2 50 im LSElm� 8061 5 6 w 1' „ fi m TIMNATH 80547 3 q1 .I 0 4.2 100' { I vm 1Vr yIVU11. I GVIQL11VIGIIJ Sloans Lake PPO Network Colorado Zip code access standard detail information A IMMIR k' U Pj �� d lY. '% U U irk CWAIP.ri,i �R dik zAFR v+ M'� M1U '�° 31:TM!,;1� i x U"fi AIIE`mpayee YAN' R;Y%„1 5J'rC 3b, ei ilk ii� 14 �� 1 ���;� „ Rill, '.Ui�IMkh ��p✓"U'14, e RS'bRF��1'C Nk' WW I$I �" �( N dNiA✓ril}v 1 rl Z'1 e{ n �a • .• mi . a -"MOMr. a q grj '".il ' a _y 1� x a a,-. 1 �,� a� �, � a a :31Ct 3 1 n 1 , 1YI�mpoyeeascessto2" R, 1 �i�„r k rovtte� �u, �� p�1"' •1 i l I� �'C�� ,,4z; sm, II55.. 1 �,11 � 3 1'IMP" To a �'��h ' 1 1 � Tcta1 P., v,�i i�u�aY � � � � Y 74, �, won r-�� � Pct otf ern to eee��ith 2 p Y ��F .p, ky '` u51Y by Lxw '§'i� ✓"Y'iR';,Ia:�lu�17 ber o q�1. �" ndmber"o I t Average ,prodders within x miles a� Ctya c y ,wl�, EMI .pro idersr tlistariceR . 10 W�ryIELLINGTON 80549 29 0 5.6 100� .:3,� �YYIIYI:JSQ�I.�a ':#,ry'iiR+^,"I!�.,I]LfSJ1V TOTALS 1,203 58 4.2 98 �v�.w. ylwUp. rculaull lcum Sloans Lake PPO Network Colorado Zip code access standard detail information k iA k y' " '.a, u' '&i:. W ks F%dki? iyL�'gg,.:y yrc W. pq All ,. w'; ro•v �rw{ Er�iy�loyeules iA" irza^s.. QQQ=. ,��WxN__� an> ��,I��rxi:ux {w?wrtMu+s". q�� �x,',t "A �.'- Y,I ,�d -ih�.a �G. 'fl:k a N4 . Sn� :: �a1i� Q Ii M i3iNiig Employee aim xe q,4da W.*I .-"s�-l+l �ll�id`@p�1:r�,.,'I v o „rov 4-4 9' �� iS�'a, -x�`t access" t, cler :4�'d x ilea1 ii 11otal� Total: Pct of em to ees with 1r, p y `.Zipnumber'o nmliei a Average rouirierwnthin x Imi�es ,m !? il3, �, code, mpl�errnnrteArs ., �»vW�»_ten ,» .WA�_�.�. ARVADA 8/0�0003 1 0 2.2 1100 �,y� ,,,,Y, AAA °" '" � it ' `kaii"3P +'T" di '+- w � , ', fi! ,51' '».' 8061a 3 I -'i p- 2�1 yk,:L � y gtl j ��'Ill AN .A''�'`� -`raw`. &� �' I""l AURORA >C.,Js,Gw. a.Jw.,eww.'�."^i L�_d'.s,,..0 rw 80014 1 0 2.5 100 CELt/Ulry .' � �y,_ 8'95 'pa15��„"RY 10W , BERTHOUD 80513 1 0 4.8 i ,% 100 BQ., LErAa "�A'�Py 80302,;� a i�u _ 80304 2 1 W 0.5 100 �d ,aw.*'R iLkwwm a.rt lllwi=mk 2eWe iiwv�� '.uAlui''A +b a�d'.I�i>"�,#�W+ �P 'rip "NI rig.A 1QO �v,� f .�Ki 80234 1 If 0 3.2 100 r4,�a WJ� gm D ?�4.. $, "v3"3 )� rvi'xD� IF �'dt� »WW lai��.s>.�v g- T f �' �s � IX� '� 83'�". ry egg 4" I�ii ,vj9i1^ I'fl� IM£i pp ;i... DENVER .tl�'iXkI 80215 . 1 v��. 4� 1 q)q�"NY�] �{ L�Ykfl�.Se.. xRmM 2.4 100 �S�Mw� _ 8U23" " $j 3 V a,. m� DT �,J,Y I»�'�w..•,... .S N,v`4�" ,».i�'v.�»�'id„„t»�QQ.;#, �,ii�,�: 80252 3 0 1.9 100 �g����� a 7 �igg� d�� �°��.�� A:n44LW ?W .''aNiW' a�0151 WIN: 0 i'�' _�2 fb i �= ' �10Q =^ ,� 3 EATON .m4u6 awA mtl:.'9, �..,., v, a $»»d64bi'l ' 80615 5 0 114 100 _ I � , 805 7 pl fi I0� O wl 7 EVANS 80620 �' mwd.� 2 'w 0 .0 a. 17100 uiui s, a. «,a,.ax ww, „,uuwWwJ za. �a p' k 1oa nyJ E, .. .. �0,2 , aN �" 80522 11 0 4.7 100- 80524 »" s `180 " ° ". ; 1 ` 14 100 80525 243 1 3.8 100 gig 3ry k 1o0a r =o52s Ball y " 80527 7 0 4.8 100 �W G�2EEEY»� z ° ;Wy QQ q5. »Z %NViw 8Q63 :u p �'4 'i00%, alv,L."9 "Sw'315L 4Y dti mS 2`... t� 80634 b�" YYLv'� 4 xin 3.. 0 .IS ilk i'vE 4 ) w �A Y'L Y..�..�rei row%v 4 100 Jf4l' 1 OVVW '� �`ianlwv@uUWtliyiVfr tlnxd 3., e mw veil®� l.a ve i"3�-Aanfi �k,=: y'+n ®-:tl,�aM s�.'udi :ien.n °:�vwD43 �W«T M03ll sOi^14 {i LAFAYETTE 80026 @' 1 0 ., v. aW€.. 3.0 100 lam' ». „ "; S5, a;p .' ''OQ LIVERMORE 80536 8 0 36.3 0 !.' 2. k O LONGMO`jNT 2 11( � 4.0 ,_, ., �'�.�, ,arc�O�' 100 %u" ailY;+2.iSN.nO A�..b=..va=ti.. t`;�dASG'Nax .� �' !C.. H,1. m ^1 E' p80501 Va3'�.. _� 'yy�3 *A+"i�u''�'i.- Bn kAaa rtK5.matffi 80538 .P+?Y. m 41 ,..�j�% il �'. Mk 0 ��nt1d w�Y.._ 5.7 l,,�`»::., 'Sl�r u sltti`" d*rva h r W c` &.6' 100 �SSr ffl tt Li k" �� $13+t 8f153 iilevibl6. 2 J'.'�.inVa p'�yg�y»�;,�ej,, LYO_ NS 8p05�+4�0.y 1 0 13_4100 " Ri7!=Rs Yi^�Nn MdiO,4'i dhnQ{M =d ,;:YJ� PIERCE 850 2 0 i� 14.2 mig r 4 �R sQ651 �1 o Qw��I1aQ 3 3j TIMNATH 80547 w. 3 . A »,." , 0 k .., ., 4.8 100 n .— .-- y. ..r.........+.. va.v 4 ivaNuaFa Sloans Lake PPO Network Colorado Zip code access standard detail information 3 a' AIIEmpfoyees� , yw ai'.Fd'Nw "� pL ury � �"N'w3'ArviIM'� 31W zl � � � � A A 'a a H< nN I i a'� „ e� u x Employ a 3� 4 IM; ,�i;, n,;� ��AM," " access prov�tler ,. �L"' Pig � � Total �� Total P,ct of erirployees with 1' ZIp;� number o � number o Averag"e p rovider within x miles �� City z, °, ' a cods mp11 proVi en; distance 20 . , ., . WELLINGTON 80549 29 0 8.0 100 WINDSOR. „' 8550 m �8.' r'0 11.9 100' " 99 TOTALS 1,203 9 4.8 Provider group: Acute Care Hospitals r Utilization. Management Questionnaire I M C•�� SWANS LAKE • MANAGED CARE 1355 S. Colorado Blvd. Suite 902 • Denver, Colorado 80222. 303/691-2200 GRID 2 AGE SEX ORIGINAL REQUESTING DATE OF RATIONALE REQUEST Dr. SERVICE 40 F Continued Wingate 7/15/97 No criteria for inpatient stay inpatient to continue stay 56 M Varicose vein Eckert 7/29/97 No diagnostic test or surgery conservative treatment 49 M Continued Graves 7/10/97 No criteria for inpatient rehab inpatient to continue stay stay 30 F TAH MMK Mondragon 7/21/97 No conservative treatment 46 F Continued stay Finn 7/23/97 No criteria for inpatient to continue stay 54 F Continued stay MacDougland 7/26-7/31/97 No criteria for inpatient to continue stay 8 M Medical admit Williams 8/8/97 No clinical information 20 F Septoplasty Levey 9/4/97 Not meeting criteria 43 M Continues stay, Rosolack 9/5/97 No inpatient post -op continued stay criteria met 32 F Hysterectomy Wilson 9/18/97 No conservative treatment 41 F Shoulder Ochsner 10/9/97 No conservative Arthroscopy treatment 40 F Pelvic Detray 10/8/97 Did not meet criteria Laparoscopy 36 F Hysterectomy Norstog 11/13/97 No conservative treatment 32 F Laparoscopy Wagner 10/23/97 No diagnostic test or conservative treatment EFFECTIVE DATE: REVISED DATE: SLOANS LAKE MANAGED CAPE, INC. MEDICAL MANAGEMENT POLICY RECONSIDERATION AND APPEALS November 1995 1 /96, 9/97 STATEMENT OF PURPOSE Appendix D The purpose of this Reconsideration and Appeals Policy is to ensure consistency in handling requests for review following a decision not to authorize/certify treatment, admission, or other health care service. This policy applies to all providers participating in the Sloans Lake Managed Care, Inc. ("SLMC') provider panel including HMO, PPO, and PIP providers. ("Providers includes both health care professionals as well as health care facilities.) and patients. i. RECONSIDERATION PROCESS If SLMC, through its Department of Medical Management, has made a decision on behalf of the HMO, PPO and PIP programs: to not authorize or certify treatment, admission, or other health care service without a peer to peer discussion, -the Provider has the right to request -econsideration. The reconsideration is strictly for Providers, and although a request for reconsideration rh'- haft iti i Red by a- N'rovider at th:• request of a ::iert, €t is not applicac!a :o and may not be used by HMO members or other patients. The wl«en procedure outlining the Provider's role and responsibility in the reconsideration process will be enclosed with the written notification of nan-autharzationlnon-certification. 1. A request for reconsideration must be made to the Ris;< ?vlanagement Coordinator within twenty (20) business days of the date of written notifica-:Cri of non of The Provider may initiate a request for reconsideration at the request of the patient or the patient's representative. 2. The reconsideration shall be performed by the peer reviewer who made the initial determination, or his/her designee if the original reviewer cannct be available within one (1) business day. 3. The Provider is solely res'ponsible for submitting suet: additional documentation or information as needed to evidence the need andlor effectiveness :f u.- non -authorized health care service when requesting reconsideration. d. The reconsideration shall occur within one (1) bus:: ass day after receipt of the request for reconsideration and Sl'bm15_IOII of 2ddlilOnal InfO(mat[C•- 5. The Peer revle'wer =i;911 review the SUMC file, a= .•c a_ u��e i on addltl0 riol IniO(matr. Provider. Th- reviewer may discuss the -' a=:ion with the Provider. provided by the , "'' I\JIf l\,rphC,1I O.-NII, IOPS. J0: p :6 6. The peer reviewer will document his/her decision a`�_r reconsideration, including rationale if the decision is to continue non -authorization or non -certification and fon412rd the decision to the Risk Management Coordinator and the appropriate (Medical (Director. The Risk _. Management Coordinator will telephone the Provider and provide written notification to the Provider of the decision within hwo (2) business days after the decision. 7. A decision upholding the prior non -authorization or non -certification may be appealed by the Provider through the Expedited or Standard Appeal process. The Provider shall be informed in writing of the right to these processes. II. APPEAL PROCESS Providers have the right to appeal a decision not to authorize requested health care services when the reconsideration process has upheld the original decision or the provider does not meet the requirements for a reconsideration or chooses not to request a reconsideration. Providers, HMO members and PPO patients have the right to appeal a decision not to authorize or certify requested health care services Bath Expedited and Standard Appeals shall be reviewed by a Medical Management Committee peer member. All appeals must be submitted in writing, the only exception is an Expedited Appeal. Both first and second level appeals will be entered into the complaint log maintained by member services. Expedited Aooeals An Expedited Apoeal must be initiated by the Provider within five (5) working days a�er the date of the written Notification of Reconsideration. Expedited appeals shall be accepted telephonically or in writing when there is an ongoing service involved, and the Provider believes the determination warrants an immediate apceal. It is within the Provider's sole discretion whether the patient's condition or the nature of the proposed health care sErvice(s) warrants expedited review by a Medical (Management Committee peer member. Both the Provider and Risk Management Coordinator will: share information by phone, facsimile or otherwise to gather and translEr information necessary to resolve the expedited appeal. All supporting ciccu,mentation should have been submitted during the reconsideration process but the Provider may submit updated medical records and/or a written statement from the Provider or patient during the appeal process. All additional information shall be provided at the time of the request far an Expedited Appeal. The Risk Management Coordinator shall contact a eer reviewer other than the original reviewer far Zn Expedited Appeal within one (1) business day after receiot of the request for Expedited Appeal from the Provider. The Peer Reviewer shall review the SUMC rile and all documentation submit[a= by the Provider. The Peer R-viewer may conduct the review and discussions via telephone conference call or any other rrzt,cd %v�,,ich expedites the review process. ,411 decisions to uphold a decision not tc authc~=' or c_-,,ify health car-e s.=rvic=_ sh=11 be in writing and shall _rovider an d;pr facilitv. Tha provide all CIUTC=i tea: 5 for ii & de:erminatlOn iJ I tj1r1l_r9hCA6.hhnwc.C= ,:oc -- will be resolved in favor of the language contained in the proposal or correspondence relating to your proposal? Sloans Lake Managed Care has answered this proposal in good faith however, the final contract supersedes any prior agreements. 8. Describe any lawsuits which have been brought against your firm. There have been no lawsuits brought against Sloans Lake Managed Care. 9. Please state the time line your company intends to follow to commence work as of January 1, 1999. Once notified of the award, a draft of the contract will be executed within one day of notification and any necessary changes to the draft will be made within a few days. The final contract will be sent out for signatures. If needed, stickers to the TPA can be placed on I.D. cards. 10. What is your perspective on the health care industry in five years? What changes do you foresee? Sloans Lake foresees the continuation of consolidation of networks and insurance companies. We see more providers and payors moving towards electronic data interface. Lastly, we see that government legislation will have an impact on the healthcare industry. 11. If you have obtained national accreditation, please state through which agency and when it was obtained. As of May, 1998 Sloans Lake Managed Care achieved the broadest scope of accreditation from the American Accreditation HealthCare Commission /URAC (The Commission/URAC). Sloans Lake is the first managed care organization in the country to receive full accreditation for its PPO network, HMO network, and utilization management program. Sloans Lake Managed Care 7 City of Fort Collins July, 98 patient will receive in writing the decision and be refarr=d to the treating physician for the clinical basis of the determination. For PPO/HMO, the written decision will be sent to Zhe Provider and the covered person and include: 1. Name, title, and credentials of the revie`rrer. 2. Statement of the reviewers understanding of the reason for the appeal. 3. Medical rationale. 4. Reference to evidence used as a basis for the decision. 5. Instruction for second level appeal. The Risk Management Coordinator will notilf%j the Provider of the decision of the Peer Reviewer immediately via telephone. The Provider and patient shall be sent written notification of the decision within two (2) business days of receiving the information required for the expedited appeal. Decisions regarding authorization/certification of requests for health care services made on a retrospective basis can only be appealed through the Standard Appeals process. Standard Aooeal - First Level _ (Group Health PPO only) A request for a Standard Appeal must be riled within sixty (060) clays of the date of .thp written Notification of Reconsideration or P. dec;sicn not to.a�thorize/certify and. .should include supportting docur—::cnrtation ( PIP'and HMO only) A request for a Standard Appeal must be filed within �1,venty (20) business days of the date of the written Notification of Reconsider_iian or a decision not to authorize/certify and should include supporting documentation. (All lines of business) All supporting documentation should have been submitted during the reconsideration process, but the Provider may suc,nit updated medical records and/or a written statement from the Provider or p=_tier;t. If the Provider chooses not to appeal and the me::.ber chooses to appeal, the current documentation will be given to the Medical 141=-agement Committee. The Director of 1Gledical \&I2nagenent shall cony-e a meeting of the Medical (Management Committe-e for a Standard Appeal Sri::` r. twenty (20) business days aiier receiat Or a request and documentation fron i,:e Provider. If the aooeal is for PIP the Risk Coordin=tor will orse.— the aooeal with suoporine documentation, if it is for PF0 or ;;CIO, the Cpe'= : ,s IManagar vill present the acceal and su�C.a..ne COcurnentnt:cn. The Ca r11-a: shill r$VL=`N tilt SUAC ii e Provide d = Commute_ and all docume:,:_::on suC:Tilti�u Lv thedecision Oi t i\jlr1%,rphcalt\ghhrnap Cp. Zoc = . shall be by a majority vote. All decisions of the Cc.-,mittee upholding a decision not to authorize or certify health care services shall c=_ in writing and shall provide: Notification will be sent to the member and the Provider of the decision of the Committee in writing as soon as practical, but in no event later than twenty (20) business days after the Committee convened. (For PPOiHMO only) a) Notification to both the covered person and Provide(. b) The name, title, and credentials of the reviewer. c) Reviewers understanding of the reason for appeal. d) Reviewer decision and medical rationale e) A reference to the documentation used as a basis for the decision, including the clinical review criteria used to make the determination, and instructions for requesting the clinical review criteria. f) Description of the process for submitting a griavance in writing requesting s further second level appeal review of the case. (For PIP Only) The clinical basis for ttie determination to the provider. The patient will receive in writing, the %A for, and be ref�cred to the treating pl:Jsic:_; for the clinical basis of tha determination. Standard Aooeal - Second Level (PPO and PIP only) The second level of appeal will be rendered by the carrier. (HMO only) A second level grievance review panel will be appointed by the Director of Medical Management for each grievance. The panel apopint will have no less than three people, they will be health care professionals, and t :� majority of the panel will net have been involved previously in the grievance. -::a health care professionals chosen will have the appropriate expertise for ,"fie -=-;cular appeal, they will not be a member of the beard cf.directors, not have a Gire.: financial interest in the case or in the outcome of the review, and not be �"=:�yee's of the health plan. O written decision will be issued to the covered c_ s ,� and to the Provider who submits a grievance an benali of a covered Procedura for conduc ir_ sacand level pa nel revie-v o q 1.\tlrl\yrphcal c\,hhmookp dog a The review meeting will be held within 45 rrorking days of receiving a request for second level review. Whenever a covered person has requested to appear in person, the review meeting will be held during regular business hours, _ a location accessible to the covered person. if this is not practical far geographi: reasons, the review will be done by conference call. The covered person will be notified in writing at least 15 working days in advance of the review date. Upon the request of a covered person, the carrier shall provide to the covered person all relevant information that is not privileged or confidential. The covered person will be notified in writing of the following rights: May attend the second level review. May present their case to the panel. Submit supporting material. Ask questions of any representative of the he-ith carrier. Be represented by a person of his or her choice. The review panel shall issue a written decision to the covered person within 5 working days, to include: Names, titles, and qualifying credentials 21 -Uh-a review panel. A statement of the review panel's understanding of the nature of the grievance. The rationale far the panel's decision. Reference to evidence considered by the panel in making the decision. Notice of the covered person's right to.ccr,tact the commissioner's ence and the telephone and address of the ccmm1:SSioner's office. HMO Only The results of a Provider reconsideration and/or appz_al shall be made available to • senior HMO management and the Appeals and Policy Committee considering any grievance filed by the HMOmember who is the subject of the reconsideration/appeal determinations. Because of the potential for simultaneous consideration of an HMO member review/appeal and a Provider request for reconsideration, the Manager of the Membership Services and the Group Health Clinical Manager shall each forward a list of pending f.considerations:reviebvs/appeals to the other on a :' ea<ly basis. Dirunldoo I I I .doc �- IU L\jlr Ihrphcsld�hhuw F•CF ,:�c = I ' Requested Attachment Appeal C 4 P losure Letter n G November 20, 1997 Pamela L. Kimbrough, M.D. 1601 E. 19`h Avenue, Suite 4200 Denver, CO 80218 Re: Patient Name: Carrier Name: Dear Dr. Kimbrough: S LOANS LAKE MANAGED CARE 1355 South Colorado Blvd Suite 902 Dc'er, Colorado $0222 Tcicphone (303) 691-2200 We received your request to appeal a decision not to authorize an abdominal hysterectomy for the -above referenced patient. A careful review of the provided clinical information was conducted by the Medical Management Committee. The specialty review was performed by Darrell R Warren, M.D., Obstetrics and Gynecology. Our internal appeal process is complete and the original opinion is upheld. It was the determination of the Medical Management Committee that the documentation does not provide objective clinical findings to support the medical necessity for the removal of the uterus. The basis for this decision was the -small size of the uterine fibroid, the absence of abnormal uterine bleeding and the short duration of the abdominal pain. A copy of the clinical review criteria may be obtained by submitting a written request to the Group Health Clinical Manager. This now exhausts the appeal processes through Sloans Lake Managed Care. The next level of appeal is to the insurance carrier. Benefits payable for health care services are determined by the insurance company subject to provisions of the policy. This includes contractual limitations, eligibility requirements, coordination of benefits and any other policy Iimitations in effect when service is rendered. The carrier has been notified of our decision. Sincerely, 0-,—n cl� c, Sandra L. Sims Medical Management Commitree Chairperson c: Colorado Counties, c/o National benefit Administrators Billing, PSL Medical Ce:aer 0 a Requested Attachment Utilization Management Plan SLOANS LAKE MANAGED CARE MEDICAL MANAGEMENT UTILIZATION MANAGEMENT PLAN FOR SLOANS LAKE MANAGED CARE Review Date Department Head Chief Medical Director 03/92 03/93 03/94 11/91 04/95_6/96 1/97 j � f t—s 2 — ;'�� j f /�Ilzel,t r — THE SLOANS LAKE MANAGED CARE UTILIZATION MANAGEMENT PLAN DISCLAIMER The Sloans Lake Managed Care (SLMC) Utilization Management Plan applies to those employee groups and insurance companies who contract with SLMC for this service. It is the responsibility of the provider to correctly identify the Utilization Management company and comply with their mandates regarding the certification process for inpatient or outpatient services. Client and Provider Services publishes a list of all the SLMC insurance carriers and Third Party Administrators (TPA's) and lists their phone numbers for Benefit Verification and Pre - certification. This information is distributed with the SLMC newsletter. These lists are compiled and maintained in order to assist the provider's office in identifying the appropriate employer group or insurance carrier so that benefit information and the certification process can be expedited with minimal effort. The role of Utilization Management is to review medical services to determine if they are medically necessary, rendered at the appropriate level of care and meet professionally recognized standards of care. The provider bears the ultimate responsibility for medical treatment decisions and has a duty to appeal utilization management determinations if he/she disagrees with a decision. TABLE OF CONTENTS Organizational Flow Chart I. Introduction...................................................................................................................4 A. The Goal B. The Utilization Management Process II. Roles and Responsibilities............................................................................................4 A. Chief Medical Director B. Director of Medical Management C. Operations Manager for Medical Management D. UM R.N. E. UM L.P.N. F. Specialty Peer Reviewer G. Medical Management Committee III. Providers......................................................................................................................8 A. Physician B. Hospitals IV. Utilization Management.............................................................................................8 A. Monitoring Criteria B. Pre -surgery Review C. Maternity Certification D. Inpatient Medical/Surgical UM Procedures E. Coordinated Care Management F. Psychiatric and Alcohol Substance Review Procedure G. Case Management H. Decision to not authorize/certify treatment, admission or other health care service I. Reconsideration and Appeals Procedures V. Ambulatory Services Review....................................................................................13 VI. Non-compliance with Review Procedures and Decisions........................................14 VII. Care Determined to be Medically Inappropriate......................................................14 Appendix A Pre -Surgical Review Expanded List..........................................................15 Appendix B Provider Non -Compliance With UM Review Procedure ..........................16 Appendix C Referral Guidelines for Case Management................................................17 3 I. INTRODUCTION A. The Goal The goal of Sloans Lake Managed Care (SLMC) is to ensure the provision of comprehensive, cost effective medical care for individuals insured with self - funded groups and insurance carriers. It is a system of managing health care costs, as well as a commitment to the provision of quality health care for members and clients. This goal is achieved by monitoring through the Utilization Management (UM) Program. The UM process is an on going process of monitoring and evaluating medical care delivery services, including inpatient and outpatient treatment on a prospective, concurrent and retrospective basis. The UM process provides an organized systematic approach for reviewing and evaluating the health care delivery practice of hospitals and physicians. It also ensures the provision of timely, cost effective, quality patient care. H. ROLES AND RESPONSIBILITIES A. Chief Medical Director The Chief Medical Director is responsible for overseeing the operational activities of the UM Program. This includes but is not limited to the following: Appoints members of the Medical Management Committee and credentialing Committee. 2. Chairs the Credentialing Committee. 3. Reviews UM problems and if necessary refers them to the appropriate Specialty Peer Reviewer 4. Provides medical supervision of the UM R.N.s/L.P.N.s Recommends inclusion or exclusion of providers form his respective areas of supervision of credentialing 6. Other duties as assigned by the Chief Executive Officer Medical Managed Care Plans (PPO, POS, & EPO) Questions to be Answered Organization t. Please provide the names and positions of officers and board members, and whether they represent any hospital, physician medical association, or other interest. Mr. Jim Basey 1820 Blake Street Denver„ CO 80202 Phone: 292-4722 Fax: same Sits on Centura Board. Mr. Nelson Cole 78 Ash Street Denver, CO 80220 Phone: 393-1140 Fax: 320-5651 Sits on Centura Board. Mr. Terry White Executive VP, Centura Health 5570 DTC Parkway Englewood, CO 80110 Phone: 804-8230 Fax: 804-8231 Henry C. Cleveland, MD Chairman, Sloans Lake Managed Care 1355 S. Colorado Blvd., Ste. 902 Denver, CO 80222 Phone: 504-5702 Fax: 504-5747 Mr. Arthur Dunn Mr. Neil Waldron Interim President & CEO, Centura Health President & CEO, Sloans Lake Managed Care 5570 DTC Parkway 1355 S. Colorado Blvd., Ste. 902 Englewood, CO 80110 Denver, CO 80222 Phone: 804-8152 Phone: 504-5440 Fax: 290-6699 Fax: 504-5401 2. Please indicate the person(s) who would be the liaison to the City. Kelly Redpath will be the liaison to the City and can be reached at (303)504-5303. 3. What is your network's service area? Sloans Lake Managed Care operates in the state of Colorado. 4. How many enrolled groups and total number of enrolled participants participated in your managed care plan during the most recently completed quarter? During the same quarter last year? Sloans Lake Managed Care has the following participation: Sloans Lake Managed Care 8 City of Fort Collins July, 98 B. Director of Medical Management c The Director of MM is responsible for the operational and fiscal activity of the MM Department. This includes research, development and implementation of new product lines within the MM Department. Position responsibilities include: Provides direct supervision of the Administrative Assistant Supervisor, Manager of Operations for Medical Management, CIinical Manager for Auto, and Manager of Credentialing. 2. Attends the monthly operations meetings 3. Chairs the Medical Management Committee C. Operations Manager for Medical Management ., The Operations Manager of UM is responsible for the day to day operations within UM. Position responsibilities include: l . Serves as a liaison with insurance carriers and employer groups 2. Provides direct supervision of all UM R.N.s/L.P.N.s 3. Conducts clinical UM file review 4. Serves as a liaison with Specialty Peer Reviewers 5. Coordinates the development of the UM P&G manual 6. Coordinates education inservices at SLMC for the nursing staff 7. Coordinates problematic issues with providers and carriers interdepartmentally 8. Conducts bi-monthly UM nursing meetings 9. Assists in marketing activities as they pertain to UM 9 D. UM R.N. The UM R.N. is a registered nurse with extensive clinical experience in medical, surgical and/or psychiatric areas. The UM R.N. performs all pre- certification/admission reviews, pre -surgery, concurrent and retrospective review functions. Any utilization problems identified by the UM R.N. are referred to the Senior Medical Director or his designee. E. UM L.P.N. The UM L.P.N.s are licensed practical nurses with extensive clinical experience in medical and surgical nursing. The primary responsibility is the Coordinated Care Management (CCM) line of business. The UM L.P.N.s are responsible for authorizing referrals to specialists and allied health professionals, ambulatory services, surgery, acute hospitalization, as well as extended care and hospice care. The UM L.P.N. works under the supervision of the designated Manager of UM. Any utilization problems are referred to the Chief Medical Director or his _ designee. F. Specialty Peer Review Role and Purpose a. Provide Specialty Peer Review b. These providers are responsible for reviewing claims, utilization and quality issues. C. They may function as level I or II reviewers in the appeal process. 2. The Medical Management Committee monitors the activities of the peer review process. A provider involved in peer reviews may meet with the Chief Medical Director to discuss matters related to the UM activities at any time. 3. Specialty Peer Reviewers are reimbursed for each review. 4. The Specialty Peer Reviewers serve as advisors in each area to the UM R.N.s/L.P.N.s and Nurse Case Managers. as well as to the Respective Medical Directors. 5. Members serve open terms based on the Chief Medical Director's recommendation. 6 G. Medical Management Committee 1. The role and purpose of the Medical Management Committee is to serve in an advisory capacity to the Chief Medical Director regarding development of UM guidelines and criteria and to review appeals. 2. The provider participants serving on the Medical Management Committee are selected by the Chief Medical Director. Sloans Lake Medical Directors can make recommendations to the Chief Medical Director for inclusion on the board. (See Appendix D) 3. The Chief Medical Director is a member of the Medical Management Committee which meets monthly. Records and minutes of the Committee's activities and meetings are maintained. 4. The Director of MM is the chairperson of the Medical Management Committee. Minutes and records are considered confidential and available only to the committee members. III. PROVIDERS A. Physicia 1. SLMC is dedicated to providing quality medical service through a broad - based physician network. Physicians of all specialties are represented through the PPO. ' 2. SLMC physicians accept several contractual responsibilities when they join the PPO. a. The physician agrees nQ to bill the patient for charges other than for non -covered services, deductibles and coinsurance. b. The physician agrees to participate in the UM process, providing patient care information as requested by SLMC. C. The physician agrees to initiate pre -certification and admission review, as well as cooperate with the concurrent review process for all patient groups involved in the UM Process. d. The physician agrees to accept recommendations from the Chief Medical Director and/or Specialty Peer Reviewers regarding utilization criteria and standards. 7 B. Hospital The participating hospital network has agreed to cooperate with the UM process. The UM R.N./L.P.N. interacts frequently with hospital staff to monitor patient care and length of stay, and conducts on -site concurrent reviews as needed. IV. UTILIZATION MANAGEMENT A. Monitoring_ Criteria The Medical Management Committee has adopted monitoring criteria to be used in the review of hospital services. These criteria are based on the Milliman and Robertson Health Care Guidelines, and are modified, as necessary, by the committee and/or Chief Medical Director to cover special circumstances. B. Pre -Surgery Review The pre -surgery review is done prior to surgery on specified procedures utilizing clinical information and patient history to determine if the procedure is medically " necessary and appropriate. Clinical information is evaluated using the SIM V Manual for Surgical Indicators. If criteria are not met the case will be discussed with the Chief Medical Director or his designee, before giving the provider the l final decision. (See Appendix A) C. Maternity Certification A pregnancy must be physician confirmed before certification can be initiated. The program is voluntary and introduces the patient to the pre -certification process. It also enables early identification of complications of pregnancy that can be referred to case management for possible intervention. D. Inpatient Medical/Surgical UM Procedures Pre -admission Certification a. Pre -admission certification is required for all elective hospital admissions for those groups contracting with SLMC for this service. This procedure serves to monitor and evaluate the medical necessity and appropriateness of admissions prior to scheduling. Failure to comply with required procedures will be referred per the Physician Review Process section. (See Appendix B) b. The objectives of pre -admission certification are as follows: • To ensure that admissions are appropriate and that care is rendered at the appropriate level of treatment and intensity of service, e.g., outpatient versus inpatient 8 _ To evaluate the anticipated course of treatment and length of stay C. Review Procedure • The components of the UM process are prospective, concurrent, and retrospective review. Review of an individual case may involve any or all of these procedures. • The level of services to be reviewed include inpatient and outpatient treatment. • For inpatient hospitalization the provider is required to phone the UM R.N./L.P.N. or designee with clinical information, a treatment plan and an estimated length of stay. Demographic and insurance information required. This request is evaluated by the UM R.N./L.P.N. and a decision is given to the physician. Non- certifications/authorizations are reviewed by the Chief Medical Director. • In the case of an emergency admission, the provider will seek authorization within 48 hours, or the next working day in the event the patient is admitted over the weekend or on a holiday. A message to this effect may be left at the Pre- cert number, 1-800-850-1899, for those patients whose plan requires this notification. 2. Concurrent Review Including Discharge Planning for Inpatient Services Concurrent review serves to further evaluate the necessity and appropriateness of hospital stays by periodically monitoring continued hospitalizations. Concurrent review is initiated by the UM R.N./L.P.N. or designee within forty-eight (48) hours following notification of admission. Telephone conversations with the attending provider to assess the medical necessity and appropriateness of continued confinement may be required. Concurrent review also includes an assessment of the quality of care being provided. All cases are reviewed according to M&-R Criteria. SLMC encourages early discharge planning for every inpatient hospital ization. �By having a functional, readilx activated plan, discharge can occur on a timely basis, without delay. once maximal hospital benefit has been achieved and the patient no longer meets NIRR criteria. 9 3. Retrospective Review of Physician Inpatient Services Through compilation and data analysis, retrospective review evaluates the necessity and appropriateness of physician services after medical care has been rendered. The objectives of this procedure are as follows: a. Identifies and compares patterns of care with parameters established by the Medical Management Committee. b. Recommends, when indicated, changes in the provider practices. C. Analyzes consumer patterns of utilization for appropriateness and directs this information to clients for use in the design of medical benefit plans at the time of renewal. E. Coordinated Care Management Coordinated Care Management (CCM) provides ready access to primary health care providers. Specialty care requires a referral authorization. Primary Care Physicians (PCP)include: • Family/General Practitioners • Internists • Pediatricians 1. Referral Authorization Referrals must be initiated by a primary care physician. Specialty providers may call for a referral for diagnostic procedures. Specialty providers and therapists may call for an authorization for follow-up care within 90 days of the initial authorization. Whenever a CCM client requests a referral to a specialist or allied health care provider the following steps are followed by the UM R.N./L.P.N.: a. Confirm the insured and dependents have selected a PCP; that the physician who requests a referral is the selected PCP; and that a network specialist is selected for the referral. b. Evaluate clinical information using the Healthcare Management Ambulatory Care Guidelines. Review all referrals for appropriateness with respect to: • the diagnosis and/or procedure • the selection of the specialist and.'or proposed diagnostic testing, lab work, etc., • the number of visits authorized H c. Non-certifications/authorizations are reviewed by the Chief Medical Director. d. Create a record of the referral decision within the system. The system will capture the referral information, i.e. date of the receipt of call from the PCP, etc. e. Monitor referral practices of PCP's, including appropriateness of referrals, volume of referrals and compliance with program procedures. 2. Presurgical Review (PSR) PCP's are required to contact SLMC for a referral for selected procedures. The UM R.N./L.P.N. Nurse will authorize the procedure after a review of the clinical information using the InterQual SIM V Manual for Surgical Indicators. (See Appendix A) 3. Pre -admission, Concurrent and Retrospective Review Admission to acute hospital care, rehabilitation, extended care and hospice care is reviewed prospectively and concurrently. Clinical information is evaluated to assess the medical necessity and appropriateness of confinement. F. Psychiatric and Alcohol Substance Review Procedure All psychiatric and substance abuse will be reviewed by the Psychiatric Review Organization (PRO). G. Case Management The UM department maintains a systematic approach to identifying and referring cases. (See Appendix C) H. Decision to not authorize/certify treatment, admission or other health care service If the UM R.N./L.P.N. cannot certify medical necessity for treatment, hospital admission, continued stay or other health care services based on the M&R criteria, the case is referred to the Chief Medical Director. 2. The Chief Medical Director may contact the attending physician to obtain additional information. Based on the additional information, the treatment, admission, continued stay or other health care service may be approved. 3. If the medical necessity is approved, the appropriate notification letters are issued. 4. If the Chief Medical Director determines that criteria is not met, notification is issued for non-certification/authorization. The notification in writing is issued to the facility, provider, patient/insured and claim administrator, all of whom will also receive notification by telephone, informing them of the last certified day. Included with the notification are appeal procedures. 5. The written notification explains the action necessary to initiate an appeals procedure. The clinical rationale will be made available upon written request by the provider and/or facility. The patient will be referred to the physician for explanation of clinical rationale. I. Reconsideration and Anneals Procedures 1. When an -initial determination is made not to certify an admission, continued stay, or other service and no peer -to -peer conversation has been attempted, the provider may request a reconsideration by the clinical reviewer making the initial determination. The reconsideration is conducted within one business day of the receipt of the request. If the process does not resolve the difference, the provider is notified of the right to initiate an appeal. 2. If any party to an initial non -certification determination wishes to appeal, they may request so by writing. Appeals are reviewed by the Medical Management Committee, using a board certified provider, with the same or similar specialty, that was not involved in the original non -certification decision. I Expedited appeals can be done telephonically when there is an ongoing imminent service requiring review. V. Ambulatory Services Utilization Review Claims are reviewed by providers specialty to identify coding problems and over or under utilization of services. These reports are periodically reviewed to monitor provider performance and maintain performance standards. The data is reviewed by the Director of MM, the Manager of Provider Services and the Chief Medical Director. Variations are confirmed by reviewing sentinel provider profiles. Correspondence is sent out to the provider commending their performance, recommending a chan`_e or requesting an explanation for treatment. Client and Provider Services is available for on -site assistance. 12 VI. Non-compliance with Review Procedures and Decisions If a provider does not comply with the pre -admission, or concurrent review, or any other review procedures, the provider non-compliance with UM review procedure can be implemented. (See Appendix B) VII. Care Determined to be Medically Inappropriate In the review process, when the medical services are determined to be medically inappropriate, the Senior Medical Director or his designee may recommend a denial of payment or partial payment for care rendered after appropriate notification to the affected parties. It PRESURGICAL REVIEW EXPANDED LIST Cardiovascular Coronary Angiography Coronary Artery Bypass Carotid Endarterectomy Percutaneous Transluminal Coronary Angioplasty Gastrointestinal Colonoscopy UGI Endoscopy Hemorrhoidectomy Gynecological Dilation & Curettage Hysterectomy Pelvic Laparoscopy - me Abdominoplasty Capsulotomy for Scar Contracture following Augmentation Mammoplasty Dermabrasion of Skin Orthopedic Any Arthroscopic Procedure (Knee, Shoulder, Wrist) Carpal Tunnel Release Excision of Nail and Nail Matrix, Partial or Complete Lumbar Laminectomy Spinal Fusion Otolaryngology Otoplasty Tonsillectomy or Adenoidectomy Tympanostomy Tube Insertion Cystourethroscopy The PSR list is reviewed when surgery is performed in a hospital or licensed ambulatory surgery center. 14 PRODUCT 1997 PARTICIPATION 1998 YEAR-TO-DATE PARTICIPATION PPO 450,000 467,835 UM 64,187 59,367 CCM 11,908 10,303 5. What is the projected enrollment for the next fiscal year? Projected enrollment for the PPO product for 1999 is 485,000. 6. Will you provide client specific directories to the City, at no cost, for employee distribution? If no, will you agree to provide directories on diskette to the City for internal production? Sloans Lake Managed Care does not provide client specific directories but will agree to provide directories on diskette to the City for internal production. 7. How often will you update your directories? What is the turn -around time for getting these updated directories to the City? Sloans Lake Managed Care prints directories once a year and updates every six months. However, the directory listings are updated daily on the internet at www.sloanslake.com. Turn -around time, depending on the quantity of the request, is up to one week. 8. Please provide sample utilization reports readily available for clients. How often are they produced? Is there a charge? If so, please state the charge. Standard reports can be run quarterly for the City at no charge. Additionally, ad hoc reports can be run at a negotiated fee. Please see Requested Attachments section -Sample Reports. 9. Describe recent network provider utilization experience for the following: a. lab procedures per office visit; Not available. b. x-rays per office visit; and Not available. c. C-section, as a percent of total deliveries. Not available. 10. Are there any "reconstructing" plans for expansion or reduction of the network over the next 18 months? Please specify. Sloans Lake Managed Care 9 City of Fort Collins July, 98 PROVIDER NON-COMPLIANCE WITH UM REVIEW PROCEDURE When a provider is non -compliant with the UM process, the Senior Medical Director may impose the following corrective actions: 1. Corrective action visit by Provider Services 2. Consultation with the Medical Director 3. Removal from panel 15 REFERRAL GUIDELINES FOR CASE MANAGEMENT Diagnosis: 1. AIDS 2. Newborn Conditions: A. AIDS B. Prematurity C. Respiratory Distress Syndrome D. Short Gut Syndrome E. Hyaline Membrane Disease - F. Ventilator Dependent Infants G. Congenital Anomalies (Tetralogy of Fallot, Downs Syndrome) H. Addicted Infants 3. Major Trauma and Neurological conditions A. Traumatic Brain Injury B. Spinal Cord Injury C. Burns D. Multiple Fractures or Injuries E. Guillian-Barre Syndrome F. ALS (Lou Gehrig's Disease) 4. Ventilator Dependent Patients 5. In -Patient or Out -Patient Programs Involving A. Long -Term, Frequent OT, PT, Speech Therapy B. On -Going Hyperalimentation C. IV Antibiotic Therapy D. On -Going Chemotherapy E. IV Pain Control Programs F. Prospective Review of Purchase vs. Rental of Equipment ro a 6. High Risk Pregnancy A. Hyperemesis B. Premature Labor C. History of Premature Deliveries D. History of Multiple Births E. Diabetic Mothers with History of Problems 7. Length of Stay A. Two or More Related Admissions in the Last Six Months B. any In -Patient Stay Greater Than 14 Days 8. Situations When Benefits Requested For A. Long -Term Skilled Nursing Care B. Extended Care Facility C. Day or Partial Hospitalization D. Altemative Treatment Facility 9. Mental/Nervous and Alcohol/Drug A. Hospitalization of Greater Than 30 Days B. Request for treatment in Non -Covered Facility 10. Chronic Conditions A. Any Terminal or Progressively Deteriorating Disease Requiring Long - Term Care 17 DiRCV a,.,.. Dx SLOANS LAKE MANAGED CARE MEDICAL MANAGEMENT (MM) APPEAL PROCESS Subject: Medical Management (MM) Appeal Process Policy No.: 90060.001 Scope: All Parties Responsible Dept.: Medical Management - Group Health Effective Date: October 1995 Revision Date: 96, 6/96, 1/97, 12/97, 1/98 Approval: FEB 111998 Vice, Pres' ent / � Date FEB 1 11998 �Decto Date - V FEB t8 Manager Date Policy: To ensure consistency in handling requests for review of a decision not to authorize/certify treatment, admission, or other health care service. (Provider includes both health care professionals as well as health care facilities.) Procedure: I. The Utilization Management (UM) nurse confers with the Medical Director when the case does not meet criteria for medical necessity and/or appropriateness. The UM nurse will elicit from the provider why certain criteria has not been met. II. The Medical Director may perform the review or refer to a Specialty Peer Reviewer, the review determines medical necessity. III. When a decision not to authorize/certify has been determined, the provider may invoke the Reconsideration and Appeal Process. (Appendix D) IV. The patient or patient representative may initiate an appeal process. V. All written responses from the Medical Management Committee will be initiated by the chairperson of the committee and will be in compliance with content and time frames as stated in Appendix D. L\j1r1\grphea10ohhmop&p Joe Pa-e 4 I VI. If the request is for an elective procedure that is being done the next working day and does not meet criteria, the UM nurse needs to advise the office that all efforts will be made to complete the Medical Director review that day, but it may not occur until the next working day. A. The Team Coordinator or manager must be advised of the urgent request. C\jlrl\grphcalt\ghhmop&p.duc Page 5 SLOANS LAKE MANAGED CARE, INC. MEDICAL MANAGEMENT POLICY RECONSIDERATION AND APPEALS EFFECTIVE DATE: November 1995 REVISED DATE: 1/96, 9/97 STATEMENT OF PURPOSE Appendix D The purpose of this Reconsideration and Appeals Policy is to ensure consistency in handling requests for review following a decision not to authorize/certify treatment, admission, or other health care service. This policy applies to all providers participating in the Sloans Lake Managed Care, Inc. ("SLMC") provider panel including HMO, PPO, and PIP providers. (°Providers includes both health care professionals as well as health care facilities.) and patients. I. RECONSIDERATION PROCESS If SLMC, through its Department of Medical Management, has made a decision on behalf of the HMO, PPO and PIP programs to not authorize or certify treatment, admission, or other health care service without a peer to peer discussion, the Provider has the right to request reconsideration. The reconsideration is strictly for Oroviders, and although a request for reconsideration may be initiated by a Provider at the request of a ,patient, it is not applicable to and may not be used by HMO members or other patients. The written procedure outlining the Provider's role and responsibility in the reconsideration process will be enclosed with the written notification of non-authorization/non-certification. 1. A request for reconsideration must be made to the Risk Management Coordinator within twenty (20) business days of the date of written notification of non-authorization/non-certification. The Provider may initiate a request for reconsideration at the request of the patient or the patient's representative. 2. The reconsideration shall be performed by the peer reviewer who made the initial determination, or his/her designee if the original reviewer cannot be available within one (1) business day. 3. The Provider is solely responsible for submitting such additional documentation or information as needed to evidence the need and/or effectiveness of the non -authorized health care service when requesting reconsideration. 4.' The reconsideration shall occur within one (1) business day after receipt of the request for reconsideration and submission of additional information. 5. The peer reviewer shall review the SLMC file, as well as the additional_ioformation provided by the Provider. The peer reviewer may discuss the clinical situation with the Provider. 6. The peer reviewer will document his/her decision after reconsideration, including rationale if the .-Jecision is to continue non -authorization or non -certification and forward the decision to the Risk Management .00rdinator and the appropriate Medical Director. The Risk Management Coordinator will telephone the Provider and provide written notification to the Provider of the decision within two (2) business days after the decision. 7. A decision upholding the prior non -authorization or non -certification may be appealed by the Provider through the Expedited or Standard Appeal process. The Provider shall be informed in writing of the right to these processes.. II. APPEAL PROCESS Providers have the right to appeal a decision not to authorize requested health care services when the reconsideration process tras upheld the original decision or the provider does not meet the requirements for a reconsideration or chooses not to request a reconsideration. Providers, HMO members and PPO patients have the right to appeal a decision not to authorize or certify requested health care services Both Expedited and Standard Appeals shall be reviewed by a Medical Management Committee peer member. All appeals must be submitted in writing, the only exception is an Expedited Appeal. Both first and second level appeals will be entered into the complaint log maintained by member services. Expedited Appeals • An Expedited Appeal must be initiated by the Provider within five (5) working days after the date of the written Notification of Reconsideration. • Expedited appeals shall be accepted telephonically or in writing when there is an ongoing service involved, and the Provider believes the determination warrants an immediate appeal. It is within the Provider's sole discretion whether the patient's condition or the nature of the proposed health care service(s) warrants expedited review by a Medical Management Committee peer -member. • Both the Provider and Risk Management Coordinator will share information by phone, facsimile or otherwise to gather and transfer information necessary to resolve the expedited appeal. All supporting documentation should have been submitted during the reconsideration process but the Provider may submit updated medical records and/or a written statement from the Provider or patient during the appeal process. All additional information shall be provided at the time of the request for an Expedited Appeal. • The Risk Management Coordinator shall contact a peer reviewer other than the original reviewer for an Expedited Appeal within one (1) business day after receipt of the request for Expedited Appeal from the Provider. The Peer Reviewer shall review the SLMC file and all documentation submitted by the Provider. The Peer Reviewer may conduct the review and discussions via telephone conference call or any other method which expedites the review __process. All decisions to uphold a decision not to authorize or certify health care services shall be in writing and shall provide all clinical basis for the determination to the provider and/or facility. The patient will receive in writing the decision and be referred to the treating physician for the clinical basis of the determination. • For PPO/HMO, the written decision will be sent to the Provider and the covered person and include: 1. Name, title, and credentials of the reviewer. 2. Statement of the reviewers understanding of the reason for the appeal. 3. Medical rationale. 4. Reference to evidence used as a basis for the decision. 5. Instruction for second level appeal. • The Risk Management Coordinator will notify the Provider of the decision of the Peer Reviewer immediately via telephone. The Provider and patient shall be sent written notification of the decision within two (2) business days of receiving the information required for the expedited appeal. • Decisions regarding authorization/certification of requests for health care services made on a retrospective basis can only be appealed through the Standard Appeals process. Standard Appeal - First Level (Group Health PPO only) • A request for a Standard Appeal must be filed within sixty (60) days of the date of the written Notification of Reconsideration or a decision not to authorize/certify and should include supporting documentation ( PIP and HMO only) • A request for a Standard Appeal must be filed within twenty (20) business days of the date of the written Notification of Reconsideration or a decision not to authorize/certify and should include supporting documentation. (All lines of business) • All supporting documentation should have been submitted during the reconsideration process, but the Provider may submit updated medical records and/or a written statement from the Provider or patient. • If the Provider chooses not to appeal and the member chooses to appeal, the current documentation will be given to the Medical Management Committee. • The Director of Medical Management shall convene a meeting of the Medical Management Committee for a Standard Appeal within twenty (20) business days after receipt of a request and documentation from the Provider. If the appeal is for PIP, the Risk Management Coordinator will present the appeal with supporting documentation, if it is for PPO or HMO, the Operations Manager will present the appeal and supporting documentation- The Committee shall review the SLMC file and all documentation submitted by the Provider. The decision of the Committee shall be by a majority vote. All decisions of the Committee upholding a decision not to authorize or certify health care services shall be in writing and shall provide: • Notification will be sent to the member and the Provider of the decision of the Committee in writing as soon as practical, but in no event later than twenty (20) business days after the Committee convened. (For PPO/HMO only) a) Notification to both the covered person and Provider. b) The name, title, and credentials of the reviewer. c) Reviewers understanding of the reason for appeal. d) Reviewer decision and medical rationale e) A reference to the documentation used as a basis for the decision, including the clinical review criteria used to make the determination, and instructions for requesting the clinical review criteria. f) Description of the process for submitting a grievance in writing requesting s further second level appeal review of the case. (For PIP Only) The clinical basis for the determination to the Provider. The patient will receive in writing, the decision and be referred to the treating physician for the clinical basis of the determination. Standard Appeal - Second Level (PPO and PIP only) The second level of appeal will be rendered by the carrier. (HMO only) • A second level grievance review panel will be appointed by the Director of Medical Management for each grievance. The panel appointed will have no less than three people, they will be health care professionals, and the majority of the panel will not have been involved previously in the grievance. The health care professionals chosen will have the appropriate expertise for the particular appeal, they will not be a member of the board of directors, not have a direct financial interest in the case or in the outcome of the review, and not be employee's of the health plan. A written decision will be issued to the covered person and to the Provider who submits a grievance on behalf of a covered person. Procedure for conducting second level panel review • The review meeting will be held within 45 working days of receiving a request for second level review. • Whenever a covered person has requested to appear in person, the review meeting will be held during regular business hours, at a location accessible to the covered person. If this is not practical for geographic reasons, the review will be done by conference call. The covered person will be notified in writing at least 15 working days in advance date. Upon the request of a covered person, the carrier shall provide to the covere relevant information that is not privileged or confidential. • The covered person will be notified in writing of the following rights: • May attend the second level review. • May present their case to the panel. • Submit supporting material. • Ask questions of any representative of the health carrier. Be represented by a person of his or her choice. • The review panel shall issue a written decision to the covered person within 5 wor include: Names, titles, and qualifying credentials of the review panel. • A statement of the review panel's understanding of the nature of the grievar The rationale for the panel's decision. Reference to evidence considered by the panel in making the decision. Notice of the covered person's right to contact the commissioners of. telephone and address of the commissioners office. HMO Only The results of a Provider reconsideration and/or appeal shall be made available to management and the Appeals and Policy Committee considering any grievance HMO member who is the subject of the reconsideration/appeal determinations. Be potential for simultaneous consideration of an HMO member review/appeal an( request for reconsideration, the Manager of the Membership Services and the C Clinical Manager shall each forward a list of pending reconsiderations/reviews/ar other on a weekly basis. DinurtJd00I I Ldoc Sloans Lake Managed Care will continue to expand as necessary but does not at this time plan any expansion or reduction. 11. Please enclose all pertinent materials regarding your network and managed care services. Please see Attachment C- Marketing Materials. 12. Will you agree to allow the City to omit providers from your existing network? Contact directly with network providers? Contact directly with non -network providers? Sloans Lake Managed Care will not allow the City to omit providers or contract directly with network or non -network providers. 13. Please indicate the person(s) who will by the liaison to the City. Include resume. Kelly Redpath will be the liaison to the City and can be reached at (303)504-5303. Physician Specific Issues 1. Please outline the physician selection criteria utilized by your managed care program in contracting with primary care and speciality physicians. How are their credentials verified? How often are they reviewed? Please see Attachment D-Provider Credentialing Plan. 2. How is the quality of care and physician cost efficiency monitored on an ongoing basis? How often is this review conducted? Please see Attachment E-Quality Program. 3. How many physician members have been terminated within the last two years? For what reasons? What provisions are made for patients of terminated physicians? What has the average turnover rate been of the physician network over the past two years? Currently less than 1% of Sloans Lake Managed Care physicians are terminated. The reasons are varied and are of a proprietary nature. Patients of terminated providers are immediately sent letters which inform them of their doctor's departure and provide them with instructions for selecting a new provider. The net turnover rate is less than 1% for all providers. Sloans Lake Managed Care 10 City of Fort Collins July, 98 I Disruption Analysis Directory Match 0 A i lI RC-4mL= (�% 1 Northern Colorado Physicians .. 4shington County Clinic 482 Adams Akron, CO 80720 (970)345-2262 Telephone Enrollment: 17239 Thompson James DO 120 N 2nd Ave Ault, CO 80610 (970)834-2255 Telephone Enrollment: 16614 t/Armour Ross MD 401 loth Street Berthoud, CO 80513 (970)532-4602 Telephone Enrollment 17199 voo'Goacher Cynthia Lee MD 549 Mountain Ave Berthoud, CO 80513 (970)532-4644 Telephone Enrollment: 17103 er Richard MD 549 Mountain Ave Berthoud, CO 80513 (970)5324644 Telephone Enrollment 17285 Ringel Marc MD 2400 W Edison Street Brush, CO 80723 (970)842-2833 Telephone Enrollment 17143 I Lee Jeffrey MD 600 S St Wain Suite 2 Estes Park, CO 80517 (970)586-1904 j Telephone Enrollment: 16765 /Nichol Thomas MD i555 Prospect Ave Suite B Estes Park, CO 80517 (970)586-5317 Telephone Enrollment: 14050 Van der Werf Guy MD 555 Prospect Ave Suite A Estes Park, CO 80517 (970)586-2200 Telephone Enrollment: 16689 Allen Thomas MD 2160 W Drake Rd Fort Collins, CO 80526 (970)221-5595 Telephone Enrollment: 16732 V/ Bailey Jr Austin MD 1025 Pennock PI Fort Collins, CO 80524 (970)495-8800 _ Telephone Enrollment: 15458 ' Bender Edward MD 1212 E Elizabeth Fort Collins, CO 80524 (970)482-2791 ® Telephone Enrollment: 13439 r Bermingham Roger MD 1025 Pennock PI Fort Collins, CO 80524 (970)495-8800 - Telephone Enrollment 15462 L ehman Charles MD Le ma7th Broman Steven MD St Street 1221 E Elizabeth Suite 4 Eaton, 80615 I Fort Collins, CO 80524 (970)454-2296 (970)484-1757 Telephone Enrollment: 13647 Telephone Enrollment 17134 Carlson H G MD t Ir 1040 E Elizabeth Suite B Howton James DO I Fort Collins, CO 80524 131 Stanley Ave Suite 202 (970)432-0213 Estes Park, CO 80517 Telephone Enrollment: 16554 (970)586-2343 I T-lephone Enrollment: 17106 VCarroll Cory MD 2001 S Shields Bldg J Suite 100 j Fort Collins, CO 80526 (970)221-5858 Telephone Enrollment: 16932 Carson Jr Frank MD j I006 Luke St i Fort Collins, CO 80524 (970)221-2290 Telephone Enrollment: 14367 I Coburn Thomas MD 1 2561 S Shields Bldg 3F Fort Collins, CO 80526 (970)484-4498 Telephone Enrollment 17263 (Cranor J David MD 1124 E Elizabeth Suite C Fort Collins, CO 80524 (970)484-0798 Telephone Enrollment: 14846 ' DeYoung Douglas DO 1212 E Elizabeth Fort Collins, CO 80524 (970)482-2791 Telephone Enrollment: 13441 'Ferguson David MD 1025 Pennock PI Fort Collins, CO 80524 (970)495-8800 Telephone Enrollment: 15460 Fields Jacqueline MD 1017 Robertson Fort Collins, CO 80524 (970)472-5000 Telephone Enrollment: 17446 'Gray April MD 2001 S Shields Bldg L Fort Collins, CO 80526 (970)221-3855 Telephone Enrollment: 17510 'Jinich Daniel MD 2561 S Shields Bldg 3F Fort Collins, CO 80526 (970)484-4498 Telephone Enrollment: 16890 Kasenberg Thomas DO 2160 W Drake Rd Fort Collins, CO 80526 (970)221-5595 Telephone Enrollment: 16731 v Kauffman Jeffrev MD 1124 E Elizabeth Suite C Fort Collins, CO 80524 (970)484-0798 Telephone Enrollment: 14847 Kent Cherie MD 1025 Pennock PI Fort Collins, CO 80524 (970)495-8800 - Telephone Enrollment: 17276 YLopez Joseph MD 1136 E Stuart Suite 4202 Fort Collins, CO 80525 (970)221-5925 - Telephone Enrollment: 14397 ►'Mercer Jeannette MD 1212 E EIizabeth Fort Collins, CO 80524 (970)482-2791 Telephone Enrollment: 13442 rMerkel Lawrence MD 1006 Luke St Fort Collins, CO 80524 (970)221-2290 Telephone Enrollment: 14368 Murphy Lawrence MD 1113 Oakridge Dr Fort Collins, CO 80525 (970)225-0040 /Telephone Enrollment: 13651 Howell Dawn MD vmevrivy Thomas MD 2025 Bighorn Dr 12001 S Shields Bldg I Fort Collins, CO 80525 Fort Collins, CO 80526 (970)229-9800 (970)221-5255 Telephone Enrollment: 17289 Enrollment: 13650 _.. ° M Ax 9 lggB Closed to new members Member Services: 1-800-877--9777 Published February, 1998 6 MNMI-I— ttolenghi David MD 200i S Shields Bldg L Fort Collins. CO 80526 (970)221-3855 / Telephone Enrollment: 17512 ✓ Paddack Michael MD 1025 Pennock P1 Fort Collins, CO S0524 (970)495-8800 / Telephone Enrollment: 15459 J Paulsen Mark MD 1221 E Elizabeth Suite 4 Fort Collins, CO 80524 (970)484-1757 / Telephone Enrollment: 13657 . / Piccaro John MD 1025 Pennock PI Fort Collins, CO 80524 (970)495-8800 Telephone Enrollment: 17052 ✓Podhajsky Timothy MD 2025 Bighorn Dr Fort Collins, CO 80525 (970)229-9800 Telephone Enrollment 16546 Roasback Christine MD 1212 E Elizabeth Fort Collins, CO 80524 (970)482-2791 Telephone Enrollment: 17290 Rotman Mark MD 2001 S Shields Bldg I Fort Collins, CO 80526 (970)221-5255 Telephone Enrollment: 13653 .� Rubright Jon MD 2001 S Shields Bldg 1 Fort Collins. CO 80526 (970)221-5255 Telephone Enrollment: 16778 Samuelson Scott MD 1124 E Elizabeth Suite C Fort Collins. CO 80524 (970)484-0798 / Telephone Enrollment: 17016 ./' Seeton James MD 2001 S Shields Bldg L Fort Collins. CO 80526 (970)221-3855 Telephone Enrollment: 17511 heppard-Madden Dena MD 2160 W Drake Rd Fort Collins. CO 80526 (970)221 5595 Telephone Enrollment: 17048 Smith David MD 1025 Pennock PI Fort Collins, CO 80524 (970)495-8800 �Telephone Enrollment: 17275 N`Smith Jerome MD 2025 Bighorn Dr Fort Collins, CO 80525 (970)229-9800 �Telephone Enrollment: 13646 ✓Sprowell James MD 1221 E Elizabeth Suite 4 Fort Collins, CO 80524 (970)484-1757 Telephone Enrollment: 13655 V'Stephens Floyd MD 1113 Oakridge Dr Fort Collins, CO 80525 (970)225-0040 Telephone Enrollment: 13648 4toddard Andrew MD 1124 E Elizabeth Suite C l Fort Collins, CO 80524 (970)484-0798 Telephone Enrollment: 14845 VSullivan Donna MD 1025 Pennock P1 Fort Collins. CO 80524 (970)495-8800 Telephone Enrollment: 15461 ✓Sunthankar Shivalini MD 1014 Centre Ave Fort Collins. CO 80526 (970)482-8881 Telephone Enrollment: 16352 Vfhieman William MD 1217 E Elizabeth Fort Collins. CO 80524 (970)484-7245 / Telephone Enrollment: 13976 V Thieszen Milford MD 811 E Elizabeth Fort Collins. CO 80524 (970)2"4-1596 Telephone Enrollment: 15041 horson Steven MD reen Deborah MD 1212 E Elizabeth I 315 Park Ave Fort Lupton, CO 80621 Fort Collins, CO 80524 (970)482-2791 Telephone Enrollment: 13438 (303)857-6111 Telephone Enrollment: 14194 � �fippin Steven MD /McDermott Martin MD 2025 Bighorn Dr Fort Collins, CO 80525 327 Park Ave Fort Lupton,80621 (970)229-9800 Telephone Enrollment: 16475 93 t 51 elephonc Enrollment: 14434 Awbin Michael MD VSpray Selwyn MD 1113 Oakridge Dr 305 B Denver Ave Fort Lupton, CO 80621 Fort Collins, CO 80525 (970)225-0040 ! (303)857-I007 Telephone Enrollment t7491 eP Telephone Enrollment: I3656 linger Mark MD s 114 Bristlecone Drive Fort Morgan Medical Group Fort Collins, CO 80524 102 W 9th Ave (970)495-8900 Fort Morgan, CO 80701 Telephone Enrollment: 17163 (970)867-5817 Walley George MD � Telephone Enrollment: I7522 Kevin MD 1212 E Elizabeth �/L.indell Fort Collins, CO 80524 1220 Beaver Creek Place I(970)482-2791 l Fort Morgan, CO 80701 Enrollment 17127 (970)867-8221 , I `Telephone v vanfarowe Cynthia MD i Telephone Enrollment 17198 I 1014 Centre Ave I Salud Family Health Center ' Fort Collins, CO 80526 909 E Railroad Ave (970)482-2201 Fort Morgan, CO 80701 Telephone Enrollment: 17498 (970)867-0300 �/Weiskittel Deborah MD Telephone Enrollment: 17763 1113 Oakridge Dr Fort Collins, CO 80525 Fretwell James MD (970)225-0040 332 Sth St Telephone Enrollment: 13654 Frederick, CO 80530 xemm Stephen MD (303)833-2475 1212 E Elizabeth �Telephone Enrollment: 17521 MD Fort Collins. CO 80524 ,/Mathwich Brian (970)482-2791 332 5th St Telephone Enrollment: 13440 Frederick, CO 80530 ort Lu to n4 (303)833-2475 Telephone Enrollment: Mao rignoni Hector MD 305 N Denver Ave — w_ __Y Fort Lupton. CO 80621 �Audensiek Richard DO (303)g57-4096 3211 20th St Suite A Telephone Enrollment. 17449 Greeley, CO 80631 (970)353-9011 Telephone Enrollment: 1 "07 Published Febntarv. 1998 "Closed to new members Member s: 1-800-377-9777 ✓Chesley Charles MD 2520 16th St - Greeley, CO 80631 (970)356-2520 Telephone Enrollment: 13033 0 Colgan Ann MD 2520 16th St Greeley, CO 80631 (970)356-2520 Telephone Enrollment: 13031 t/Coriiss Scott MD 3705 W 12th Street Greeley, CO 80631 (970)351-7134 Telephone Enrollment: 16787 V/Corona Joseph MD 2010 16th St Suite C Greeley, CO 80631 (970)353-7666 Telephone Enrollment: 12412 /Dallow Kurt MD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 Telephone Enrollment: 16766 Fahrenholtz H Daniel MD 1600 23rd Ave -eley, CO 80631 /0)356-2424 Telephone Enrollment: 15623 Flower Thomas DO 2122 9th St Greeley, CO 80631 (970)356-7555 / Telephone Enrollment: 12398 ✓ Garber Stacy MD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 Telephone Enrollment: 16495 /Guthrie Pamela MD 2010 16th St Suite D Greeley, CO 80631 (970)353-7668 / Telephone Enrollment: 17457 tr Haskins Robert Scott MD 2520 16th St Greeley, CO 80631 (970)356-2520 Telephone Enrollment: 13035 "Closed to new members ✓Hicks James MD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 Telephone Enrollment::7161 Jensen -Fox ChristinMD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 Telephone Enrollment: 16936 I i� Kennedy Christopher MD 2010 16th St Suite D Greeley, CO 80631 (970)353-7668 Telephone Enrollment: 17458 ee Miles DO 2627 1 Oth St Suite 3 Greeley, CO 80631 (970)352-3274 Telephone Enrollment: 12535 i Martinez Matthew MD 2520 16th St I Greeley, CO 80631 (970)356-2520 Ii Telephone Enrollment: 17262 tV McCall Janis MD 2520 16th St Greeley, CO 80631 (970)356-2520 Telephone Enrollment: 13029 ✓Ids Kenneth MD 2520 16th St Greeley, CO 80631 (970)356-2520 Telephone Enrollment: 13030 Oligmueller William MD 3705 W 12th Street Greeley, CO 80631 (970)351-7134 Telephone Enrollment: 14296 Paczosa Michelle DO 1 1028 5th Ave I Greeley, CO 80631 I (970)353-9403 i Telephone Enrollment: 17128 1 Powell Patricia MD i 1028 5th Ave Greeley, CO 80631 (970)356-6014 Telephone Enrollment: 17265 I ✓Schmalhorst Brian MD 1900 16th St Greeley, CO 80631 (970)353-1551 / Telephone Enrollment: 14262 r^ Shea Ellen MD 2010 16th St Suite C Greeley, CO 80631 (970)353-7666 Telephone Enrollment: 16771 Simons Louise MD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 Telephone Enrollment: 17280 Tucker Kelly MD 2420 16th St Greeley, CO 80631 (970)356-1775 Telephone Enrollment: 13032 Wallace Mark MD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 i Telephone Enrollment 15622 / tV Wigpall William MD 1600 23rd Ave Greeley, CO 80631 (970)356-2424 Telephone Enrollment: 15620 Wilson D Craig MD 2420 16th St Greeley, CO 80631 j (970)356-1775 Telephone Enrollment: 13034 'vLey James MD 233 W Strohm Haxtun, CO 80731 (970)774-6187 Telephone Enrollment: 17122 i "'Volk John W MD 16 N Parish PO Box 520 Johnstown, CO 80534 (970)587-4974 Telephone Enrollment: 16585 Regier Donald MD 116 E 9th Street Julesburg, CO 80737 (970)474-3376 Telephone Enrollment: 17237 �'Brignoni Hector MD 190 S Main Keenesburg, CO 80643 (303)732-4268 Telephone Enrollment: 17444 /Allen Thomas MD 295 E 29th St Loveland, CO 80538 (970)669-6000 Telephone Enrollment: 16905 Anderson R Scott MD 2701 Madison Sq Drive Loveland, CO 80538 (970)663-0722 Telephone Enrollment: 16631 Young Mark MD rower Annette MD 2010 16th St Suite D 2701 Madison Sq Drive Greeley, CO 80631 Loveland, CO 80538 (970)353-7668 (970)663-0722 i Telephone Enrollment: 17455 Telephone Enrollment: 15617 Vucker Charles MD Cabrera Anthony MD 2420 16th St i 914 W 6th St Greeley, CO 80631 Loveland, CO 80537 (970)356-1775 (970)667-3976 Telephone Enrollment: 16703 elephone Enrollment: 17278 Clemens Orrie MD 2701 Madison Sq Drive Loveland, CO 80538 (970)663-0722 Telephone Enrollment: 15615 Afember Services: 1-800-877-9777 8 Published February, 1998 Danforth III James MD 2701 Madison Sq Drive Loveland, CO 80538 (970)663-0722 Telephone Enrollment. 15614 /de la Torre Rebecca MD 914 W 6th St Loveland, CO 80537 (970)667-3976 Telephone Enrollment: 15613 ✓Frickman Carl MD 3320 W Eisenhower Loveland, CO 80537 (970)669-2849 / Telephone Enrollment. 14594 �/ Grosboll Robert MD 232 W 4th St Loveland, CO 80537 (970)667-3565 Telephone Enrollment: 13313 / Hailey Mark MD 914 W 6th St Loveland, CO 80537 (970)667-3976 Telephone Enrollment 15612 ✓' Hughes Andrew MD 2701 Madison Sq Drive Loveland, CO 80538 (970)663-0722 / Telephone Enrollment: 15616 r,/ Kasenberg Thomas DO 295 E 29th $t Loveland CO 80538 (970)669-6000 Telephone Enrollment: 16730 ✓Krantz Laurence MD 3320 W Eisenhower Loveland, CO 80537 (970)669-2849 Telephone Enrollment: 14513 ✓Nye Brett MD 3320 W Eisenhower Loveland, CO 80537 (970)669-2849 Telephone Enrollment: 14595 V// Reents William MD 914W6th St Loveland, CO 80537 (970)667-3976 Telephone Enrollment: 15610 R�grid MD 1323 Harlow Lane Suite 2 Loveland, CO 80537 (970)667-3030 . Telephone Enrollment: 14625 Salazar -Tier Maryruth MD 1805 E 18th St Suite 6 Loveland, CO 80538 (970)669-9700 1 Telephone Enrollment: 16794 chafer Donald MD 914 W 6th St Loveland, CO 80537 (970)667-3976 Telephone Enrollment: 15611 Schaffer Scott MD 2701 Madison Sq Drive Loveland, CO 80538 (970)663-0722 Telephone Enrollment: 16739 Sheets Ronald MD 1808 N Boise Ave Loveland, CO 80538 (970)669-6660 Telephone Enrollment: 15609 Sheppard -Madden Dena MD 295 E 29th St Loveland, CO 80538 (970)669-6000 1 Telephone Enrollment: 17049 lark Curtis MD i 1405 S 8th Ave Suite 103 Sterling, CO 80751 (970)522-3304 Telephone Enrollment: 17131 VFillion Robert DO 615 Fairhurst Sterling, CO 80751 (970)521-3223 Telephone Enrollment: 17248 VKahler Durand DO 1405 S 8th Ave Suite 102 Sterling, CO 80751 (970)522-7100 Telephone Enrollment: 17454 ✓Mackey Jack MD i 1410 S 3rd Ave Sterling, CO 80751 (970)522-2630 Telephone Enrollment: 17133 VNlx Shirley MD 615 Fairhurst Sterling, CO 80751 (970)521-3223 Telephone Enrollment: 17166 Smith Lori MD 615 Fairhurst I Sterling, CO 8075I (970)521-3223 Telephone Enrollment: 17158 Vanschooneveld Craig MD 108 Delmar Sterling, CO 80751 (970)522-6120 Telephone Enrollment 17124 Bradley Robert MD 1230 W Ash St Windsor, CO 80550 (970)686-5646 Telephone Enrollment; 14678 .arey Michael MD 1230 W Ash St t Windsor, CO 80550 (970)686-5646 / Telephone Enrollment: 14677 IJ Lawton Susan MD 1190 W Ash St Suite B Windsor, CO 80550 (970)686-5655 Telephone Enrollment: 15157 {/ Lembitz Deanne MD 1190 W Ash St Suite B Windsor, CO 80550 ! (970)686-5655 Telephone Enrollment: 17009 ✓Mason R Anthony MD 1190 W Ash St Suite B Windsor, CO 80550 (970)686-5655 Telephone Enrollment: 16966 V'tangel Keith MD 1230 W Ash St Windsor, CO 80550 (970)686-5646 Telephone Enrollment: 16747 Buchanan Robert MD 517 Adams Street Wray, CO 80758 (970)332-4897 Telephone Enrollment. 17136 14/Eddens Christopher MD 517 Adams Street Wray, CO 80758 (970)332-4895 Telephone Enrollment: 17146 �i yemura Monte MD 1 517 Adams Street Wray, CO 80758 (970)332-4895 Telephone Enrollment: 17139 Yuma Clinic 910 S Main Yuma, CO 80759 (970)848-3896 Telephone Enrollment: 17524 /Scanlon Charlotte MD ! 555 Prospect Ave Suite D Estes Park, CO 80517 (970)586-2200 Telephone Enrollment 16999 Abbey David MD l 100 Poudre River Dr I Fort Collins, CO 80524 (970)224-9508 Telephone Enrollment: 15003 yAlessi Grace MD 1025 Pennock PI Suite 107 Fort Collins, CO 80524 (970)482-3712 Telephone Enrollment: 17059 V/x(len David MD 1260 Doctors Lane ^ Fort Collins, CO 80524 (970)484-3496 Telephone Enrollment. 13776 Member Services: 1-800-877-9777 Published February, 1998 "Closed to new members 4 Bush James MD 1021 Luke St Fort Collins. CO 80524 (970)484-6406 Telephone Enrollment: 14121 v .tmburg Robert MD 1100 Poudre River Dr Fort Collins, CO 80524 (970)224-9508 Telephone Enrollment: 15005 Johnson Richard MD 1260 Doctors Lane Fort Collins, CO 80524 (970)484-9027 Telephone Enrollment: 13382 /Lopez Jr William MD 1136 E Stuart Suite 2140 Fort Collins, CO 80525 (970)22I-3782 /Telephone Enrollment: 14084 ✓/Lynch Michael DO 1100 Poudre River Dr Fort Collins, CO 80524 (970)224-9508 Telephone Enrollment: 15004 ✓ Meyer Fred MD 1217 E Elizabeth Suite 9 "'rt Collins, CO 80524 ,0)482-1685 Telephone Enrollment: 16493 V' Ow Cathy MD 1025 Pennock PI Suite 107 Fort Collins, CO 80524 (970)482-3712 /Telephone Enrollment: 16350 sands Arthur MD 1021 Robertson Fort Collins, CO 80524 (970)482-0666 Telephone Enrollment: 17468 Stuart Jr Robert MD 1050 E Elizabeth Street Fort Collins, CO 80524 (970)221-4433 Telephone Enrollment: 17442 Wingate Dana DO 1040 E Elizabeth Suite 101 Fort Collins. CO 80524 (970)484-9796 Telephone Enrollment: 16627 -L/OSed to new members Musani Ali MD 419 E 9th Fort Morgan, CO 80701 (970)867-4823 Telephone Enrollment: 17459 ZRi�✓ Rice Robert N MD 419 E 9th Fort Morgan, CO 80701 (970)867-4823 Telephone Enrollment: 17197 Gret ie ,, aker Christopher MD 900 14th St Greeley, CO 80631 (970)353-4322 Telephone Enrollment: 16604 I Berntsen Mark MD 1900 16th St Greeley, CO 80631 (970)353-1551 Telephone Enrollment: 17196 Branum Russell MD 1900 16th St Greeley, CO 80631 (970)353-1551 Telephone Enrollment: 14252 Vruce Julia MD 1 900 14th Street i Greeley, CO 80631 ! (970)3534322 Telephone Enrollment: 17236 Cary Ethan MD 1900 16th St Greeley, CO 80631 (970)350-2437 / Telephone Enrollment: 14265 CashRobert MD 1900 16th St Greeley, CO 80631 (970)350-2438 Telephone Enrollment: 14253 Christensen Dana MD 900 14th St Greeley, CO 80634 (970)353-4322 Telephone Enrollment: 17259 h Tbens John MD 1900 16th St Greeley, CO 80631 (970)353-1551 Telephone Enrollment: 14255 ✓ Fellers Neal MD 1900 16th St Greeley, CO 80631 (970)350-2438 Telephone Enrollment: 14257 Pace R Scott MD j 2000 16th Street Suite 5 Greeley, CO 80631 (970)351-0155 Telephone Enrollment 17141 ✓Quintana Elaine MD 900 14th Street Greeley, CO 80631 (970)353-4322 / Telephone Enrollment: 17130 J' Rademacher Donald MD 1900 16th St Greeley, CO 80631 (970)350-2438 Telephone Enrollment: 14261 Thompson Keith MD 1900 16th St Greeley, CO 80631 1 (970)353-1551 Telephone Enrollment: 14263 /ryggestad David MD I 1900 16th St Greeley, CO 80631 (970)353-1551 Telephone Enrollment: 14264 of Hagan John MD 1808 N Boise Ave Loveland, CO 805-8 (970)669-6660 Telephone Enrollment: 16971 Parliment Joel MD 1808 N Boise Ave Loveland, CO 80538 (970)669-6660 ✓Telephone Enrollment: 17523 ello Robert MD 232 W 4th St Loveland, CO 80537 (970)667-3565 xTelephone Enrollment: 13314 ebster Douglas MD 1808 N Boise Ave j Loveland, CO 80538 i (970)669-6660 Telephone Enrollment: 17224 amb Richard MD 620 Iris Drive Sterling, CO 80751 i (970)522-7266 jTelephone Enrollment: 17064 Soper Thomas DO 615 Fairhurst Sterling, CO 80751 (970)521-3223 Telephone Emollment 17387 /Cooper John D MD V' Yockey Raymond MD 555 Prospect Ave Suite C 900 14th St Estes Park, CO 80517 Greeley, CO 80631 (970)586-2200 (970)353-4322 Telephone Enrollment 13390 Telephone Enrollment 17261 II / F tpr MQS 1� Zenk Daniel MD eard Donald MD 1900 16th St j 1200 E Elizabeth Greeley, CO 80631 j Fort Collins, CO 80524 (970)353-1551 (970)482-2515 Telephone Enrollment: 14284 / Telephone Enrollment: 16476 Booth Richard MD �:=- - -..>+ Loveland, "� ""° 2001 S Shields Bldg G Fort Collins. CO 80526 (970)484-4871 Telephone Enrollment: 14093 Member Services: 1-800-877-971 i 10 Published February, 1998 Dierauf Susan MD 1200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 Telephone Enrollment: 16671 ✓Eillott Maz MD I200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 / Telephone Enrollment: 13267 Guenther John MD 1200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 Telephone Enrollment 13264 ,Hanson Vaughn MD 1200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 Telephone Enrollment: 13269 ✓McGinnis James MD 1200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 Telephone Enrolimenr. 0265 ✓paisley Jan MD 1200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 Telephone Entollotenr 13266 d Sullivan William MD 1200 E Elizabeth Fort Collins, CO 80524 (970)482-2515 Telephone Enrollment 13268 Dabynsky Omt MD 1620 25th Ave Greeley, CO 80631 (970)356-2600 / Telephone Enrollment: 15670 t/ Fink Anthony MD 1900 16th St Greeley, CO 80631 (970)350-2445 Telephone Enrollment: 14256 aplan Kenneth MD 1620 25th Ave Greeley, CO 80631 (970)352-1900 Telephone Enrollment: 14729 Kolanz Meshelle MD 1900 16th St Greeley, CO 90631 (970)353-1551 Telephone Enrollment: 17195 Ryan Joseph MD i 1900 16th St Greeley, CO 80631 1 (970)350-2448 t Telephone Enrollment 14282 I Middlebrook M Tammy MD 2802 Madison Sq Dr Suite 3 Loveland, CO 80538 (970)663-5437 Telephone Enrollment: 17225 Quintana Michael MD 1931 N Boise Ave Loveland CO 80538 (970)669-3298 Telephone Enrollment 13551 ,/Tomlinson Alan MD 2802 Madison Sq Dr Suite 3 Loveland, CO 80538 (970)663-5437 4 Telephone Enrollment: 17227 Wiesner Mark DO 2802 Madison Sq Dr Suite 3 Loveland, CO 80538 (970)663-5437 Telephone Enrollment: 17226 'Closed to new members Vember Services: 1-300-877-9777 Published Februarv, 1998 11 6 EVERGREEN - FORT COLLINS ED MCLEAN, ANNE B MO 303425-1680 30940 STAGE COACH BL SUITE 270 EVERGREEN. CO 00439 Ne . SLMC 1 .ELL. DONNA M CMT 3036744870 27YM MEADOW OR SUITE 205 EVERGREEN, CO W439 Ne4w tSLMC IENSEN, OLE T DOS 303-674.34S2 28000 MEADOW OR Newortr. Aunt SLMC EVERGREEN. CO 0M39 E FRENCH, CINDY B OTR 303470.3263 3072 EVERGREEN PKWY SUITE 100 EVERGREEN. CO 80439 N4M . SLA4C PECHUM DOUGLASR MD 303-674.7477 28000 MEADOW OR SUITE I EVERGREEN, CO 80439 N4Mak: M4M, SIAIC ROBERTS. ALFRED 0 MO 30-474-4143 3082 EVERGREEN PKWY SUITE A EVERGREEN. CO 80439 Nerwak: SLMC KEW IOHN E MO 303674.33" 29029 UPPER BEAR CA Nowak: MMA AMC EVERGREEN. CO 80433 CAREER. DONALD R MO 303470.00" 280M MEADOW OR SUITE 106 Nrwak: M64A. SLMC EVERGREEN. CO 80439 '),CAROLM MO 307.470.3220 I BERGEN PKY .IE C240 EVERGREEN. GO W09 AAWWOi:: CLAP, AMC I WGELOW. USA I PT 303-674.1594 59029 UPPER BEAR CR SLIM 200 Nowak: SLMC EVERCREEN. C0 W439 GARBUS EDWARD PT 303-6746-1394 29029 UPPER BEAR CR SURE 200 EVERGREEN CO 00139 NW*:SLMC GILMORL ELIZARETH 8 PT 303-674.1394 29M UPPER BEAR CR SUITE 200 EVERGREEN. CO OD439 Nfr c *. Suwc CLOTH, VALERIEI PT 303474.7889 12W ERGEN PKY SURE C210 EVERGREEN. CO B04:19 Nowak: SLMC . MATEY, VIRGINIA C PT 303474.1594 29029 UPPER BEAR CR SURE 2w EVERGREEN. CO 60439 Nowak: SLMC KAISER. KIMBERLY PT 3036704802 294E EYERCEEN PKWY SUITE 300 EVERGREEN. CO 00439 Nowak: SLMC KUPFUL VICTOR IT 303-674-IS94 29029 UPPER BEAR CK SUITE 200 EVERGREEN. CO 80439 Nowak: SLMC MCCORO. PATRICIA PT 303674.1594 19029 UPPER BEAR CR SURE 200 EVERGREEN. CO 80439 Nowak: SLMC VOGEL. LANETTE PT 303.670.3594 29029 UPPER BEAR OR -1117E .100 EVERGREEN. CO B0439 •wak: SIAIC PAYER. NORMAN P MO 303 .9029 UPPER BEAR CK EVERGREEN. NM•ak: mmA. SLMC '- MURTHY, KRISHNA C MD 970E1-2370 _ � ZPSYCHtA'TR 1124 E ELIZABETH ST FORTCCLUNS. CO 80524 RDIC7 �'.� " N : FOP, M . NC. SUVIC 11570N, IOHN F MD 303670-0926 /gMwk HMORE ROGER MD 970-E1.1000 17904 MEADOW OR ,II�FELEY, IANET K MO 970.4969526 1100 E ELIZABETH ST FORE COLLINS, CO 80524 {UITE 210 EVERGREEN, CO 80439 i 2001 5 SHIELDS Ne•k: FOP, NC Nowak: PRO FORT COLLINS. CC 80S24 : FOP. NC NOMP. SLMC ROGER G MD 303670.765E ��+ ZiFI •' 1 - 3580 EVERGREEN PKWY 358E EVER rEDANTHAN, PUDUPA%KAM RMDSUITE 205 EVERGREEN. CO 50439 970-221.7370 Nowak: PRO LIZABETH ST FORT COLLINS. CC 80324 OSSER. LEON E CRNA970481-07E : FOP, A4MA, NC SLA4C 241 RIVERSIDE AVE N 20 p FORT COLLINS. CO W324 YCHOtQGY �,'....1 _, A^' LUND, KATHRYN PHD 303-760.2270 UR%HART• DONALD W CRNA 970.484-0722 PO BOX 4165 EVERGREEN. CO 50439 LES9L RICHARD D MO 97048607E 1241 RIVERSIDE AVE Nowak: PRO Np8 . FOP SUITE 200_ FORT COLLINS. CO 50524 CORSOVER• HARRY D PHD 303470.8448, 28427 CLOVER LN EVERGREEN. CO W439 Ne,.ak: PRO HAURWITZ. FRANK O PSYD 303649.8733 3771 EVERGREEN PKWY SUITE 8 EVERGREEN. CO W203 Nowak: PRO WHITESELL RANDY PSYD 303670-3023 29029 UPPER BEAR CREEK SUITE 303 EVERGREEN. CO 80439 AWWork: PRO Ell ' - Q FAUX. CASS MS 303697-4230 3540 EVERGREEN PKWY EVERGREEN. CO 80439 Nv W . AMC OR POLEVOY. IRA S MO 303.5260197 903 WAGON TRAIL EVERGREEN. CO BM39 Nowak: SLMC WILLWAS'IS MD 303474.7694 28000 MEADOW OR SUITE 106 EVERGREEN. CO I10439 No.*&-MMA SLMC OEMSU._ ANL, KATHLEEN I SA 3034IW79% 28SZS EVERGREEN NANO EVERGREEN. GO 00439 Nowak: SLANG WASHWGTON, XH.V1N M DC 7194136-4131 ! 524 CASTELLO FAIRPAY, CO W"O Nowak. SU4C• RUSSELL W MD 970480.07E c FCP ERAETS, RONALD H CRNA 97048"772 1241 RIVERSIDE AVE N. THOMAS DO 970.484-0712 SUITE 200 FORT COLLINS. CO 8OS24 r.FOP N ':FOp IF. MARYLIDA MO 970A84-0722 SKFN, GARY 0 CRNA 970484-07E r. FOP 1241 RIVERSIDE AVE ' SUITE 200 FORT COLLINS. CO 80524 LAN, THOMAS MD 97048607E Nowak: FOP is FC7P ;0L MICHAELA MO 9704"47E I O FOP WFORO, DREG l DC .2105 DUANEK MO 970484-0TE 137E PROSPECT RD FORT COLLINS.SGO CO 80725 k:FOP :SING ME E 1 MO 970-495-0300 N, AVRAM A DC WO.729-006 a FOP 123 E ORAKE RO FORFCOLL04 CO 80525 Si,wIC DL GEORGE E MD 970.49S-0000 It- FOP Y4MF5 M DC M493-8360 1737 E PROSPECT RO FORT COLLINS. CO 00529 ES KATHLFEN A MO 970495-0300 SUVIC k: FOP ULTGREN, GLENN M DC 970223-1 %1 E STFPHEN G MD 970480.07E SLEMAYAVE FORT COLLINS. CO W523 Ie FOP ':SL44C NQ. MARY A MO 97049S-0300 OEPP AARON A OC SIM223-2229 k: FOP 2721 SCOLLEGE AVE SUITE FORTCCVJN'S,COSWZS VILLLAM MO 97048607E . SLMC k: FOP HRT, MELAME 1 DC 970493-0611 E THOMAS MD 970464.0722 92 5 TAFT HILLAO FORT COLLINS. CO 805E t: FCP �� RfZ, CARY MD 970484-0727 BORG. CLMG G DC 9702263797 c FL7P 3373 W DRAKERO FORTCOLLLXLCO80S26 BEM BENT. IULIO D k•F p 97048607E PEER MS 9704R-S700 FORT COLLINS, CO W524 WILLIAM E PHD 9M221.3249 F t 2001 S SHIELDS SLOG FORT COLLINS. C080526 kj I IL JOSEPH E DO 71941364131 Nowadr FOP 624 CASTELLO ST FAIRPLAY. CO 80440 Mte4a+k: SLANG GLSM. LINOA M PT 3034264899 720 W 84TH AVE FEDERAL HEIGHTS. CO BIWI Na4VAr: SLMC WENOL DEBORAH N PT 303-4264M 72D W 84TH AVE FEDERAL HEIGHTS. CO 30221 Nowak: SLMC 16OWNES. THOMAS R MO 9762M4241 1100 E ELIZABETH ST FORT COLD NS CC 80324 FNrl *. FOP O¢WNEA THOMASR MO 97048607E 41 RIVERSIDE AVE SUITE 200 FORT COWNS, C000524 DENNIS C MO 9MIZI.1000 METH ST FORT COLLINS. CO 80524 R7P, NC 4, CARY I MD 9703214241 mETH ST FORT COLONS. CO 30524 IDOVICH, CARL MO 9704U-M RNERSWE AVE 'A FORTCOWNS. GO 80524 ak: AC SOH, ANNEQU MO 970221-3795 E STUART IIZ40 FORFCOLUNS.000052S ak: FOP NFELD. BRUa W MO 9704E2.9001 RNERSIOEAVE A FORT COLLINS. CO E0S24 ak: Am NC RL PAUL MO E ELIZABETH ST • C SUITE I FORT COLONS CO 80524 ak: FOP B LYNN MO wo-221.3795 E STUART ; 3 SUITE 240 FOKrCOLLM. CO 80525 Prk- FOP 6TON. PHILIPS MD 97""000 LEMIAY AVE FORT COLLINS. CO 80524 ak: SLMC BUGLEWIC7 IOHN V MO 719.7644816 BEN' WRY I MD 97048607E f`IPDEGRAEF• 1EFFREY G MD 970.49S-8000 507 w STN 5T FIORENCE CO 01 E6In 241 RNERAOE AVE 102. LEMAY AVE FORT COLLINS. CO $0524 Sal W S: H S SUITE 200 FOE COLLINS. CO 80524 Ne14ak; SLMC Ne. *. FOP MCGARRY. IOSEPH T .MD 719.7844816 LIER, WILLIAM E MD 9702714241 501 W 5TH 5T FLORENCE• CO 31226 I00 E ELIZABETH 5T NeWak: PCP SURE 1 FORT COLLINS. CO 80524 Nemak: FOP • • • WILLIAM E MO 97046407E 241 RIVERSIDE AVE utFRc L� SURE 200 FORT COLLINS. CO 80324 CONLON, ROBERTM .MO 9704846373 t032 LUKE ST FORT COWNS. CO 80524 c: POP CULVER'. WILLIAM G .MD 970496.9226 "a' S SHIELDS :ORT COLLINS, CO 80526 et FC/P. C. NG4W. SLMC LASZLO, DANIEL I MO 970498+9226 2001 S SHIELDS `OKT COLLINS. CO $0526 N((wa/: FOP Nc. NCMP TODD 8 MO 970E1.1000 ABETH ST FORT COWNS. CO 80524 ALLEN, THOMASI MD 9MZ21.339S 2160 W DRAKE RO FORT COLLINS. CO 80525 .Ne . NcMP 4LEY AUSTIN MD 970495-SM 1075 PENNOCK PL FORT COLLINS. CO 8CS24 N//N . FOP MIND L EDWARD MD 97048E-2791 1212E ELIZABETH ST FORT COLLINS. CO 80524 No . FC7P WH/TTSITT. TOOD MO 170-221.IOW LIERMINCHAM. ROGER MO 97049S-8800 1148 E ELIZABETH ST FORT COLLINS. CO 80524 11025 PENNOCK PL FORT COLLINS. CO 00524 Nowak:FOP Nowak:FOP 7 52 SLOANS LAKE MANAGEO CARE i CONTACT YOUR HEALTH PLAN/BENEFITS OFFICE la VERIFY COVERAGE OF YOUR CHOSEN PROVIDE V _ fall 1997 FORT COLLINS - FORT COLLINS _ EVRIVG THOMAS E MO 970.484.1757 ENG. IENNIFER MO 970225•t600 OMRURG, ROBERT MO 9702249505 V - G 1221 E ELIZABETH 1330 OAKRIOGE DR FCR COLLINS. CO 8aS2S 1100 POUORE RIVER OR FORT COLLINS. CO $0524 SUITE4 : SLMC FORT COLLINS. CO BOS24 FCIP : FOP BROMAN. STEVEN O MO 970484.1757 LLEY.�GEORGE MO 970-221.22" OMBURG. ROBERT C MD 976N4-0722 l I21 E EUTABE04 ST fVJt;. THOMAS E MO 970221-S253 TOM LUXE 5T FORT CCLLWS. CO 8OS24 1241 RIVERSIDE AVE SUITE 4 FORT COLUNS. CO 80524 2001 5 SHIELDS N FOP SUITE 200 FORT GOWNS. CO 80582 ^ Newak'SIMC SLOG •SONG' FORT COLLINS CO 80526 ANFAROWE CYNTHIA K MD 970221.58S8 N FOP / SURNHAM. UNDA MD 970.482.3500 1014 CENTRE AVE FORT COLLINS, CO BOS25 OHNSON, RICHARD MO 970484.34% 1317 E ELTUBFTH ST N, MERUN MD 970482-fi656 N : NC FOP 1250 DOCTORS LN FORT COLLINS. CO $0524 SLOG 13� FORT COLLINS. CC 80524 101 S ROBERTSON FORT COLLINS. CO 50324 N : FOP NC F2Wt FCIP NC SKITTLE DEBORAH A MO 970-223.OUG I I I I OAK RIDGE OR FORT COLLINS. CO 80525 PELWILLIAM MO 970-221-3782 URLSON, H G MD 9704R2-0213NGHI, DAVID R MD 97P484.0712 N ; SLMC 1136 E STUART I040 E ELIZABETH 5T ERSIDE SLOG 2 SUITE 140 FORT COLLINS. CO Sam SURER FORT COWNS CO 805240 FORT GOWNS CO 80524 OONAIDR MD 970484.1757 ;FOP A/emoAt: FOP FOP. NC 1221 E ELIZABETH ST SUITE 4 FORT COLLINS. CD 80574 YNCH, MICHAEL I DO 970224.95% ✓CARROLL. CORY O MO 970221.5858NGHL DAVID R MD 970.221.38SS • SLMC � p RIVER OR FORT COLLINS. CO $0524 IOt4CENTREAVENUE FORT COLLINS. CO$0526HIELDSNeMotk-FOP. NC G L FORT COLLINS. CO 80525 EMM, STEPHEN MD 970�82.2791. POP. NC 1212 E ELIZABETH ST FORT COLLINS, CO 80S24 W, CATHY L MO 9704W3712 ✓CARSON, FRANK MO 970221.2290 Nenwk: FOP 1120 ELIZABETH ST 1006 LUKE ST FOKTCOLLWSC08M24 AOOACK.MICHAEL MO 970.49S-8800 BLOC FORT COLLINS, CO 00524 FOP t02S PENNOCK PL FCRT COLLINS. CO 80524 MANNp t4 L RmL R FOR NC Nowak. FOP CODD, RICHARD MD 970.482402 W, CATHY L MO 97G48b722 1217 E EUMEIH ST FORTCOLUNLCO80S2a ULSEN, MARKM MO 970-YF1757 OLLANO. ROD MD 9704M•977] 12470.1VE0.510E AVE - FOP 1221 E ELIZABETH ST 1212 E ELIZABETH ST FORT COLLINS. CO 80524 SUITE 200 FORT COLUMS, CO 80524 SUITE 4 FORT COLLINS, CO SOS24 • FOP : fOP' NC COLONS. THOMAS MD 970.69}2776 : SLA4C 1120 E ELIZABETH 5T IOSBH MD 970.454.97T3 S, ARTHUR MO 970424I66i SLOG G SURE I FORT COLLINS, CO 8N24 CCARO, IOHN C MO 970.495.8800 1212 E ELIZABETH ST FORT COLLINS. CO W524 1021 ROBERTSON FORT COLLINS. CO W524 /�ewu�lrSlMC IOIS PENS RACE FORT COLLINS. CO W524 . KIP . FOP V CRANOR.10 MO 970d84.0798 WEE H P MO 97046F97TS INWTE DANA A 00 970.48"7% 1117 E ELIZABETH ST KE I OBERT H MO 970-2214433 1212 E ELIZABETH ST FORT COWNS. CO 80324 040 E EUZASETH ST SURE 10 FORT COLLINS. CO SITIM HIM E Eta FORT COLONS CO W524 . FOP SUITE1� FORT COLLINS. CO WS24 N**AWa AW, NC MMONS, ROBERT MO 97W8"773 NC V DEYOUNG. DOUGIAS B DO 970.412.2791 DHAISKY, TP40THY P MO 970484.1TS7 12 ELF ST FORT COLLINS. CO 805N 1212 E ECQA8ETF4 5T FORT COLLINS, CO 8024 1321 E ELIZABETH ST FOP SUITE 4 FORT COLLINS. CO 80582 AFaw.ark: SLMC SCOCK, MARK E LCSW 970.4"-6667 DUFFER. HAROLO MO 970.48T•0666 .. 1049 ROBERTSON FORT COLLINS. GO W525 7 1 ROBHARON FORT COLLINS. CO W52/ OTMAN. MARK F MO 970231.32SS Netwd3r. PRO FOP 2001 S SHOLD$ CHUS, NELSON MD 970.493435] SLOG I FORT COLLINS. CO 80526 ION E R 17ABETH FORT GOWNS. C0 00524 NES USA LCSW 970-4984934 FERGUSON, DAW0 MO 970.49S-BB00 Nenwrk SLAK FOP 2361 F PROSPECT RO FORTCOLUNS• CO 8052S 7015 PENNOCKR FORT COLLINS. GO 80$2/ '�`O1~� FOP RIGHT ION MD 97DAW17S7 KELVIN F MD 970-493.7442 Ill E ELIZABEfH 1106 E PROSPECT RD FORT COLLINS. GO 80525 OCOUGHLAN, ROGER LCSW 970.4845953 PRIX JACQUELINE C MD 970K9.2849 SUITE 4 FORT COLLINS, GO 80514 Ntlwale FCBS NC SDI REMINGTON FORT COLLINS. GO 80524 PRO 700A40UNTAw FQSTCOLLW5. C080511 SIMC AWwvh: NOW GFIL ION MD 970121.52SS 1014 C04TFRJAMB ESL LCSW 970.4%•9045 /G94W. MARGOI MO 970-US-1600 2WI SSHIELOS 13700N� FOR FORT GOWNS. CO W52S SWC I SW FORT CCLLWS. 00 NS26 11]6 E STUA L MO 97022t-2827 BLDG E 5� 20 FORT COLLINS. CO W526 SURE 4.104 FOSTCOWNSCOW525 '.RAY, AMUI K MO 9702214m SCOTT MO 970-484.4798 Noma* FOP UNV, STEPNOd ICSW 970493�692 1001 S A/4fL05 1217 F LLILLB H ST 2362E PROSPECT RO FORT COLONS, CO S025 BLKIOWOL POST COUPLE. CO 80523 SURE 10 FORT COWNS. CO 80S24 i 1 �P� NrwabFOP NC I WL/ARAA LCSW 97622-nu ✓HUARHREY. ROBW MO 970.221�410 ON, TAMES F MO 970221.IBSS MICHAR MO 970-4974127 323 WHWOR FORT COLLINS. CO W924 t301 RIVERSIDE AVE FOSTCOLLP8. CO 8052/1240 N4Iwa -FOP IU LD94C L � FORT COLLINS, 00 WW SUITE MO W FORTCOWNS. CA 60324 40 AC P mmK *. FOP, OP RM LaW 97049S-18S3 JINICH, DANIEL MO 970d84.1737 503 REAYNGION FORTCOLLIM,C080524 4221 E ELOASETH ST DEN, DIVA 5 MO 970-221-3395 ILL CLINTON F MO 9704934137 PRO SUITE 4 Sln4C FCKRCOLLWS CO 8BSI4 1N 0 W D�RO FORT COLLINS. GO 80526 1240 DOCTORS W FORT COLLINS. GO W324 Nsn k FCP IOHN H LCSW 97049S46B9 2362 E PROSPECT RC FORT COLONS CO 60525 IWICH..DANIEL8 MO 9704M•44% JEROME1 MD 9702A9800 •PRO 2561 S SHIELDS AVE 025 SIGkIORN OR fOST COILINS, CO W523 ' F, ME k H LCSW 97049t-L932 SURFS FORT COLUNL CO 8026LAAC SUMAC OTT WHO T MD 970-"34]]7 61 F PRO Cf RO FORT' COLLINS. CO 50525 TAMES A MO 970.686.1757 1240 DOCTORS W /INS@IBBIG. THOMAS P MO 970221•SS9S 1221E EU2ABFM ST SUM! 200 FORT COLLINS. CO 114 R08EKT M LCSW 970221.2582 Y 21fi0 W DRAKE NO FORT CCLUNS. CO 80326 SUN 4 FORT COLLINS. CO SCS24 Nowak: FOP 1006 ROBERTSON A4Kw1Ae NOAP SUITE 205A FORT COLLINS. CO 60524 _ /KAUFFMAN. IEFFREY MO 97M640798 INS. FLOYD V MO 97W84.1757 5'D FRO 1217 F DJZA51TH 5T 221E ELIZABETH ST FORT COWNS. 00 ON24 D. IUUA S LCSW 9702 -wa SUITE 10 FORT COILIW CO 8024 Nowak: SIMC OAVI0 K MO 970-2244429 760 WHALERS WAY Nowak: FOP NC 1247 RIVERSIDE AVE A•100 FOSTCOLLIN5. C060525 OARO, ANDREW MO 97$48"798 SUITE FORT COLLINS. CO 8OS24 A"Ito ePAO KUROIWA, CHRISTINA MO 9704934M 1217E wk: ELIZABETH ST NaFOP 114 BRISRECONE OR FORT COWNS CO 50524 SUITE 10 FORT COLLINS. CO W524 Newalo FOP N4lwak: FOR AC /LOPM IOSEPH MO 970-221.5923 WVAN. DONNA MO 970d9S-0800 ORON.7fEryER.RO8W5lMFT970.482-eSE7 YYY t13fi ES1UART I025 RNNOCKR FORT CCLUNS. CO WW2/ EY.OAVID MD 97WR•2572 109WOUVE Si FORT COLLINS. CO e052t SURE 4202 FORT COLLINS. CO 80525 . FOP 1100 POUORE RIVER OR FORT COLLINS. CO 80524 PRO Nelwak: FCIP PCP RAILSHIVALI F T COLLINS.CO W325970 /MACDOINLO. NOLA A DO 970.229AS00 1014 CENTIIE AVE FORT GNS. CO 8031! LESSL GRACE MD 970-481.3712 137 (OVER OR 5 LNI•T COLLINS. S26 r 2 SKO40RN OR FORT COLLINS. CO 80525 : FCP I I IO E ELIUBETH 2137 k. PR 0R FORT COIUNS. C000 60526 SIMC BLOC F SUITE 10t FORT COLLINS. CO 80524 Newwrk: PRO IFMAN, WILUAM I MO 970484.7145 Now4rt: FOP HEN. RARBARA IMFT 9702T1-0582 MALY, TIMOTHY I MO 97022S-1600 1217 E ELIZABETH ST FORT COLLINS. CO WS24 41 5 COLLEGE AVE FORT COLONS. CO -0582 1330 OAKRIOGE OR FORT CCLLWS. CO 80525 :FOP UM.DAV10 MO 970.454•I4% ,PRO FOP, NC 1260 DOCTORS LN FORT COLLINS. CO 80524 ' IESZEN. MILFORD MO 9701241S96 NelwaFt: FOp MERCER. JEANNETTE MD 970.4ST•2791 61I EELIZASETH FORT COLLINS. GO 80526 IGL70. MICHAEL LV1FT 970121-0582 , EEL12A'ETHST FORT COLLINS. CO SM24 FOP. NC SH, TAMES MD 97M84d406 ni'LLEGE AVE N4Mak: FCTP 1021 LUKE ST FORT COLLINS. CO 8OS24 SUITE 2 FORT COLLINS. CO B052s / ORSON. STEL'EN MD 970-M -2791 N : FCP NC N�wakPRO /MERKEL IAWRfNCE MD 970221.1290 1212 E ELIZABETH 5T FORT COLLINS. CO B0524 VVV 1006 LUKE ST FORT COLLINS. CO 80S24 NeMak: FOP W5. ROBERT MO 97022"508 AGIFIELD. PAUL LMFT 970.4844608 yyyeMawwhkk FOP 1100 POUORE RIVER OR FORT CCLLWS. CO 80524 ISM 5 COLLEGE AVE FORT COLLINS. CO 8052A PHN, STEVEN 8 MO 970-229.9800 N FOP ' PRO MURPHY. LAW RENCE E MO 97022l-0040 2025 EICHORN DRIVE FORT COLLINS. CO 80M 1113 OAK RIDGE DR FORT COLLINS. CO 80585 N : SLh1C RAF. PAULA MO 970484-0080 GORE KANDY LMFT 9704934006 N : RID 1337 RIVERSIDE AVE 1302 S SHIELDS DWBIN. MICHAELbt MD 970225-0040 5UITE I FORT COLLINS. CC 80524 SURE Ala FORTCOLLINS. CO 80521 1URPHY. LAWRENCE E MO 970.484.1757 1113 OAK RIDGE DR FORT COLUNS. CO 80525 I NeY.M/x: FCIP PRO ELIZABETH ST Nenrdr. AMC SUITE 4 FORT COLLINS. CO 80524 New :SLMC 8 FORT COLLINS - FORT COLLINS Fail 1997 :ONWAY. MARGARET CNM 970493.7442 `QNERS-DENNISON, MARY E OT 970.225.1990 106 E PROSPECT RD FORT COLLINS. CO 8052E 330 OAKMOCE OR furl : KIP SUT1E 100 - _ FORT COLLINS. CO 80525 REDERlCKS. PATRICIA CNM 97049}7442 706 E PROSPECT RO FORT COLLINS. CO 80325 RS-DENN. ,/ROBERTSON, MARY LMFT TM416.1918 19 OLD TOWN SO FORT COLLINS, CO BOS24 PRO 1 ; FOP WATSON, M CATHERINE MS 9704844608 15205 COLLEGE AVE i E PROSPECT IU 3 FORT COLLINS, CO 80524 .: KIP N PRO RAKAUER, KAROL CNM 970493-7442 WETZEL. BARBARA MS, LMFT 97049S•1068 1106 E PROSPECT RD FORTCOLUNS. CO $0525 327 S WHITCOMB Sr FORT COLLINS. CO 80521 N : FC Netumk. PRO ORENTLEN. SHEILA CNM 970493-1663 1006 R08ERTSON ' RAPT SURE A FORT COLLINS, CO 80524 KlP LEE, lANOA CMT 970498450Z 1190 NIAGARA OR ARCING. OMN CNM 97049}786$ SUITE IS FORT COLLINS. CO a0.525 1006 ROBERTSON N : SLMC SUITE A FORT COLLINS. CO 80324 FOP ORCIJR, EDWARD MT 970493-0971 502 PETERSON BY FORT COWNS. CO 80521 ILSON-ENRIQUEZ TERRIE GYM Neewmlr SLMC 970493-M77 1224 E ELIZABETH ST FORT COLLINS. CO W524 mmM *.FOP XILL • A I3R IENSEN.OLET 005 970-N881% • B IC4 _�. 2001 5 SHIELDS SLOG I FORT COLONS. CO 80526 CHUS. KEVIN MD - 970-493-63S3 Nw MMA SLMC Tow E ELIZABETH FORT COLLINS. CO 80524 SUTIE 100 USEY, GTHFRINEA GYM 97049}T442 N�FOP 106 PR PE RD FORT COLLINS. CO 86525 E ". • APR, LAURIE D MO M223-350 3000 5 COLLEGE SUITE 210 FORT COLLINS. CO 8052S PHILIP I MS, LPC 9m224.04R2 ,AOLDUG 141 SCOLLEGEAVE FORT COLLINS. CO 00524SLA4C NaMom: PRO r3m" / DAVID MO 970-49}5%4 . /FARTS. GARY i LPC,MA 97049Si563 It 6 E STUART 1125COLLEGE SLOG 25UITE 100 FORT COLLW5. C080525 SUITE 200 FORTCOWNS.0080524 :FOP Nert mk-PRO NEUFY. BFVERLY MO 970493.7442 OlE GROLE S LPC 970493.8006 1106 E PROSPECT RD FORT COLLINS. CO WS25 1302 S SNIELOs - FC1P. NC STE A24 FORT COWN5. CO 80321 N&%Wi-PRO O. IONATHANE MO 97049}7442 1106 E PROSPECT RD FORT COWNS CO 110325 ,/K/FM _ MS _ F� NC •t09WCWEST FORT COLONS. C08042 NalNark: PYfO MARK L MO 970493590E tt 36 E STUART AMBLE PATRICIA L MA LPC 970497iK7 BLDC I SUITE 100 FORTCOLLNS. CO HOSTS ION ROBERISON FORT COLLIN5. C.080524 FOP ver.Y *: PRO WARREN MO 97049}7442 MCKlNNEY. MAUREEN M MA LFC 9 O-MS123 106 E PROSPECT RD FORTOOLUNS, CO 80523 N7 W DRAKE RD • FOP NC SUITE 240 FORT COLLINS, CO aU526 N4MaiC PRO RANSYL MO 970-493.7441 1106 E PROSPECT RO FORT COLONS. CO 80525 •fOP. NC EFT, LARRY MO 970493.9904 HAYGOOD, THOMAS MO 970493.7733 I736 E STUART I120 E EUZABELH ST FORT COLLINS. CO 80524 RLDG 2 SUITE 100 FOATCOLLNS, CO awls •POP /NMwmk:FOP /SIMMONS. RIOURD E MO 97049}7733 L11L SUSAN MO 97049}7M2 YYY I1120 E ELIZABETH ST FORE COLONS. CO aM24 1106 E PROSPECT RO FORT COLLINS. CO 80525 Nwwk: FOP : FOP- I< OWIN. GARY MD 970-493-7442 1106 f PROSPECT RD FORT COI INS. CO 66S2S • , • E 1 FOP, NC COESTER MO. FLANS C MD 970-V93.12l2 Nell RIVERSIDE AVE fORT COlLN5. CO 80524 DLL IOHN HACK) 4677 fOP FORT COLLINS,GO 1224 E ELIZABETH ST FORT NS. CO 80521 //Nenak: MO 970493-1292 V'URNELDONN 7313 RIVERSIDE AVE FORT COLLINS, a) 80524 IAK. ELIZABETH MO 970223.3329 .vffly r . KIP 3 W S5 COLLEGE AVE 2t0 FORT COLLINS. CO a0525 �WARSON, TAMES MO 970493-1292 : SLMC VVVVVV 171J RIVERSIDE AVE FORT COLLINS. CC 80524 Nelwark: TOP CLIC7f, NORMA I MO 97022E-I600 1330 OAKRIDGE OR FORTCOLUN5.CO80525 /WIR7 TIMOTHY MO 97649}t292 W. NC V 1313 RNERSIOE AVE FORT COWNS.COe0S24 NN .- FOP �7.14.NORMAI MD 970223.332E 000 5 COLLEGE SLATE 210 FORT COLLINS, CO W525 . EUROLOO Fs: I Nwn *. KLP CURIEL MICHAEL P MO 970221.1993 EIGA 1247 RIVERSIDE AVE SUITES 2 & 4 FORT COLLINS. CO 80524 /Nen.mk: KIP INGS. BRENDA K OTR 970223•/990 t7300nKRIDCE OR V/ MONTOSH, CERALD C MO 9704024373 SUITE IW FORTCOLONS.0080523 1247 RIVERSIDE AVE N4Armk: KIP. SLMC SUITES 2 AND 4 FORT COLLINS. CO 30524 NllwarK: FOP UNHINGE. BRENDA K OTR 970493-0112 e00 E PROSPECT RD FORT COLONS. CD $0525 'ILLER. TAMARA A MO 9704824373 1 N :FOP. SLAOC 247 RIVERSIDE AVE SUITES 2 AND 4 FORT COLLINS. CO 8OS24 MMINGS. BRENDA K OTR 970282-0004 •VeMmk: FOP 407 OAKRIDGE DR SUITE Ioa FORT COLLINS. CO B0525 Nen.alr: FCIP. SLMC i IVURSE/MIOWIE ESTER. ROSANNA OTR 970-t97.1170 1136 E MART BOTTONE-POST. CAROLYN CNM 970223.3525 3000 5 COLLEGE AVE SUITE 4.106 FORT COLLINS. CO 80525 SUITE 210 FORT COLLINS. CO B052S Neon: KIP ,V M .: FOP I 4. MARY E OT 970493-0161 RO FORT COLLINS. CO 30525 i OENNISON, MARY E OT 970281-00M WRIOGE DR 100 FORT COLLINS. CO 80523 AC FOP kCH, SUSAN C OTR 97(493-"67 '.OBERTSON FORT COLLINS. CO 8GS24 M OTR 970,493.6667 ON FORT COW NS, CO 8GS24 JOWELL. ROBYN M OTR 970.225-T9% 330 OAKRIOCE OR SUITE TOO FORT COLLINS. CO 80523 WEl).FOP. SLMC . ROBYN M OTR 970.493.0161 2500 E PROSPECT RD SU IT FORT COLLINS. CO 80525 -: FOP, SIMC WELL ROBYN M OTR 970282-0004 1 GAKRIOGE OR SUITE 100 FORT COWNS, C080525 N40.mk: FCLP, SLMC KRA IOALL WENDY G OTR 970482-0521 1200E ELIZABETH ST SUM A FORT COLLINS. GO 60524 N~*.-SLMC D, DOUGLAS W MD 970-493-0112 E PROSPER RO FORT COLUNS, CO 80525 Irk: FOP, SLMC FENS, STEVEN D MD 970493-0112 E PROSPECT RD FORT COLLINS. CO 80525 Irk. SLMC ISCHUIL SARAH H MO 970493-0112 E PROSPECT RD FORT COLLINS. CO 80ZS2 Irk: SLMC NEIL E I MD 970-221-1919 5 SHIELDS FORT COLLINS. C06a526 2A_ FOP CAN, KENNETH H MD 970493-0112 E PROSPECT RO FORT COLLINS, CO BOS24 Pk: SLMC A LEE MO 970-493-0112 E PROSPECT RD FORT COLLINS. CO 90525 Irk: AMC S7MAN, TAMES K MO 970493-0112 EPRt� RD FORT COLLINS, C080S25 ISON, ROBERT V MO 970493-0112 E PROSPECT RD FORT COLLINS. CO 80525 wk.. SLAIC R, DALE C MO 970493-0112 E PROSPECT RD FORT COLLINS;, CO W525 SFATEE KIRK MO 970493-011I E PROSPECT RD FORT COLUNS. CO 6052S I k: SLMC 113L SALLY MD 970224-9890 E STUART 3 Sulk 100 FORT COLUm c0 m2s 0�02 .bUGSAMFN, BENEDICY F MD 970493-0112 RSCHKE IR ROBERT F MO 970.493IM722200EPROSPECT RO FORT COLLINS. CO 80525 1240 DOCTORS LN N SLMC SUITE 200 MM.mk: fOP FORT COLLINS, CO 80524 N, DALE R MD 970493-0112 I PFOP,CT Ro SW E PROSPECT RO FORT COLLINS. CJ 60525 N411, ommmm • T - I .MARKA MD 97049341112 13ANTI5, DLWA MO 970.4H60000 EPROSPECT RO FORFCOWNS• CO W525 20015 SHIELDS N BLOC ASUITE8 AknM *: A4MA. SLMC FORT COLLINS. Co 80526 URRAY, DOUGIAS MD 970495-0112 OO E PROSPECT' RO FORE COLLINS. CO W524 GARTHC MD 970-493.2102 OE RT S MD -5322 0201uREsT FORT COLLINS. CO 00524 N4Krwk; POP N ROBERTSON A � FORTP6. CO 80324 COLLINS.CC KENNETH A MO 970-Zn.1919 NAUEL ROBERT W MO 970-y8-0000 15 SMELDS lOG 1 FORT COLLINS. CO Ewa 5 SHIELDS k �A SURE B FORT COL INS CC 86526 AMM BB, ROG� MD 9704n4172 ER. GARY I MD 970464-S322 SOO E PROSPECT RO FORT COLLINS. CO 80525 ROBERTSON FORT COLLINS. CO 60524 Nerwmk. FCIP, SL 4C ° - FOP ROCCI V MD 970493-0112 MONO. RICHARD MO 970484.53a �MPE.R. 00 E PROSPECT RO FORT COLLwS. CO 80525 �� S� ROBERTSON FORT COLLINS. CO 80524 . ERICI MO 970.221.1919 L ROBERT A MO y�B,�B I S SNIELOS BLOGL FORT COLLINS. CO 80526 ' 55HIELDS Ner-od: fop reh: SUITEFORT COLLINS. CO WS26 AVAAMC R15. ANDREW M MD 970224.7020 V GOL GARFIELD FORT COLLINS. CO BOS24 IUk: FOP. AC CHRISTOPHER M MO 970.g-1177 201 ELIZABETH Sr N. GERALD MO 970484.5322 lOG F SURE 101 FORT COLLINS. CO W524 NH1.mk1 FOE NC NGHP ROBERTSON FORT COLLNS. CO 80524 0*: FCIP 1 RY,MARK MD 970-493-5334 NSON. MATTHEW i MD 970484.5322 36 E STUART BLOC 3 SURE 3200 FORT COLLINS. CO 30523 ROBERTSON FORT COLL:NS. CO 80524 NeMmre FOP, NC Irk: FOP NTMAN, WILLIAM A MO 970484•S372 R AN, BRAD MO 970-221.1177 0 E ELIZABETH ST ROBERTSON FORT COLLINS, CO 80524 Irk: RT LDG F SUITE 101 FORT COLL04S CC W524 N4'Mmt FOP• NC; NCVIP 4. RANDALL W MO 970221.2222 F EU7ABEfH 5T ITH, RRUCFM MD FORT COLLINS. CO 80521 070 LUKE ST FORT COLLINS. CC W5324 N.n.am fnP Nr SPEVENS, WILLIAM MO 970-221.7222 _ LA I�;y:.• TI24 E ELIZABETH ST - BLDG C FORT COLLINS. CC $0521 RD. DONALD Y MO 970442.2515 FOP 1200 E ELIZABETH 5T FORT COLLINS. CO W524 ORNTON, WILLIAM R MD 370484-0722 �C 241 RIVERSIDE AVE SUITE 200 FORT COLUN5. CC 80524 8 .RICHARD MO 97048/-M71 ,v :FOP I S SF41EL05 10RNTON. BLOC G FORT COLLINS. CC 30526 WILLIAM R MO 4-0.ypq,0�FtJF. KfP ` 001 5 SHIELDS SUSAN SUSAH BLOC A SUITE B FORT COlLINS. CO 80526 MO 970482.2575 Neelwr4: K1P S7 FORT COILINf, CO Ba5'4 SL - N G • 6 CONTACTYOUR HEALTH PLANIUNEFITSOFHCETOVERLFVCOVfRAG • • SLOANS LAKE MANAGED CARE 1355 S. Colorado Blvd. Suite 902 • Denver, Colorado 80222 •303/691-2200 A REQUEST FOR INFORMATION Prepared for: The Citv of Fort Collins Presented by: Sloans Lake Managed Care July, 98 4. How many primary care physicians do you directly contract with in the Plan's service area? How many specialists? Please enclose a copy of your directory, including any mental health/substance abuse providers. Sloans Lake Managed Care has 171 Primary Care Physicians and 433 Specialists in Larimer county. Please see Attachment F- Provider Directory. 5. Are there any specific areas of care which would not be available from your organization's contracted physicians? If so, which ones? What provisions are made for patients requiring these services? Sloans Lake Managed Care's network is comprised of providers that can treat a full -range of conditions in -network and will go out -of -network if needed to provide the best possible care. 6. Do physicians pay a membership fee to the managed care provider? If so, how much is the fee and how often is it charged? Most Sloans Lake Managed Care providers pay a yearly fee of $175 to participate in the Sloans Lake network. 7. Does your physician contract require they utilize a network lab for all or certain lab procedures? If so, please detail this requirement and the specifics of the lab contract. Sloans Lake Managed Care contracts with Clinical Labs of Colorado and does require providers to utilize their services. 8. Please provide a copy of your physician contract and physician office manual. Sloans Lake Managed Care is unable to provide due to the proprietary nature however, would be agreeable to confirm any particular clause the City of Fort Collins may be interested in. 9. What ratio of physicians to participants do you maintain? What is the ratio currently in Larimer county? Sloans Lake Managed Care's ratio of participants to physicians is 18:1 for Larimer County and Colorado. 10. Please describe the professional liability insurance arrangement your organization maintains with respect to participating physicians. Sloans Lake Managed Care 11 City of Fort Collins July, 98 Fall 1997 FORT COLLINS - FORT COLLINS M Fr•E)i-Mi�. LER. BARBARA FT 1236 E ELIZABETH 5T 970.221.2942 DNS, WANDA PT 970-221.2942 136 E ELIZABETH ULTE. ROBERT C OPM 970.493.4660 -Of�ITIi U SUITE I FORT COLLWS. CO e051t ST. COLLINS, 2001 5 SHIELDS P S Nowak - FOP FORT CO SO524 SLOG F FORT COLLINS. CO 805:5 FCTP EWOTC MAX MO 970482.3515 1200 E ELIZABETH ST FORT COLLINS. CO 80524 NOY, sum IT 970484.2219 KOLOSKI. LEONARD PF 970-223.3717 HO61A5, MICHAEL I DPM 9704844620 Nowak SEMC 1140 E ELIZABETH 5T FORT COLLINS. CO 80524 It 48 E ELIZABETH ST FORT COLLINS, CO $0524 1353 RIVERSIOE AVE /,lion MAX A MD 970484-0722 Nowak FOP Newark. FOP SUITE C FORT COLONS. CO 8052� Nowak. FOP 1241 WVERAOE AVE NDY. BETH PT 970.4842219 OLOSXI. LEONARD PT 970.22}3713 i SURE 200 FORT COLLINS, CO 80S14 41 S E Z*01! FORT COLLINS. CO 80525 449 RIVERSIDE OR FORT COLLINS. CO $0525 EWARTHA, WILLIAM OPM 970-493-"W Nowak: SLMC Newark: FCTP Nowak: FLIP 001 5 SHIELDS FORT COLLINS. CO 80526 rOLUIL DANIEL MD 970 484.917S NO, TRAVIS O rt 970-493-0161 KOLOSKI, LEONARD PT 970-223.3713 Nowak. FOP 1260 DOCTORS LN FORT COLLINS. CO 80524 25M E PROSPECT RD 1 S E MONROE FORT COWNS. CO 8052S FOR. NC SUITE 100 FORT COLLINS. CO 80SI5 Newrk: FOP Ntlwak: FOP GUENTHER, IOHN P MD 970482.2515 OUT, ROBERT 0 rt 170414,1694 BARRY MO 970.226-0222 1200 E ELIZABETH ST FORT COLLINS. CO 80514 O. TRAM$ D rt 970.202-0004 55S A S SHIELDS FORT COWNS. CO 80526 625 TICONOEROCA OR FORT COLLINS. CO 50525 N : SLMC 90t OAKWOGE DR Nowak FOP Nowak: PRO SUITE 100 FORT COLLINS, CO II0.525 N, VAUGHN W MO 970.482.2S75 Newark FOP ER, MICHAEL D PT 970.225.1990 B WNING, TAMES MO 970.223.1609 1200 E ELIZABETH ST FORT COLLINS. CO W524 30 OAKRIOCE OR 5 E HORSETOOTH RD NKMak: SLMC ON, CANOACE R PT 970.221.2328 SUITE 100 FORT COLLINS. CO 80S25 BLDG 1. SUITE 20] FORT COLLINS. DO 805Z5 21 PEFERSON Newmark: FOR SLMC Nowak PRO pHN50N, LEE MO 970-41 71 SUITES FORT COLLINS. CO 80324 I001 S SHIElOS Newark: FOP ER. MICHAEL O rt 970493-0112 1 ES. WILLIMI Mp 97p.Ly}3p4p BLDG G FORT COLLINS, CO 50526 00 E PROSPECT RD 5 SHIELDS Nowak. FOP SHARON FT 970-224.9145 SURE 100 FORT COLLINS. CO 80525 UITE AZ-t FORT COLLINS. CO 60531 00t 5 SHIELDS Newark. FCIP SLMC Nowak: PRO AGINN15, JAMESG MO 970402-2313 BWGK FORT COLLINS. CO 80526 on 300 E ELIZABETH ST FORT COWNS. CO 80524 Newark, FOP TIJANER. MICHAEL 0 PT 970.282.0004 .TAME$ MD 970.227.5/25 Newark: SLMC I OAKRIOCE OR 43 W DRAKE RO 0. OEBORAH U PT 970.484-221 SUITE IOU FORTCOLUNS. CO 80523 UITE 140 FORT CIXONS. CO 80516 NIL IAk4E5 f. MO 970484-0722 148E EU2A8EM 5T FORT COLUNL CO W524 Newaak: FOP. SLMC Nenwvk: PRO 241 RIVERSIDE AVE sawak: FOP STATE 200 FORT CCUUNS. CO $0524 St15AN PT 97a2M.2942 ER91• WIl11AM R MO 970.223.1293 . Nowak. SLMCTAMINY Rrt 91049t-93/0 36 E ELQABEfH ST 75 E NORSETOOTH RO 21 S E CUR 58 FORT COLONS. CO SOS24 SMITE I FORT COLLINS. CO 80524 LOG 2.201 FORT COLLINS, CO 80325 LAN E MO 970482.2515 Nowak FOP Nowak. FLIP Nark. PRO )AEY. 2CW E =GETFI ST FORT COLONS CO W524 Nehm*SA1C ET, MAUD PT 970.22S-1990 WIJ60N, CATHRYN A PT 970.221.2942 RICHARD MD 970.221-0077 48(1WVAN. WIWAMI MO 970484.2515 OMKRIDGE OR ITE 100 FORT COLURNI, CO W925 116XUJ6EELIZABETN ST REI FORT GOWNS. CO 80524 17 E ELIZABETH ST 6 FORT COLLINS, CO W324 V 1200 E ELIZABETH ST FORT COLLINS. CO 80524 Nowak FOP. AMC Nowak: SLMC Nowak: PRO Ne twic: SLMC / y'VERSLIN. EIIZABETH A MO II 4844871 M ET, MAUD rt E PROSPER RD 970-493-0112 M IOHN MD 970-490.1404 7 WHALERS WAY 1 S SHIELDS URE 100 FORT COLLINS. CO 805Z5 LOG 8 SUITE 201 FORT COLLINS. CO Bas25 SLOG G FORT COLLINS. CO 80526 Nowak: FOP, SL C` IL KATHLEEN PT 970-M-0521 Nowak: PRO Newdk: FOP 1200E ELIZABETH ST FORTCOWNS, CO B0S24 ECMAUD PT 970d82-0004 NeMa1r32MC 1 OAKRIOGE OR I 1 I too FORrcouua, co e0su , E N AOF 3LHC 1 MARGARETA DO 97049/4330 200/ SHIELDS Sf PAULAM rt 970.221.2942 MICI6LELC PA 970493-0112 Y _ MID 18OS" SU11E 1100 FORT COLLINS. CO 80526 6 f DVABETH ST E PROSPECT RD FORTCOlLWS, CO 80527 1 CORBETT FORTCOLLR45,C0 pP0 Nowak: FOP TEI FORTCOLUNLC080524 N4MakFOP r DEN HOVEN, RAYMOND P MD - 9704934112 Nowak: FOP CHRI ITIANA rt 9fO22S-1990 K DONALD R PA 970493-0112 00 E PROSPECT RD FORT COLLWS. C0 ems 1E PROSPECT RD 300 FORT COLLINS,OaDS25 3300ARW aOR ;FLWROR KENNETHH MD 9704954M Nowak KY SIARC SU11E WW Nowak fCIP. SIA4C FORT COLUNL CO MS35 El, ERT S PA 970497-0112 62 E PROSPECT RE)FORT COLCOLLINS.CO a0SZS 00 E PROSPECT RD FORT COLIAIS. C080523 r. Pro SIE'�L:TtI PY.` CHRISTUNA rt 970-493-0112 AhtAm.SAIC 00 E PROSPECT RD RCIAC CAROL F R 970.225.1990 itD FORT COLL015. CO a0325 1310 OAKRIOGE OR - Nowak. POP. SUWC BRiAN W PHO 97RN82.2S1s Stiff[ 100 N4erkKiP. Or FORT COLLINL CO W525 &0f1y��E PT DR 970.282-0004 8 17 f EL1L18fT1.1N MD 9704178800 I E ELIZMfTli ST FORT COLONS. CO e051t P0O Y. CAROL IF FT9704934161 vF 3500 f PROSPECT RD FORT COLUPIS. CO BOS25 TUITE too Nowmic. FOP. AMC FC911COLUNS.00805u TE7 FORT COLLINS. 0080S24 Nowak FOP Nowak: FOP. sNK POMM R08E I rt 9/0.225•1990 MD 970497.7424 NOY PHO 970.332-0365 y(pCIAY• CAROL F PT AR 970.283.0004 D 20 DAKRIOGE OR 01 1 PR PROSPECT 1701 E PROStRCT FORT COLONS, CO B03I4 SAUCE AVE YA_OIOARRK OR FORT COLLINS. CO W523 UITE 100 Nowak. FOR. SLMC FORTCOLLWS.0080525 Nowak FOP ilo FORT COLLINS. CO BOS39 SUITE t00 Nowak: FOR SA4C RD. EDWARD G MD 970-221.3878 Nowak PRO 970.221.1942 OS. ROBERT I rt E Pt105P"E 97049MI12 148E ELIZABETH St FORT COLLINS. CO 90324 Nowak: FCIP MARIUN PSYD 9f0493.8006 MAUREEN rt 5 SHIELDS � //�EST, I 23i f ELIZABETN ST SOIft I FORT COLUNL CO 90524 UITE 100 Nowak: FOP. SIMC FORT COLLWS, CO 80535 AMY B MO 97"3-744S , UfR A24 FORTCOLLWS. CO 80521 Nowak FOP 01 E PROSPECT FORT COWNS. CO 80524 N4Mak: PRO 5. ROBERT i rt NO WO.202-0064 Nowak: FOP 8 TFI0AIA5 L PHO 9704934667 ES'f. PATRICIA M rt /t9236 E ELIZABETH ST 970321.1942 I pAKR10GF OR URE 100 FORT COLLINS, CO 80S23 CHRISTOPHER .MD 9704934000 17ABETH 1 ROBERTSON TORT COLLINS, CO BOSI4 ; PRO V SUITE 1 FORT COLUNL CO 80524 Nowak FOP. SMC 17 E IS ST Nm.akFOP'SUIT! IAN1T PT IM229.1617 7 FORT CIXUNL CO BOS24 NeMak:POP 8 OLDN PHD 970493A205 STAGY rt 970.225.1990 IB IOLEOALE OR FORTCOWNS.CO80526 1 RNEPSIDEAVE E FORT COLLINS. CO 80324 AKRIOGE OR �k:� PRO ARTS 03 fORT COLLW5.G080535 Newark: FOP RA . IEFFREY rt 970-221.2942 319AL DEBRA F PHO 970-493-920S 6 E ELIZABETH ST DERSON. TAMES C DPM 9704W4620 S RIVERSIDE AVE DEHARL STACY PT 970-2824004 UITE I FORT COLLINS. CO WS24 353 RIVERSIDE AVE OSUFTE E FORT COLLINS. CO $0524 OAKRIOCE OR Nowak.- FOP SLMC SUITE FORTOOWNS.0080524 Notyk PRO .Ml V SUITE 100 FORT COLLINS. CO 80325 Nowak FOP Nowak. FOP _ V RE STEPHEND PT 970461-Z219 WERE,: E EUZABETH 5T FORT COLLINS. CO W524 YCE KRIM OFM 970.22t-0425 $0,NDON. ALLEND PHO 970.223.1293 17�(1 HORSETOOTH RD 11 J' yuKAl1T.5UEM FT OAKRIDGE DR 9MI25-1990 ; FOP "a P000RE RIVER OR FORT COLLINS. CC 8052J Nowak: FOP 1ILD_25TE 201 FORT COLLINS. CO 80525 Nowak -PRO J1330 suite t00 FORT COLLINS. CO W525 5 VER. COZETTE 8 FT 970.223.1990 Neawrt: FOP SLR 30 OAKRIOGE OR RNS.MICHAEL DPM 970.221.0425 LHOUN, ROBERTW PHO 9704914006 SURE 100 FORT COLLINS. CO 80523 100 POUORE RIVER OR FORT COLLINS. CO 605IJ 702 S SHIELDS I ART. SUE M PT 970493-0161 Nowak FLIP Nowak: FLIP /••�. suITEA24 FORT couNs.cDeosl! 2s00EFRO5PECr.Ro SUITE 100 FORT COLLINS. CO 60525 5 ER. COZETTEa 970493-016t K TSEN, CHAD OPM 970.493-L660 No"acPRO Nowak: FOP SLMC E PROSPECT RD 15 SHIELDS DY, STFFHEN E PHD 970498.904S SUE M PT 970.182 0004 UITE 100 Nowak: FOP FORT COLLINS, CO 50525 BUILDING F•I FORT COLLINS. CO$0526 N ; fC/P 24 CENTRE AVE BLOC E SUITE 2W FORT COLLINS. CO 80526 � /4pO(I�KART. Y - OAKRIOCE OR SUITE 100 FORT COLLINS. CO 60523 5 COZETTE 8 rt 970.2R-0004 GA. THOMAS DPM 570-493-/660 PRO velwak: FOP. SLMC I OAKR,OCE OR .001 S SHIELDS RCORAN, TAMES R PHO 970476-9626 L URE 100 FORT COLLINS. CO 80525 BLDG F -CRT COLONS. CO 80526 001 S SHIELDS ST /EOWARDS. SYLVIA 5 PT 970221-0773 nen«vr: fC1P ,von.ark; rCIP BLOC L FORT COLLINS. CO 80526 /// 1325 E PROSPECT RD FORT COLLINS. CO 6052S 'Venwkk: PRO Newar: FLIP OHALLORAN. WILLIAM DPM-0481.36" j 11101 RIVERSIDE AVE FORT COLLINS. 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Collins Top 20 PCP's Reported as of 5/98 PROVIDER NAME ITEPHEN YEMM MD ✓GEORGE VALLEY MD X�IVALINI SUNTHANKAR MD ,,My -FORD THIESZEN MD ICHARD BOOTH MD �OUGLAS DEYOUNG DO �=PH LOPEZ MD , &RY CARROLL MD .&VID ABBEY MD XDWARD BENDER MD XPRIL GRAY MD /I G CARLSON MD ,ATEVEN THORSON MD VbAVID OTTOLENGHI MD ,F OBERT HOMBURG MD JEANNETTE MERCER MD /AALLIAM THIEMAN MD /AUSTIN BAILEY JR MD /)ANA WINGATE DO /6AVID ALLEN MD Page 1 t t I l tt�-t1 ! It I: �j 1 J FMPA00 FM1AO1 9a153 15:21 1998 JUNE 02 PAGE E X P E N 3 E D 1 S T R I B U T 1 0 N 8 Y P R O V I D E R P A 1 0 GROUP 17 CITY OF FORT COLLINS DATE SPAN 97101 TO 97/12 PROVIDER N DAYS RB CHGS BENEFIT ANC CHGS BENEFIT OUT PAT CHGS BENEFIT 'ME CLAIMS ENO CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT X TOT ADDRESS CITY ST ZIP PHONE a-. iiiiii .. _s fii .. --w lfii - �3'..-•. a4-11uas7 PRO BEHAVIORAL HEALTH 553 DEPT 0574 DENVER CO SM63 (303)512-1240 8382405 4-JCLINICAL LABS OF COLORADO 515 PO BOX 46504 DENVER CO 80201 (303)922-2210 84-1178797 ADVANTAGE CLINICAL LABORATORY 420 13952 DENVER WEST PKWY STE 400 GOLDEN CO a0401 (303)271-0484 "47567 2 ✓ MURTHY KRISHNA C MD 274 1124 E ELIZABETH SLOG E FORT COLLINS CO a0524 (303)221-2370 84-0985071 SCHRAM BRIAN L DC fit* 2" 1424 E HORSETOOTH RD STE 3 FORT COLLINS CO BU525 (303)482-4047 e4,6Ts1su ✓ N35 JZNICH DANIEL no I zza 1221 EAST ELIZABETN SUITE 4 FORT COLLINS CO W524 C ) f 90973 BOOTH RICHARD R MD 176 20M 3 SHIELDS BLDG G FORT COLLINS CO 80526 (3037484-4a71 84;VJ47567 3 V YEOANTHAN ► K MD 169 1124 E ELIZABETH BLDG E FORT COLLINS CO 80524 (303)221-2370 84-g732417 1 ✓ YEMM STEPHEN ! NO 151 1212 EAST ELIZABETH ST FORT COLLINS CO aO524 (910)482-2791 84-0592063 3 PIRCH HOWARD NO 143 4200 WEST CONEJOS PL SZ34 DENVER CO 80204 (303)592-7284 """ _��_�11� 8c-yF'2417 2 ✓✓ BENDER EDWARO L MD 136 1212 EAST ELIZABETH STREET FORT COLLINS CO aO524 (3U3)482-2791 84-v 1 HMAASSJ DAMES M DC 126 1337 E PROSPECT ROAD FORT COLLINS CO a0525 (303)49.5-8360 / 84-Ob6=6 1 EARD v/BDONALD Y MO 124 12M E ELIZABETH FORT COLLINS Co 80524 (970)482-2515 1 MPAOO FM1A01 9a153 15:21 1998 JUNE 09 PAGE 2 EXPENSE DISTRIBUTION BY PROVIDER PAID GROUP 1T CITY OF FORT COLLINS ,,YIDtm DATE SPAN 97/01 TO 97/12 0 DAYS RB CHGS BENEFIT AMC CHGS BENEFIT OUT PAT CHGS BENEFIT MANE CLAIMS ERG CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT X TOT ADDRESS CITY ST ZIP PHONE =eaza==c=e=caocv�c=c=ccc.......s.s-c--cocazczss..na:=:sssv:>�aasssr_vsr_arsare=s:s=sssass:=sssasas-�sasrsr_:aesreaas "--aasssra 18i 19841 SAYERS CLINTON / NO 120 1120 EAST ELIZABETH 62 FORT COLLINS CO 80524 (970)484-6303 i 84-�812032 2 ✓ MERKEL LAURENCE A NO 118 1006 LUKE ST FT. COLLINS CO $0524 (303)221-2290 184-0706789 2 LUTTENEGGER THOMAS NO 115 1221 EAST ELIZABETH 83 FORT COLLINS CO =24 (303)490-4193 184 DA10541 ;00 CONLON ROBERT M MD 115 1032 LUKE STREET FORT COLLINS CO M24 (303)484-8686 I B4-OJS2417 4 THORSON STEVEN J NO 114 121Z EAST ELIZABETH STREET FORT COLLINS CO 80524 (303)482-2791 i 84-1209445 1 KRAUSS-MILLER LORI L OC 110 1302 S SNIELOS STE Al-3 FORT COLLINS CO aO521 (303)224-5006 9J32417 3 OEYOUNG DOUGLAS 8 DO 108 1212 EAST ELIZADETN ST FORT COLLINS CO aO524 (303)482-2791 - 84-O?9626MACI 1a SORACI LTNNE MA YrAlR 106 1200 E ELIZABETH FORT COLLINS CO 80524 (303)482-2515 6 17 SULLIVAN WILLIAM MD ttat 105 12M E EL11AGETH FORT COLLINS CO W524 (303)484-2515 84-1j8F6W 9 v/SEELEY JANET MD 101 1808 BOISE AVENUE LOVELAND CO W538 (303)669-6660 84-1209390 MILLER VERN K OC xtfrt 100 3120 REMINGTON ST FT COLLINS CO 80525 (303)223-9993 84-1 3 ALLEN LLEN THOMAS J MD % 2160 WEST DRAKE RD FORT COLLINS CO 80526 (97D)221-5595 8L-1SI 1 IE52EN MILFOAD MD 94 811 E ELIZABETH FORT COLLINS CO 80524 (303)224-1596 2 FMPA00 FM1A01 98133 15:21 1990 JUNE 02 PAGE 3 E X P E N S E D 1 S T R I 8 U T 1 0 N B T P R 0 V 1 0 E R P A I D GROUP : 17 CITY Of FORT COLLINS DATE SPAN 97/01 TO 97112 PROVIDER N DAYS RB CHGS BENEFIT AMC CHGS BENEFIT OUT PAT CHGS BENEFIT NAME CLAIMS ERG CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT % TOT ADDRESS CITY ST ZLP PHONE --sxxxs�sr__sszaaaauea�--s_ssss=exs�ssesaaaaacss--xsxsxxesxsxs=e_siaaaaae�-�sxe �ssssa--s-s_xs---_ __ M 54-1102662 RUSSELL HAL V DC AAA+► 94 200 SOUTH MASON FORT COLLINS CO W524 (30)462-2053 M 84-9679626 4 MCGLNNIS JAMES G NO 93 1200 E ELIZABETH FORT COLLINS CO 80524 (303)482-2515 M 84-1203645 VEST B LYNN MD PC 89 1136 E STUART 93-240 FORT COLLINS CO B0525 (303)221-579S N 1 L74590 ✓/ LYNCH MICNAEL J PRO DO 83 1100 POUDRE RIVER DRIVE FORT COLLINS CO W524 (303)224-9508 M 64-0679626 19 JAN E NO ##t 61 ,/PAISLEY 120D E ELIZABETH FORT COLLINS CO W524 (303)482-2515 N 84-0706789 11 LOSASSO CARL RD 81 1221 E ELIZABETH 03 FORT COLLINS CO W524 C ) N 54-Q732417 5 MERCER JEANETTE RD 81 1212 E ELIZABETH STREET FORT COLLINS CO 80524 (303)482-2791 N 84-967%26 22 HAHSON VAUGHN V NO 79 1200 E ELIZABETH FORT COLLINS CO W524 (970)482-2515 M 94-0y79626 3 v/ELLIOTT MAX A NO ltt! 79 1200 E ELIZABETH FORT COLLINS CO W524 (303)482-2515 M 84-92 ✓ JEFFRE JEFFREY RANSY L MD 79 110E E PROSPECT FORT COLLINS CO 80525 (303)493-7442 M 8h ZUJ645 2 �HULTSCH ANNE-LISE A MD 76 1136 E STUART STE 3-240 FORT COLLINS CO W523 (970)221-5795 M 84-0688325 1 ✓/ ONEILL JONN J MD 75 1224 E ELIZABETH FORT COLLINS CO 80524 (303)493-6677 M 84-0706789 12 PLORANT TRACY MD 75 1221 E ELIZABETH NO 3 FT COLLINS CO 80524 (9T0)484-4757 K MPA00 FM1AO1 98153 15:21 1998 JUNE 02 PAGE 4 EXPENSE D 1 3 T R 1 8 U T 1 0 N BY PROVIDER P A 1 0 GROUP : 17 CITY OF FORT COLLINS DAIS SPAN 97/01 TO 97/12 PROVIDER M DAYS RB CMGs BENEFIT AMC CH03 BENEFIT OUT PAT CH63 BENEFIT NAME CLAIMS ENO CHGS BENE►IT TOTAL CH03 TOTAL BENEFIT X TOT ADDRESS CITY ST ZIP PHONE assxxvs+-z_Y_ pp O=ate CCuuuww�uwuwvs.xs__=sxaxxaszaznsxazszzxnsxaasasszzassazazxxasaaxzsxasaxxnxrsxxxaaarm i 791312 11 NEVRIVY THOMAS E ND 75 1221 EAST ELIZABETH STREET SUITE 4 FORT COLLINS CO W524 (303)484-1757 i "59607 1 ✓ BURNHAM LINDA NO 71 1217 E ELIZABETH R3 FT COLLINS CO 80524 (303)482-3500 84-909M 1 KIEFT LARRY 0 NO 71 1136 E STUART 82-100 FORT COLLINS Co W525 (970)493-5904 84-1012032 4 ARSON FRANK NO 71 1006 LUKE FT COLLINS CO $0524 (303)221-2290 8iO'245 S �/ LUDUDYIN GARY A NO 71 1106 E PROSPECT FORT COLLINS CO 80525 (303)493-7442 74-2161737 UNIVERSITY PHYSICIANS NON-PPO RAxR 69 PO BOX Z2029 DENVER CO W222 (303)372-2232 44M2 CQLLIOlL1N5 THOMAS J MD 60 1120 E ELIZABETH SLOG G 01 FORT COLLINS CO 80524 (303)493-Z776 84-0911601 STALLINGS THERON N PC RAtiIA 615 2200 SO COLLEGE AVE FORT COLLINS CO W525 (970)484-0686 84-Dj96245 1 ✓KESLER KELVIN F NO 67 1106 E PROSPECT FORT COLLINS CO 80525 (303)493-7442 84-0706789 10 PACINI RICHARD J NO 66 1221 EAST ELIZABETH FORT COLLINS CO 80524 (303)490-4193 84-0791312 39 ✓SMITH JERONE NO i R 66 1221 E ELIZABETH 04 FORT COLLINS CO 80524 (970)484-1757 84-yt74590 3 ✓ ABBEY DAVSD M MD 66 1100 ►OUDRE RIVER DRIVE FORT COLLINS CO W524 (303)224-9508 84-0706T89 8 CRAVEN YINFIELD N NO 65 1221 E ELIZABETH 03 FORT COLLINS CO 80324 (303)484-4757 MPA00 FNIA01 98153 15:21 EXPENSE DISTRIBUTION BY 1998 JUNE PROVIDER 02 PAGE 5 P A 1 0 GROUP : 17 CITY OF FORT COLLINS PROVIDER N DAYS R8 CHGS BENEFIT AMC CH63 BENEFIT OATS 3PAM 97/01 TO y'F/12 NAME CLAIMS EMS CHGS OUT PAT CHGS BENEFIT TOTAL CH63 BENEFIT ADDRESS CITY ST ZIP PHONE TOTAL BENEFIT X TOT ---"----�'-''-''----- ------ -----___:raouovrsrraararuaururouraaooroasraoasapr 79626 10 GUENTNER JOIN MD lRRA 65 1200 E ELIZABETH FORT COLLINS CO 80524 (303)482-251S 84-}Z7602 27 INN WIDON BARBARA MD 64 1808 BOISE AVE LOVELAND CO W538 ( ) 84-0y99555 GOLUB DANIEL E NO 61 1260 DOCTORS LAN8 FORT COLLINS CO W524 (303)454-9175 84-1174590 2 V HOMBURG ROBERT C MO 59 1100 POUDRE RIVER DRIVE FORT COLLINS CO W524 (303)224-9508 84�P991312 5 BROMAN STEYEN D MO 545 12M EAST ELIZABETH STREET SUITE 4 FORT COLLINS CO B0524 (303)484-1757 64-0706789 3 SINGER CHARLES J MD j7 1221 EAST ELIZABETH FORT COLLINS CO W524 (303)490-4193 311028 2 DETERS ROBERT L MD 57 2918 W 10TH ST GREELEY CO awl ( ) 84-1210823 3CHLEE BRUCE 0 OC trftR 57 429 S HOWES FORT COLLINS CO 80521 (303)493-4012 84- 10280 ✓ MEYER FRED N NO 55 1217 E ELIZABETH 89 FORT COLLINS CO 80524 ( ) 84d7G02 25 LASZLO DANIEL NO 54 1BOB BOISE AVENUE LOVELAND CO 80538 ( ) 84-1013M MICHIE XEVIN J DC Mi►Y 54 3120 REMINGTON ST FORT COLLINS CO 80525 (303)484-5995 84- 02032 1 ✓ VALLEY GEORGE E MD 53 1U(16 LUXE ST ti. COLLINS CO 80524 (303)221-2290 84-0706789 9 GEIS J RAYMOND MD S3 1221 E ELIZABETH STE 3 FORT COLLINS CO W524 (303)484-4757 5 MPA00 FNIAOI 98153 15:21 1998 JUNE 02 PAGE 6 EXPENSE DISTRIBUTION a PROVIDER P A 1 0 GROUP 17 CITY OF FORT COLLINS DATE SPAN 97/01 TO 97/12 PROVIDER R DAYS RB CHGS BENEFIT ANC CHGS BENEFIT OUT PAT CHG3 BthEFIT 'AME CLAIMS ERG CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT X TOT ADORtSY CITY ST ZIP PHONE 1 "96245 15 ✓ KOZAK SUSAN NO 53 1106 E PROSPECT FT COLLINS CO BOS25 ( ) 184-1/3M20 3 J�CRANOR JOHN no 52 - 1124 E ELIZABETH EC FORT COLLINS CO 80524 (303)484-0798 1 EL-029120 1 ✓ 3TODDARO ANDREM NO 50 1124 E ELIZABETH RC FT COLLINS CO 80S24 (303)484-M98 1 7576 2 VREYARTHA WILLIAM CPR 50 2901 S SHIELDS BLDG F1 FORT COLLINS CO 80526 (303)493-4660 184 -� 129120 8 WUEL30M SCOTT NO 48 1124 E ELIZABETH RC FOR1 COLLINS CO 80524 (970)484-OT98 I "no 7 / SHACHTRAN WILLIAM A MD 47 1T25 E PROSPECT FORT COLLINS CO a0525 (970)4aG-5322 1 L 91312 37 Vol RUBRIGHT JON s no 46 1221 E ELIZABETH FORT COLLINS CO W524 (970)221-5255 ✓ BUSH JMES F n0 45 1021 LUKE STREET FORT COLLINS CO W524 (970)464-6406 154-6929390 BRATMAN STEVEN MD * 4G TOO Y MOUNTAIN AVE FORT COLLINS CO 80i21 ( ) 18L-0706799 1 DAVIDSON JAMES E NO 44 1221 EAST ELIZABETH FORT COLLINS CO 80324 (3M)490-4193 1 84-0745274 1 TIAMRT MAURICE 0 DC **** 43 211 CANYON AVE FORT COLLINS CO $0522 (303)493-Mll 1 33-0057155 37 A/RIA-FORT COLLINS 43 PO BOX 2259 LOVELAND CO W539 (970)203-1299 J0760a 24 CULVER VILLIAN RD 43 180E BOISE AVENUE LOVELAND CO a053a ( ) n MPA00 FHlA01 98153 15:21 1998 JUNE 02 PAGE 7 EXPENSE D13TRI8UTI0H BY PROVIDER PAID GROUP 17 CITY OF FORT COLLINS DATE SPAN 97101 TO 97/12 PROVIDER N DAYS RB CHGS BENEFIT AMC CHGS UtNtFll OUT PAT CHGS BENEFIT NAME CLAIMS EMG CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT X TOT ADDRESS CIlY ST ZIP PHONE 3333isazazsszSiisi�x---3:Z�if3NL33335iiiaa:azaaaaaaxaSaxaLa3xYzt33i------a-�szaxzzazasaa3axxaz�+x5xr ������ ---- A ---- 1 84 1257598 � LOURY MARK MD LS 2001 5 SHIELDS BLDG E 101 FORT COLLINS CO W526 (303)493-5334 1 %/ FA9L75 FANGMAM MICHl1EL P MD 42 1240 DOCTORS LANE SUITE 200 FORT COLLINS CO 90524 (303)493-6337 184— 5% LOPEZ JOSEPH NO 42 1136 E STUART STE 4202 FORT COLLINS CO W525 (970)221-5925 184 V3455 25 VCOUPENS STEVEN 0 MO 42 PO BOX 451 FT COLLINS CO W522 ( ) 43-1843587 LEVY J J LSWII LCSW 41 31S CANYON FT COLLINS CO W521 (303)493—BT80 1841 1 YOUNG E YOUNG ERIC MD 41 19W N BOISE 0110 LOVELAND CO W538 ( ) 1129120 6 KAUFFMAN JEFFREY MO *has 41 ���////1124 E ELIZABETH NC FORT COLLINS CO BM24 (303)484-UlyB 164-118074E WILBURN MONTY OC A#tf 40 1015 S LEMAY FORT COLLINS CO 80524 (970)224-2282 I 69T1T 11 LARSON DENNIS NO 40 1100 E ELIZABETH STREET FORT COLLINS (0 80524 (970)221-1000 1 84-1105900 ✓CRAWFORD GREG L VC 39 1337 E PROSPECT RO FORT COLLINS CO 80525 (30 1493-2103 133-0057155 47 APR1A HEALTHCARE INC >* 39 PO BOX 2259 LOVELAND CO W539 (970)663-0500 1 63-1115340 8 / POOLOS ROBERT RPT 39 V DRAWER 0519 PO BOX 11407 BIRMINGHAM AL 3524E (800)781-6899 84-9679626 12 oIaRAUF su"m No 39 `// 1200 E ELIZABETH FORT COLLINS CO 8052L (970)482-2S1S II Sloans Lake Managed Care carries an Employee Benefits Liability in the amount of $6 million per incident and $7 million aggregate. Sloans Lake Management Corporation carries a professional liability of $1 million and excess professional liability is $4 million, totaling $5 million per claim and annual aggregate. Insurance is carried with Lexington Insurance company. Providers are required to carry at least $1 million/$3 million of professional liability coverage. 11. Provide a GeoAccess and disruption analysis/network analysis as described in the General Information section. Please see Attachment G-GeoAccess Analysis. Hospital/Facility Specific Issues 1. What criteria are used to select hospitals and other health care facilities? How are the hospitals monitored for cost efficiency and quality of care on an ongoing basis? How often is this review conducted? Have any hospitals been terminated or dropped from the managed care program? Sloans Lake Managed Care has not terminated or dropped any hospital from the network. The following criteria are utilized in the process of credentialing and selecting network hospitals: • JCAHO accreditation • State licensure • Medicare approval • Malpractice coverage • Full disclosure of current malpractice liability or other disciplinary activity • No admissions within seven days of discharge • Appropriate utilization review procedures • Adherence to per case or per diem rates and hospital management protocols • Appropriate billing procedures A site visit by Medical Quality Management (MQM) on behalf of Sloans Lake Health Plan is required or HCFA accreditation may be used in place of a site visit. Network hospitals are recredentialed every 2 years. 2. Identify all hospital/health care facilities that have contractual relationships with the managed care program. Sloans Lake Managed Care's network contains 63 hospitals. Sloans Lake Managed Care 12 City of Fort Collins July, 98 MPA00 FM1AO1 98153 15:21 1998 JUNE OZ PAGE 8 EXPENSE DI5TR18UT10N BY PROVIDER PAID GROUP 17 CITY OF FORT COLLINS DATE SPAN 97101 TO 97112 °IDER 8 DAYS RB CHGS BENEFIT ANC CHGS BENEFIT OUT PAT CHGS BENEFIT NAME CLAIMS ERG CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT X TOT ADDRESS CITY ST 2IP PHONE .xxssxxasa_ae:.u.aascxxosxxse_a_ .a.::�axxxs_=_:�:aa.ae=-�==_—=�—aa..sse-xxac=s=xwcz:a—�=LaaaaN.aasa.sssxxxxaax�x 1 84- 3030 YANFAROVE CYNTHIA ND 39 1014 CENTRE FORT COLLI14S CO W526 ( ) { 6471711 1 ERI ERIKSEN CNRiSTOPHER MD 39 1120 E ELIZABETH SLOG F N101 FT COLLINS CO 80524 (30)221-1177 1 84-1217723 22 OLSEN ERIC B MD 38 PO BOX 7179 LOVELAND 00 OW37 ( ) 134-0675076 9 / ROBINSON MATTHEW NO 38 �/ 1725 E PROSPECT FORT COLLINS CO 80525 (970)484-5322 { bG-0�38074 ✓PIKE ROBERT H MD 37 10M E ELIZABETH FORT COLLINS CO 80524 (303)221-4433 1 8415750 2 LLEN DAVID K NO 37 1260 DOCTORS LANE FORT COLLINS CO aU524 (303)484-3496 1 t. 1 ONALLORAN 4ILLIAM D RPM 36 15M RIVERSIDE AVE FORT COLLINS CO W524 (303)482-3668 1 31-9369144 2 CARR EDMARD E DC lRItR 35 1700 S COLLEGE AVE FORT COLLINS CO W525 ( ) ( 840-61-8T/9 4 / STANDARD PETER J MD 35 1500 SOUTH LEMAY FORT COLLINS CO 80524 (303)484-6700 1 64-1119490 1 CRANDALL VENDY MS OTR 35 ✓ 1200 E ELIZABETH SUITE A FORT COLLINS CO MS24 (303)482-0521 4 64-1205909 / MAUER SALLY MD 35 1136 E STUART 83190 FORT COLLINS CO 60525 (303)224-9890 1 84-1217723 20 TEUMER JANES K NO 35 PO Box 7179 LOVELAND CO 80537 C ) 4 64-0593455 9 $06EL ROGER M MO 34 ✓ PO BOX 451 FORT COLLINS CO W522 (3=493-5615 MPA00 FAlA01 93153 15:21 1998 JUNE 02 FACE 9 E X P E N S E 0 I S T R 1 D U T I 0 N B T P R O V I D E R P A I D GROUP 17 CITY OF FORT COLLINS DATE SPAN 97/01 TO 97/12 PROVIDER N DAYS RB CHGS BENEFIT AN; CHO$ DENEPIT OUT PAT CHGS DEHEFIT NAME CLAIMS EMG CHGS BENEFIT TOTAL CHO$ TOTAL BENEFIT X TOT ADDRESS CITY ST ZIP PHONE ��i{{{YtttaC�-s����ff{t{ff{iAaaassQ�sSWtss633L3sa'aassaasasasaa-tsr����aa--- 1 84-9f 96245 b ✓ DONNELLEY BEVERLY HD 34 1106 E PROSPECT FORT COLLINS CO W525 ( ) 184-59435 1 ✓ STIGLICN HORMA NO 33 3000 S COLLEGE STE 210 FT COLLINS CO 80525 ( ) 1 di-1117607 1 POUDRE CARE CONNECTION INC 32 1119 VEST DRAKE RD STE C30 FORT COLLINS CO W526 (970)20T-4900 JAMES WARREN K RD 32 1106 PROSPECT ROAD FORT COLLINS CO W525 (30)493-7442 / CARLSOII H G NO 32 1040 E ELIZABET14 STE D FORT COLLINS CO 90524 (503)482-0213 ✓/ SIMMONS ROBERT A ND 31 1330 OAKRIDGE DRIVE SUITE 100 FORT COLLINS CO $0525 (B00)279-9773 1 769717 6 ✓ DOYNES THOMAS R MD 31 1109 E ELIZABETH FORT COLLINS CO 80524 (303)221-4241 1 7576 5 SCHULTE ROBERT DPM 31 20M S SHIELDS SLOG F-1 FORT COLLINS CO W526 ( ) 1 74-21617J7 1 UNIVERSITY PHYSICIANS PPO 31 PO BOX 220" DENVER CO W222 ( ) 1 64�0"OSTER 10 FOSTER DART MD 51 ✓/ 101? ROBERTSON FORT COLLINS CO W524 (303)484-5322 119490 2 84y1M13 MORRIS KATHLEEN ►T JO ✓/ 12DO E ELIZABETH SUITE A FORT COLLINS CO W524 (303)482-0521 R 8L-0593455 2 / HOASTMAN JAMES K MD 30 v Po Box 451 FORT COLLINS CO W522 (303)493-0112 M 84ABURNS"7601 / BURNS AICHAEL J OPN 30 1100 POUDRE RIVER DRIVE FORT COLLINS CO 8%24 (303)221-0425 9 HPAO0 FN1A01 95153 15:21 1995 JUNE 02 PAGE 10 EXPENSE 015TA18UTI0N BY PROVIDER PAID GROUP : 17 CITY OF FORT COLLINS DATE SPAN 97/01 TO 97/12 PROVIDER R DAYS RB CHGS BENEFIT AMC CHGS BENEFIT OUT PAT CHGS BENEFIT VAME CLAIMS EMG CHGS BENEFIT TOTAL CHGS TOTAL BENEFIT X TOT ADDRESS CITY ST ZIP PHONE aaaafa�2�JaffYf{i Y�3asasaaaa3=YfaYTiaeaasasilliYiiL-^-3ss�3Y-4�iYfitC �---_�---�-- �-aafa{{N{iJiaaaiasiaaaaaifaasa ' a4E312 a STE►HENS fLOTO Y RD tttR 30 1221 EAST ELIZABETH STREET SUITE 4 FORT COLLINS CO 50524 (970)225-0400 i 35-2427192 KLEKER MICHAEL OC 30 2691 S LEMAY SUITE 2a FORT COLLINS CO 80525 (303)223-4422 1390-Sa-634a FOLBRECHT CHIROPRACTIC! 30 134 U HARVARD STE 5 FORT COLLINS CO 80525 (303)226-5545 t IIL�59-3455 7 ✓ GRANT LEE B NO 29 PO Box 451 FORT COLLINS CO 80522 (303)493-5615 t 84-0593455 62 TRUMPER BOCCI V NO 29 PO Box 451 FORT COLLINS CO a0522 (970)493-5615 163- I153M 41 BARCLAY CAROL PT 29 GRAYER 0519 PO BOX 11407 BLRMINGHAM AL 35246 (800)781-6899 1 t 47312 11 JENSEN CHRIS MD 29 1241 RIVERSIDE 0200 FORT COLLINS CO W524 ( ) 1 84-0647312 1 DECKER JOIN T MD 29 1241 RIVERSIDE STE 200 FORT COLLINS CO 80524 (303)484-0722 18474217M 28 UPOEGRAFF JEFFRET NO 29 PO BOX 7179 LOVELAND CO W537 (970)663-2742 I a4-1177485 2 STEELE'S PHARMACY 29 1001 E HARMONY RO FORT COLLINS CO 80522 ( ) I W1287602 12 THOMPSON J STEPHEN MD 29 1008 BOISE AVE LOVELAND CO 80538 (303)669-6660 I2t3/602 22 "DOPER PHILLIP NO 28 1a0a $0139 AVENUE LOVELAND CO 80538 ( ) 1947 3AND56 ✓/ SANDS ARTNVR C MD 28 1021 ROBERTSON FORT COLLINS Co au524 (303)482-0666 10 July 28, 1998 City of Fort Collins Purchasing Division 256 West Mountain Av( Fort Collins, CO 80521 Re: Proposal for the City of Thank you for the opportunity to SLOANSLAKE MANAGED CARE 1355 South Colorado Blvd. Suite 902 Denver, Colorado 80222 Telephone (303) 691-2200 Collins a proposal for the City of Fort Collins. Sloans Lake Managed Care was Ie tly accredited by The Commission/URAC for multiple lines of business including HMO, PPO, and Utilization Management. This accreditation demonstrates our com y's commitment to exceptional levels of quality and service and recognizes us as a premier company with all lines of business. I welcome the opportunity to discuss the specifics of this proposal and answer any questions. Please feel free to contact me at (303)504-5303. Sincerely, Kelly Re a Account ager Sloans Lake Managed Care Enclosure SLOANSLAKE MANAGED CARE Kelly Redpath, HIA Account Manager 1355 South Colorado Blvd. Suite 902 Denver, Colorado 80222 Direct Line: (303) 504-5303 Facsimile (303) 504-5321 Toll Free: (800) 457-2345 AR kredpath@sloanslake.com REOITEl NCCPEOI SLOANS LAKE MANAGED CARE PRESENTATION TO: CITY OF FORT COLLINS Presented by: Sloans Lake Managed Care Representatives: Kelly Redpath, Account Manager Judy Green, Contracts Manager Linda Adams, Group Health Clinical Manager Diane Norby, Provider Contracts and Services Director Kris Marlier, PPO Relations Manager History of Sloans Lake 1 Preferred Provider Network Z Medical Management 3 Coordinated Care Management 4 Behavioral Health 5 Alternative Care Services 6 Internet Services Conclusion ®AVERY — Table'n Tabs" Dividers No Text ` xtl Perltaps of most interest to our customers, we were the f rst HMO in the state to create a com prebensive,k credentialecl alternative care network for inclusior a , into our health Mans. iVetr.wl# udutx�T t `, ;oi servi e plal,, i „vid, otit-oI-1,:lw„11� le Statab � aUtX} �lBCt#ance'carhers 1 plan hrnrn a lit- ill lip tradn itioal I *'Vv & aCGe�9: kq health cam `� — .I Imo lxuelits, and our Frecdom clivic�wa�a i�xjnxe� 3x Ail aca e�jts �4 .@ ' ;jerks plans provide dircat acIcs� to airy — k +1 'parliciiiatin,' plrveician in the liealth c6iver3`Ct - �vlanagad heCgmi� t na4Ch s)si cane i w'�� ' -• agn�ttn>er C �' ,,ea8vet0 pradueta Ixx -�exe.q _1 E 7l gelW the alms plan net��orl;. I lir6.tps of ,nost interest tt `wwVe auto 4o''we Have 'to our customers, we were tie I -first — 76 HMO in tic stale to create a ipri" q. eCi Compre��ensive, credentialed alternative mLon bpe yea care networiz for inclusioli into our ' 9i�t�'�r�'r�udac�,nie�icaj • , health plans. , SLOANS' LAKE... !•,�LOCALLYOWNED t diNptiittnin� truss t xaterest xeµ�tWe to H. we — AND OPERATED r , w�F�ggt39 ` Heal h'P &M in. Like you, we have witnessed the. le`e(iWtign tll: " ongoing consolidatiorys and mergers that it stratogid,4jtcKve�fq 64' have impacted the healthcare industry 1z�anaged Car®'ozanizaaoYs -4 d th e acua §� n�evar.; t 1 ` ttlVer'th'e '> tO;nee.f,i 'n of,Co6ado ,� an recen years, an e res mg con- t :cern and turmoil experienced by cus- 9e:t7iC4. � +� Cdn , �4dir he1.3LtOovB tomers. To solidify our financial future, i1s'lis fPL *-our sttd raVx eX .'we felt it was important to partner with a etr�la r Zet1O1il�� '11e '"a ocal organization with which we could r.. cdte�setiei�"e,tl existi�,preeenae m pursue our goals. To that erid, Sloans yg'y C/4Ytt?n# ` . rr,,,J-lealth Lake was acquired in 1997 by Ccntura ] 1 .Systems, the largest non -for- G�Cli7al111'!or Oet uAd I teE ; 't t -profit hospital system m Colorado. r ) p 7 � �.t; c�7 q �hgiCe S4A4- S10�d7wLa�8,- This relationsbip'strengthens Sloan s -� lwth P" 6s"i�'o U&IJ'vanoue' Lake f nancially, yet enables us to main- jsts�of ', "- in�" P-M-1ixCt 6*e ' 11Oint twin our own identity. No Text 3. Are there any forms of treatment that cannot be provided by your hospital network? If so, which ones? Sloans Lake Managed Care's network is comprised of providers that can treat a full -range of conditions in -network and will go out -of -network if needed to provide the best possible care. 4. Please submit a list of negotiated rates for all participating health care facilities in your network. Please note that the preference is DRGs or per diems. Hospitals are reimbursed in the following manner: Reimbursement % of Hospitals Discounted Charges 68% DRGs 3% Per Diems 29% 5. Are there additional discounts available to the group for "prompt payment"? If so, please define "prompt payment" and state amount of discount. Sloans Lake Managed Care does not offer "prompt payment" discounts. 6. How long are these hospital rates guaranteed? Are you able to deliver multiple year agreements with increases tied to economic indicators? Hospital contracts self -renew automatically annually. Rates are reviewed regularly to insure cost-effectiveness. Rates are renegotiated no more than once a year. Sloans Lake Managed Care is unable to deliver multiple year agreements with increases tied to economic indicators. 7. What has been the average rate of increase for participating facilities since you first became operational? Sloans Lake Managed Care's average rate of increase for participating facilities is approximately 3% in the last five years. S. Are there any ancillary services not contracted? Please explain. (i.e., emergency room physicians, durable medical equipment, hospice, rehabilitation, laboratory, home health care, etc.) Please identify negotiated terms of those under contract. Sloans Lake Managed Care contracts all ancillary services. 9. Please describe the liability insurance requirements for your contracted hospitals. Sloans Lake Managed Care 13 City of Fort Collins July, 98 MISSION STATEMENT: Sloans Lahe will distinguish itself as a customer friendly health care solutions company. W will build relationships with our customers focused on serving their needs and contribu- ting to heir success. 1ne %ey to our efforts will be the dedication and enthu- siasm of our employees — ` our greatest resource. reflect balanc, in all of our lines of business, including PPO, PIP and HMO, while our medical management processes will focus on system_imptove- ments and -the implementation of outcomes studies and quality programs: Our focus on quality is unsurpassed. Embodied within our business We will continue to fine-tune a- ` philosophy is a return to old-fashioned physician profiling system and evolve values, which have been lost during the Our outpatient medical management last several years of frantic industry review process. Our quality merger and consolidation activity. We management program provides for the will strive to restore consumer development of duality measures, confidence in the managed care collection of,data, and implementation industry by providing good service and a of appropriate interventions. The PPO broad product spectrum, and building and -HMO lines of business and our strong, positive relationships with our Utilization Management Program were varied customers. We will work to awarded full network accreditation by develop health care solutions,which will the American Accreditation HealthCare ultimately improve the quality of health , Con-mission/formerly UPZAC, We are in our community. the first managed care company in the nation to recgive full Our wehsite, at www.sloanslake.com, accreditation for multiple product provides general industry information, lines. further, we -are committed to Sloans'Lake's company and pr`atl'uct achieving NCQA accreditation for'the information;_ our joh-line, timely health LIMO by the year 2000. care and'wellness articles, PPO and HMO provider directories, and a- PPO claim status look -up function for providers and payors. Please visit its! We would he interested in knowing how to makethe website work for you. SLOAlNTs LAKE HEALTH PLAN 1355 South Colorado. Blvd, Suite 902 Denver, CO 80222 303.753.7537 www.sloansliike.com PREFERRED PROVIDER NETWORK Sloans Lake offers the state's largest hospital network. We negotiate individual rates up front with each hospital to control costs. Our network facilities include: • General Acute • Tertiary • Mental Health • Skilled Nursing • Rehabilitation, and • Hospice We also offer the largest statewide network of multi -disciplinary physicians and related providers. These providers include: • Outpatient Surgery Centers • Home Health Care • Specialty Physicians • Mental Health Providers • Laboratory • Occupational Therapists • Physical Therapists • Speech Pathologists • Chiropractors, and • Podiatrists Our physicians and related providers have agreed to reimbursement according to predetermined rates derived from the well established St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines. This RVP determines unit values for each CPT code, which we then convert to annually negotiated dollar values. Most of our physicians and providers have long-standing contracts with Sloans Lake Managed Care. All must meet the highest educational and medical practice quality standards, and receive training in managed care treatment guidelines and administrative procedures. The Preferred Network In an effort to continue offering a broad provider network with substantial discounts, we have created our "Preferred Network." Patients treated at our Denver metropolitan hospitals will receive per diem arrangements, resulting in greater discounts. In addition, all patients still have access to our specialty care hospitals and statewide network of acute care hospitals outside of the metro Denver area. (See attached PPO Directory.) PPO PROVIDER RATES FOR FORT COLLINS Poudre Valley Hospital: 2% discount for both inpatient and outpatient services Ambulatory Surgery Centers: 20% discount to a maximum allowable of $1,200.00 per date of service Physician rates equal to a discount from billed charges of approximately 20-25%: Range of Conversion Factors Medicine Physical Medicine 97001-97799 Surgery OB 59400 59510 Anesthesia Radiology Clinical Pathology Surgical Pathology $ 6.25 - 6.55 n/a - 5.95 $ 77.50 - 79.50 $ 81.00 - 80.10 $ 1800.00 - 1865.00 $ 2100.00 - 2210.00 $ 36.00 - 36.55 $ 17.00 - 17.65 $ 11.00 - 10.50 $ 15.50 GROUP HEALTH CUSTOMER SERVICE PHONE REPORT July 1998 PPO/CCM Total Queue Calls: 19,009 Average Answering Speed: 24 seconds Benchmark: 45 seconds Abandoned Rate: 3.3% Benchmark: 4% SLOANS LAKE MEDICAL MANAGEMENT • Utilization Management department has been accredited by URAC (A.A.H.C.C.) for six years Two of the supervisory staff hold Certified Professional Utilization Reviewer (CPUR) certification through Interqual Full time, on -site Medical Directors Excellent customer service Compliant with all Colorado healthcare legislation Industry standard criteria, with regional and community practice adjustments made by the Chief Medical Officer • Twenty four hour, seven days per week, live coverage for Medical Management Utilization Department UTILIZATION MANAGEMENT Over the years, Sloans Lake Managed Care has developed and refined a sophisticated, comprehensive Utilization Management system to make sure patients receive necessary, appropriate, cost effective inpatient and outpatient care. Our Utilization Management professionals monitor patient care through our computer systems and through direct contact with providers and insurers when necessary. Hospital Utilization Review Our hospital Utilization Management system calls for Pre -Admission Certification. The process requires the provider, patient, or facility professional to call our toll -free number for pre -certification. Our Utilization Management professional then collects relevant information such as provider name, facility, admission date, admission reason, anticipated length of stay, and subscriber information. Our professionals compare collected information against our medical necessity criteria within one working day of the date of the request for admission. If the information meets our criteria, our Utilization Management professional authorizes admission and issues a letter of approval to the patient/insured, provider, facility and the plan administrator. If the information fails to meet our criteria, the request is discussed with our medical director within the same working day. If more information is needed, the attending provider is called and asked to supply the information. If the proposed admission still fails to meet our criteria, the hospital admission is not authorized as medically necessary. The provider, the facility, the patient/insured, and the plan administrator is then notified in writing. Admission Review By reviewing patients' medical records, our professionals can make sure hospital admission offers the most appropriate and effective treatment setting. Admission Review requires assessing the patient's condition and treatment needs when entering the hospital and at the time of Admission Review. This helps control costs while preserving quality by making sure patients receive the most appropriate care. Concurrent Review/Continued Stay Review Shortly after admission, our Utilization Management professionals begin periodically monitoring continued hospitalization for necessity, effectiveness, and discharge planning. We frequently call providers daily in order to document the medical necessity and appropriateness of continued hospital confinement. We also follow the quality of care provided to ensure that it benefits the patient, meets local practice standards, and enables the earliest possible discharge. Exhibit B illustrates how our inpatient Utilization Management techniques keep overall admissions and lengths of stay well below local and national averages. (See Exhibit B - Inpatient Utilization January 1, 1997 to December 31, 1997). Discharge Planning At Sloans Lake Managed Care, discharge planning begins at the time of admission when our professionals estimate the expected length of stay based on our objective guidelines. Our professional staff follows up with providers on a predetermined frequency to make sure patients are moved to the least restrictive, most appropriate and safest treatment setting as soon as possible. Pre -Surgical Review When certifying inpatient or outpatient surgery, our Utilization Management professional relies on specific objective criteria to measure surgical appropriateness. Our professionals review specific procedures using physician -provided clinical information and patient history. We evaluate this information against nationally published criteria for surgical necessity and effectiveness. Pre -Surgical Review helps eliminate expensive, unnecessary surgery or surgery of unproved effectiveness. Exhibit C displays the surgical procedures reviewed in licensed surgical suites, licensed ambulatory surgical centers, and hospitals. (See Exhibit C - Pre - Surgical Review List). CASE MANAGEMENT Sometimes, because of complexity, severity, or delayed recovery, a case requires more than the usual tracking by our Utilization Management professionals. Case Management controls costs by making sure things happen when and where they should in complicated, high -risk cases. Case managers make sure patients get the appropriate level of care, care setting, and equipment and services. Utilization Review professionals identify candidates for Case Management through Pre - Admission and Concurrent/Continued Stay Review. Case managers identify high -cost claims situations, assess potential opportunities to coordinate care, and develop quality, cost-effective treatment. We get involved one-on-one with patients to expedite progress and recovery. In complex and catastrophic cases, case managers intervene early to coordinate care among multiple providers. This prevents treatment from progressing in inappropriate, expensive directions. It enables us to develop treatment plans that assure quality, control costs, and enhance care continuity and effectiveness. GROUP HEALTH UTILIZATION MANAGEMENT PHONE REPORT July 1998 PPO/CCM Total Queue Calls: 5256 Average Answering Speed: 21 seconds Benchmark: 30 seconds Abandoned Rate: 4.43% Benchmark: 5% Note: Two nurses were hired in July and completed their training in August, making us fully staffed. Providers are required to carry at least $1 million/$3 million of professional liability coverage. 10. Please enclose a sample hospital contract. Not available, proprietary information. Utilization Management/Quality Assurance Please respond to the following questions about your organization's internal utilization management and quality assurance programs. The City is concurrently seeking proposals for utilization management services, and your network will be required to interface with the selected organization. 1. Please provide a detailed description of your utilization management and quality assurance programs, how they operate and the protocols and criteria used. Please see Requested Attachment section- Utilization Management Plan. 2. Describe in detail how your organization determines the medical necessity of medical treatment. What types of standardized quality measurement systems do you use? Sloans Lake Managed Care's professionals compare collected information against medical necessity criteria within one working day of the date of admission. Clinical information is evaluated using the Interqual for Surgical Indicators. If the information meets the criteria, the Utilization Review coordinator authorizes admission and issues a letter of approval to the member and the plan administrator. If the information fails to meet the criteria, the coordinator discusses the request with Sloans Lake Managed Care's medical director within the same working day. If more information is needed, the medical director immediately calls the attending provider to discuss the case. If the proposed admission still fails to meet the criteria, the medical director recommends an alternative level of care or denies admission authorization. The medical director then notifies the provider, the facility, the member, and the plan administrator in writing. 3. Is there a review committee to monitor quality of care? Who is on the committee and how often do they meet? Please see Attachment E- Quality Program. 4. Does the managed care program have a formal procedure for addressing member grievances? If so, please explain? Please see Requested Attachment section- Utilization Management Plan. Sloans Lake Managed Care 14 City of Fort Collins July, 98 Exhibit B PPO INPATIENT UTILIZATION January 1,1997 to December 31,1997 All Utilization Management Groups Admits Days Avg. Admits /1000* Days /1000* LOS* Medical 1,761 12.70 5,617 40.50 3.19 Surgical 1,287 9.28 4,224 30.46 3.28 Maternity Vaginal 523 3.77 971 7.00 1.86 C-Section 258 1.86 882 6.36 3.42 Pre -Term Labor 67 0.48 263 1.90 3.92 Sub Total 39896 28.09 119957 86.22 15.67 Rehabilitation 40 0.29 652 4.70 16.3 Total 39936 28.38 129609 90.92 3.20 Members 63,043 X 2.2 = 138,695 /1,000 = 138.69 Admits per 1,000 = Admits per 1,000 = Days per 1,000 = Days per 1,000 = Avg. Length of Stay (LOS) _ The average number of admits per 1000 members (Admits)/(Members/1000) The average number of days per 1,000 members per year (Days)/(Members/1000) Days/Admits CCM INPATIENT UTILIZATION January 1,1997 to December 31,1997 Admits Days Avg. Admits /1000* Days /1000* LOS* Medical 576 20.06 2,318 80.74 4.02 Surgical 359 12.50 1,159 40.37 3.23 Maternity Vaginal 305 10.62 561 19.54 1.84 C-Section 48 1.67 138 4.81 2.87 Pre -Term Labor 21 0.73 34 1.18 1.62 Sub Total 1,309 45.58 4410 146.64 Rehabilitation 9 0.31 268 9.33 29.77 Total 1,318 45.89 41478 155.97 3.40 Members 13,052 X 2.2 = 28,714 /1,000 = 28.71 *Admits per 1,000= Admits per 1,000 = *Days per 1,000= Days per 1,000 = Avg. Lgth of Stay (LOS) _ The average number of admits per 1,000 members (Admits)/(Members/1,000) The average number of days per 1,000 members per year (Days)/(Members/ 1,000) Days/Admits Exhibit C PRESURGICAL REVIEW LIST Cardiovascular Coronary Angiography Coronary Artery Bypass Carotid Endarterectomy Percutaneous Transluminal coronary angioplasty Gastrointestinal Colonoscopy UGI Endoscopy Hemorrhoidectomy Gynecological Dilation & Curettage * Hysterectomy Pelvic Laparoscopy Integumentary * Abdominoplasty Capsulotomy for scar contracture following augmentation mammoplasty Dermabrasion of Skin Orthopedic Any arthroscopic procedure (knee, shoulder, wrist) Carpal Tunnel Release Excision of nail and nail matrix, partial or complete * Lumbar Laminectomy * Spinal Fusion Otolaryngology Tympanotomy Tube Insertion Otoplasty Tonsillectomy and/or Adenoidectomy Urology Cystourethroscopy *Inpatient Procedures COORDINATED CARE MANAGEMENT Our optional Coordinated Care Management (CCM) product allows patients ready access to primary care providers but reviews access to specialty care, certain diagnostic services, physical, occupational, and speech therapy, home health care, durable medical equipment, and all skilled nursing and hospice care. CCM helps control cost even more effectively than our standard PPO product by relying on primary care physicians to coordinate care. Primary care physicians - including family/general practitioners, internists, and pediatricians - provide high quality, appropriate, and effective medical care for the majority of patient conditions at a lower cost than specialty care physicians. When a primary care physician decides a referral is necessary, he or she contacts Sloans Lake Managed Care. That's when our Coordinated Care professionals get involved to authorize the referral. We verify medical necessity and appropriateness, making sure patients receive the necessary level of cost-effective care. Our Coordinated Care professionals willingly answer patient and provider questions and assist in resolving concerns. We also help patients make sure all specialty referrals and subsequent referrals are made to Sloans Lake network providers. Primary care physicians must obtain authorization for all specialty referrals from Sloans Lake, and specialty providers must obtain authorization for all subsequent referrals and follow-up care. Throughout the program, Coordinated Care professionals monitor inpatient and outpatient services. Our Coordinated Care Management product consumes the least amount of health care resources while preserving quality of care. COORDINATED CARE MANAGEMENT (CCM) • Insured and dependents select a primary care physician (PCP) Family/ General Practice Internal Medicine Pediatrics • The patient's PCP is required to obtain authorization for the initial referral to a specialist • The ordering doctor must obtain authorization for invasive diagnostic testing if the test is on Appendix B. • An authorization is required for any test on the attached list of Diagnostic Tests Requiring Authorization (Appendix B). • An authorization is required for allied health services Home Health DME PT/OT/Speech • The ordering physician is required to obtain authorization when performing a procedure on the Elective Surgery list (Appendix A) in a hospital or licensed surgery center. • An authorization is required for Skilled Nursing Facility, Intermediate Care Facility and Hospice Care • An authorization is required for all inpatient hospitalization • Emergent care does not require authorization • Well Woman exam (GYN) does NOT require authorization, with the exception of the first prenatal visit. • Mental Health/Chemical Dependency treatments require an authorization. Crisis intervention does not require authorization. COORDINATED CARE MANAGEMENT GUIDELINES RESPONSIBILITIES OF SLOANS LAKE MANAGED CARE Sloans Lake Managed Care (SLMC) will be responsible for: • confirming that the insured and dependents have selected a primary care physician (PCP); that the physician who requests a referral is the selected PCP; and that a network specialist is selected for the referral. • creating a record of the authorization within the system. The system will capture the authorization information, i.e. date of the receipt of call from the PCP and document medical criteria. • monitoring referral practices of PCP's, including appropriateness of referrals, volume of referrals and compliance with program procedures. • reviewing all referrals for appropriateness with respect to: - the diagnosis and/or procedure, - the selection of the specialist and/or proposed diagnostic testing, lab work, etc. - the number of visits authorized. Additional responsibilities of SLMC: Elective Surgery List (Appendix A) The network physician performing the surgery is required to contact SLMC for an authorization for selected procedures. The Coordinated Care Nurse will authorize the procedure after a review of the clinical information. Preadmission, Concurrent and Retrospective Review Hospital utilization review is performed by a Coordinated Care Nurse and physician reviewers. RESPONSIBILITIES OF THE INSURED/PATIENT At the time of enrollment the insured and all covered dependents must select a primary care physician. This is accomplished by completing the Primary Care Physician Selection/Change form. Designated Primary Care Physicians (PCP's) are: • Family/General Practice • Internal Medicine • Pediatrics In order to receive the maximum benefits available, when the insured/patient receives a referral they should: • confirm that the specialist is in SLMC. This can be accomplished by: calling SLMC Member Services; checking the most current directory; calling the provider. • call the specialist's office to make an appointment. • identify themselves as a patient and a member of SLMC CCM. Additional Responsibilities: ChangingPrimary rimary Care Physicians The insured/patient may change their PCP by contacting SLMC Member Services. The insured may either call SLMC directly or complete and mail the "Primary Care Physician Selection/Change" form to SLMC Member Services. The change is effective on the date of the call or the date the form is signed. The number of times that an insured is allowed to change PCP's is determined by the benefit plan. Specialist to Specialist Referral The specialist must notify the patient's PCP if a referral to a second specialist is needed. As always, the patient should verify that the new specialist is in SLMC. The PCP or the specialist will call SLMC for authorization of the second referral. Once the referral has been authorized the patient can then make the new appointment. Specialty Referral by a Non-SLMC Provider In rare situations where an insured/patient chooses to use a non-SLMC provider, and that provider refers them to a specialist within SLMC, the patient must call SLMC CCM for authorization. RESPONSIBILITIES OF THE PRIMARY CARE PHYSICIAN Once the PCP determines the appropriateness of a referral he or she will: • assist the patient in identifying the appropriate specialist, facility, or program (if necessary). • notify SLMC CCM to request an authorization and the number of authorized visits. All authorizations are done by either phone or fax. • provide the specialist's office with the necessary supporting records and/or pertinent information. • provide ongoing monitoring and evaluation of the case. • obtain retroactive authorization for urgent care in a free standing facility within 48 hours of the service being rendered RESPONSIBILITIES OF THE SPECIALIST The specialist will be responsible for: • making an appointment within an appropriate period of time following the initial call of the insured and within the authorized period of time for the referral. • confirming the referral through the normal course of their consultation with the PCP. If the specialist has any questions regarding the authorization, they should call the PCP to discuss the specifics of the authorization. • notifying the PCP and SLMC CCM of the need to refer to a second specialist and notifying SLMC CCM for diagnostic testing or for additional treatments/visits. • providing the PCP with a report on their assessment of the patient and their proposed course of treatment. • notifying the PCP if an admission is recommended. The specialist must contact SLMC CCM for required Preauthorization and Utilization Review Services. Insured/Patient Presently Under the Care of a Specialist Insured/patient who is under the care of a specialist on the effective date of the program must notify their PCP or SLMC CCM for an authorization for the continuation of the care. If they do not have a PCP, SLMC Member Services will work with the insured in identifying and selecting a PCP. SLMC will not seek to interrupt the existing relationship between the insured and the specialist in situations where a long-term relationship exists as the result of a chronic or terminal illness. Instead, SLMC will work to transition the insured through the identification and selection of an appropriate PCP. The PCP will coordinate and direct the care. As always, out of network benefits will be determined by the carrier. COORDINATED CARE MANAGEMENT REFERRALS THE REFERRAL PROCESS The primary care physician (PCP) or specialty provider will call the referral to Sloans Lake Managed Care. (If the provider is in the same location and has the same tax identification number as the PCP, no referral is required). The primary care physician (PCP) or specialty provider will call the referral to Sloans Lake Managed Care. 2. The CCM nurse will view the authorization summary screen to see what authorizations have already been authorized for the member. 3. The CCM nurse will then gather information for the authorization. a) Patient Information: name, SSN, insurance company and the employer group b) Physician Information: referring physician, referred to provider and facility if an out -patient procedure is scheduled c) Diagnosis and Pertinent Information: subjective/objective data, diagnostic testing performed and treated to date. d) Type of Service: specify service requested, e.g. consult only, eval and treat, diagnostic testing, DME, ER, HHC, and therapy. 4. If the CCM nurse is unable to authorize a referral, he/she will pend the authorization and inform the PCP or specialty provider. The CCM nurse will then discuss the authorization with the Director of Utilization Management and/or the Medical Director. All non -certifications are reviewed by the Medical Director. WHO CAN REQUEST A REFERRAL? Initial referrals must be initiated by a primary care physician. a) Family/General Practice b) Internal Medicine c) Pediatrics 2. Specialty providers may call for authorizations for diagnostic procedures, follow- up visits and surgery. (Refer to Appendix C.) 5. Please provide copies of your standard reports applicable to utilization management and quality assurance. Please see Requested Attachment section- Sample Reports. Administration/Fees 1. Are any administrative costs for your network paid for via a physician withhold? If so, please describe in detail. Sloans Lake Managed Care does not offer a withhold program. 2. Would your organization consider a multiple year fee guarantee? If yes, please state monthly fee(s) per member. Sloans Lake Managed Care is willing to discuss, and has in the past, provided multi- year rate guarantees in the form of negotiated maximum rate increases. 3. This RFP requires that the fees you quote for the City's 1999 plan year be guaranteed for the 12-month period. Will your organization comply with this requirement? Sloans Lake Managed Care will guarantee fees for a 12-month period. 4. Are there any additional costs or fees which are not covered by the fees outlined in your fee quotation? There are no additional costs or fees which are not covered by the fees outlined in the quote. Legal 1. Will you agree to a contract provision requiring your organization to provide at least a 120-day written notice to the City prior to the renewal dates of the contract of change in rates? Sloans Lake Managed Care agrees to provide at least a 120-day written notice to the City prior to the renewal dates of the contract of change in rates. 2. Are you willing to enter into a hold harmless agreement? Please explain. The following is from a standard Sloans Lake Managed Care provider contract: Sloans Lake Managed Care 15 City of Fort Collins July, 98 Appendix A Elective Surgery Requiring Authorizations Angioplasty Any Arthroscopic Procedure Bunionectomy Cardiac Catheterization Carotid Endarterectomy Carpal Tunnel Release Cataract Removal Cholecystectomy Colonoscopy Cystourethroscopy Dilation & Curettage EGD Hemorrhoidectomy Hysterectomy Laparoscopy (Pelvic) Lithotrispy Lumbar Laminectomy Myringotomy with Tube Insertion PTCA Reduction Mammoplasty Septoplasty Spinal Fusion Tonsillectomy and/or Adenoidectomy Tympanostomy with Tube Insertion UGI Endoscopy This list is reviewed when surgery is performed in a hospital, licensed ambulatory surgery center or licensed surgical suite. Appendix B Diagnostic Tests Requiring Authorization Coronary Angiography CT Scan EMG MRI Myelogram Sleep Studies Treadmill/Cardiac Stress Test Appendix C Services Requiring Authorization Any referral to a specialist Exceptions: • ER Visits • Well Woman • Mental Health/Chemical Dependency Crisis Intervention Any Inpatient Hospitalizations Durable Medical Equipment Home Health Care Hospice Intermediate Care Facility Occupational Therapy Physical Therapy Skilled Nursing Facility SLOANS LAKE MANAGED CARE GROUP HEALTH LEVEL I APPEALS PROCESS • Any patient or provider who has received a decision not to authorize/certify and has had that decision upheld through the reconsideration process or through a peer -to -peer discussion (provider only), has the right to appeal that decision to the Medical Management Committee. • A provider or patient may request an expedited appeal within five (5) business days after written notification if he/she feels the patient's condition or the nature of the proposed health care service(s) warrants expedited review by the Medical Management Committee peer member. Requests for expedited appeals must be directed to the Clinical Manager. . • Standard appeals must be filed within twenty (20) business days of the date of the written notification that a decision not to authorize/certify was upheld through reconsideration. Appeals must be submitted to the Clinical Manager. All appeals shall be reviewed by the Medical Management Committee within twenty (20) business days after receipt of request. A specific form does not need to be utilized, however, a request for appeal must be clearly stated. The following information should be included when submitting an appeal. ➢ Any additional information the patient or provider believes evidences the need for and/or effectiveness of the proposed treatment. ➢ Conservative treatment done to date. ➢ Coexisting diagnosis and current medications. ➢ Family history (if applicable). • The patient or provider will be notified within thirty (30) days of the Committee's decision. Submit requests to: Linda Adams, RN, Clinical Manager Sloans Lake Managed Care 1355 South Colorado Boulevard, Suite 902 Denver, CO 80222 Phone - (303) 504-5480 FAX - (303) 504-5345 dt\document\appeals\GHLEV Ldoc SLOANS LAKE MANAGED CARE GROUP HEALTH RECONSIDERATION PROCESS PROVIDER ROLES AND RESPONSIBILITIES • Any provider who has requested authorization for treatment did not have a peer -to -peer discussion, and received notification of a decision not to authorize/certify has the right to request reconsideration. Requests for reconsideration are the responsibility of the provider and may not be initiated by patients or their representatives, although they may request that the provider submit a request for reconsideration. • The reconsideration request may be in writing or may be initiated by telephone to the Clinical Manager. • Reconsideration requests must be submitted within twenty (20) business days from the date of written notification of the decision not to authorize. Failure to exercise the right of reconsideration within the twenty (20) day time frame will result in a waiver of any reconsideration rights. If reconsideration rights are waived, the provider may access the appeals process. A peer -to -peer discussion may occur in lieu of reconsideration. • A specific form does not need to be utilized, however, a request for reconsideration must be clearly stated. The following information should be included when requesting reconsideration: ➢ Any additional information the provider believes evidences the need for and/or effectiveness of the proposed treatment. ➢ Conservative treatment to date. ➢ Coexisting diagnosis and current medications. ➢ Family history (if applicable). • The provider will be notified within two (2) business days of the decision after reconsideration. • If the provider believes that the health, safety, or welfare of the patient requires an expedited review, it is the responsibility of the provider to notify Sloans Lake Managed Care of the urgent nature of the request, and Sloans Lake Managed Care will then expedite the review. Submit requests to: Linda Adams, R.N., Clinical Manager Sloans Lake Managed Care 1355 South Colorado Boulevard, Suite 902 Denver, CO 80222 Phone - (303) 504-5480 FAX - (303) 504-5345 BEHAVIORAL HEALTH Sloans Lake has contracted with PRO Behavioral Health, Inc. to provide these services. This network includes highly qualified psychiatrists, psychologists, social workers, and masters' degree level psychiatric nurses experienced in child, adolescent, adult, and geriatric Mental Health care. The PRO Behavioral Health professionals review Mental Health cases to make sure patients receive the most appropriate, high quality, cost effective treatment based on sound clinical practice standards. The reviewers refrain from directing or interfering with care, focusing instead on making sure treatment meets medical necessity guidelines. The reviewer and provider work together to help patients progress as quickly as possible in a cost effective manner. PRO Behavioral Health advocates focused, goal -oriented, short-term therapy, including treatment plans designed to help patients regain their highest level of functioning. In cases where chronic illness has seriously diminished that level, every attempt is made to stabilize patients and maintain them in the least restrictive setting with the greatest opportunity for social support, and vocational or recreational skill development. Alternative Care Services A Brief Introduction SLOANS LAKE • What is Alternative Care? HEALTH PLAN • Alternative Care is a rich array of techniques, modalities and medical therapies; • Much of what is labeled "Alternative Care" comes from other cultures or from ancient healing traditions; • Alternative Care is fourlded on the belief that we have the power to influence our healing process; • Alternative medicine has undergone a tremendous amount of increased interest and usage in our community and nationally; and • Alternative Care is also referred to as "complementary" or "holistic" medicine. Why is Alternative Care Pogular? • Inability of conventional medicine,to meet patient expectations; • Conventional medicine's focus on the diagnosis and not the patient; • Alternative Care is patient -centered and treats each patient as a"unique, human being; and, • Alternative Care focuses on the mind/body connection in the healing process. Why did Sloans Lake Introduce Alternative Care? • In response to a growing un-met market need; • To introduce a unique preventive/wellness philosophy; • To promote a cost-effective approach for many stress or anxiety related problems; and i • To begin the journey to change the focus of health care by introducing a mind/body element into patient care.►'" What does Sloans Lake Health Plan Cover? • Acupuncture Chinese Medicine (traditional) • Ayurvedic Medicine Homeopathy • Herbology Naturopathic Medicine • Massage Therapy/Manual Healing Mind/Body Interventions ALTFACT$ 05/98 0 What Benefits Do We Offer' Three Rider Options are available to Sloans take Health Plan members: • $250 per member, per calendar year maximum • .$500.per.member, per calendar year maximum $750 per member, per calendar year maximum All plans feature: • $20 office visit copayment; Access to'Sloans Lake Health Plan's comprehensive, credentialed network; No Primary Care Physician referral required; - • Continued treatment available.with provider after exhausting maximum benefit at negotiated fee schedules; and • Massage Therapy is covered at 50% of the maximum benefit. Facts of • In 1997, the Journal of the American Medical Association (JAMA) • reported that in one year, Alternative Care moved from 76th to 3ra most critical subject of interest in the publication. • 42% of the population use an Alternative Care provider. In 1993, there were more Alternative Care visits than Primary Care Physician visits reported, 425 million versus 388 million. • 72% of patients did,not report their Alternative Care visit to their regular physician. • Approximately $20 billion was spent on Alternative Care services with ' — about 3/4 of that spent out of pocket. -. Health care for Everyday life ,Sloane Lake Health Plan, 1355 S. Colorado Blvd., Suite 902, Denver, Colorado 80222 Phone 800.850.5$88 Pax`303.504.532� SLOANS LAKE HEALTH PLAN _4PJCM45JVeCARE SERVICES DESCRIPTION Alternative Medicine is made up of a rich array of therapies, techniques, philosophies, practices, modalities, and medical systems that primarily come to us from other cultures or from ancient healing traditions. Because they are unfamiliar to most of us who have grown up with conventional, or allopathic, medicine, this type of medicine is considered "alternative." You may have heard alternative care referred to by different terms such as unconventional medicine, complementary medicine, holistic medicine, environmental medicine, integrative medicine, integral medicine, or preventive medicine. Generally speaking, alternative care providers believe that within us is a natural ability to heal, an inherent recuperative power that is the key to all healing. The alternative care provider's job, therefore, is to support and stimulate this natural healing ability inherent in each patient. Sloans Lake Health Plan has developed and credentialed a network of alternative care providers to provide alternative care services to Subscribing Groups which elect any one of the three Alternative Care Services Riders. These services include: acupuncture, ayurvedic medicine, Chinese medicine, herbology, homeopathy, massage therapy/manual healing, mind/body interventions, naturopathic medicine, and other services as determined by the alternative care provider.* Because it is critical to each individual's healing pattern to find the type of provider best suited to his or her needs, we have prepared the following list of definitions to help you in your search: Acupuncture is a treatment which involves the insertion of a very fine needle into one or more of over one thousand acupuncture points located along twelve energy channels or meridians on the body. This treatment affects the flow of energy, which the Chinese call "chi," to help heal the patient. Acupuncture has been shown to be an effective treatment for pain, migraines, addictions, duodenal ulcers, tennis elbow, paralysis from stroke, and osteoarthritis. Ayurvedic Medicine is an ancient system of healing from India that treats the whole person with diet, nutrition and lifestyle recommendations. The key components to this system of healing include the concept of "prana," or vital energy; the five elements (earth, water, fire, air, ether) and how well they are balanced in the individual; and the three constitutional types: vata, pitta, and kapha. The goal of Ayurveda is to bring about individual well-being so that spiritual development can take place. Chinese Medicine (traditional) is one of the oldest systems of medicine in practice in the world today. The primary focus is on prevention and a natural view of the world with the person being a microcosm of that world. Also important is the concept of "chi," or vital force, and how well it is flowing and balanced in terms of the "yin" and "yang" principles of Chinese thought. Acupuncture, Chinese herbs, massage, food therapy, exercise, and lifestyle changes are some of the treatment methods used in this system. ALTDSCRPTN O1/98 Continued Herbology includes any interventions that utilize herbs and botanicals. Many herbal products once found only in the old-time pharmacy are now finding their way back to our modem store shelves. Some of the more popular herbs being used today include ginkgo biloba for Alzheimer's Disease, hawthorn berry extract for heart disease, valerian root extract for insomnia and anxiety, milk thistle extract for hepatitis, and saw palmetto for prostate problems. This modality is a major component of Ayurvedic Medicine, Naturopathic Medicine, and traditional Chinese medicine, among others. Homeopathy is a system of medicine that is almost three hundred years old and has been practiced in the United States since 1825. It is based on the "Law of Similars" that states that "like cures like." For example, a minute dose of belladonna, normally a poison in larger quantities, may be prescribed for symptoms that are similar to those of belladonna poisoning. Remedies for treatments are made from plants, animals, and minerals. It is believed that the minute nature of the doses stimulates a healing response in the body. The official remedy book, Homeopathic Pharmacopoeia of the United States, is recognized by the FDA. Massage Therapy/Manual Healing includes those techniques that focus on touch and manipulation with the practitioner's hands on the physical body of the patient. They include such techniques as Swedish, sports, Esalen, deep tissue, soft tissue, and St. Johns massage; Rolfing; reflexology; acupressure; craniosacral therapy; shiatsu; and trigger point therapy. This modality is a major component of Ayurvedic Medicine, Naturopathic Medicine, and traditional Chinese medicine, among others. Mind/Body Interventions include those interventions that emphasize the profound interconnectedness between the mind and body and the influence each has on the other. Treatments such as guided imagery and active visualization, biofeedback, meditation techniques, relaxation techniques, hypnotherapy, art therapy, sound and music therapy, hatha yoga, Val chi, qigong, martial arts, dance/movement therapy, color and light therapy, and aromatherapy are some of the more common mind/body interventions. Also included are various exercise programs designed to increase cardiovascular health, lymphatic flow, range of motion, and increased vital energy. MindlBody Interventions are a major component of Ayurvedic Medicine, Naturopathic Medicine, and traditional Chinese medicine, among others. Naturopathic Medicine is a system of medicine that utilizes natural therapies to stimulate the body's innate healing ability. The goal of all treatments is to raise the vital energy so that the body can reestablish health. It is rooted in the concepts of the healing power of nature, treatment of the whole person, doing no harm, and treating the cause. Built on treatments sometimes thousands of years old, it first gained popularity in the United States in the 1920s. Sloans Lake Health Plan does not endorse any particular alternative care provider, service, modality, or system of treatment. While a referral from your Primary Care Physician is not required to access Alternative Care Services, we encourage you to discuss your health care needs and interest in receiving Altemative Care Services with your PCP. Reference: Morton, Mary & Michael. Five Steps to Selecting the Best Alternative Medicine: A Guide to Complementary & Integrative Health Care. New World Library, 1996. • To ensure coverage for these services, we recommend you verify the current participation status of a provider by calling Customer Service at 1-800-850-5888. I "Physician hereby agrees that in no event, including but not limited to, non- payment by HMO, HMO insolvency or breach of this Agreement, shall Physician bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Member, or persons other than HMO acting on their behalf for Covered Services provided pursuant to this Agreement. This provision shall not prohibit collection of supplemental charges or Copayment, coinsurance and/or deductible amounts in accordance with the terms of the Member Agreement between HMO or Payor and Members." 3. Will you agree to the following contract provision for termination of agreement? Termination of Agreement. This Agreement may be terminated at any time by mutual consent of both parties. This Agreement may be terminated by either party at any time upon sixty (60) days written notice to the other party. Sloans Lake Managed Care agrees to the termination of agreement clause. Financial 1. The City currently uses the 1997-98 St. Anthony's RVS Schedule for Physicians for the network services. Will you agree to continue the use of these schedules? If no, please indicate the schedules you currently use. Do your factors vary by area throughout your network? Please specify. Sloans Lake Managed Care agrees to use the 1997-98 St. Anthony's RVS Schedule for Physicians for the network services. Factors do vary by area throughout the network and the TPA will receive this information through the Provider. Conversion Factors 1. Please furnish conversion factors applicable to the 1997-98 St. Anthony's RVS Schedule for Physicians for determining your Participating Physicians maximum allowable charge for a covered service(s), as determined by the Plan. For purpose of your response to this request, please identify whether a withhold arrangement is assumed. Conversion factors are proprietary information and therefore not available. Sloans Lake Managed Care does not utilize a withhold program. Medicine $Not available Surgery $Not available Obstetrical $Not available Radiology $Not available Sloans Lake Managed Care 16 City of Fort Collins July, 98 INTERNET SERVICES Internet Provider Directory Lookup This lookup enables members, providers, insurance carriers and others to locate Sloans Lake providers. Users can locate appropriate providers based on specialty, zip code, age, gender and language capabilities. For example, a user can request a "female neurologist in xyz suburb who speaks Spanish". Internet Provider Directory Download Enables members, providers, insurance carriers and others to "download" (or copy) Sloans Lake providers. Users can download appropriate providers based on specialty, zip code or other factors. Internet Claim Status Inquiry Enables providers and insurance carriers to review status information on claims (bills) submitted to Sloans Lake. Information includes date received, date processed, repriced amount, insurance carrier (if applicable), insurance carrier phone number, etc. Locating a Participating Physician on the Internet 1. Access the Sloans Lake Managed Care web site at http://www.sloanslake.com 2. Click on the "Provider Directory" button 3. Choose the type of product you have with Sloans Lake Managed Care 4. (ie: PPO, CCM) 5. Click on "Find a Physician" 6. Enter your group name followed by the percent (%) sign, then click submit 7. Click "PPO Physician" 8. With this screen you have multiple options to aid you in the search for a physician. Choose the appropriate options by entering the physician's criteria. 9. You may click on any provider and view demographic and other information. Use the link to MapQuest to locate a map and directions to the provider's office. m J, i L J 0 v 0 N -0 }0}.� 0. N O Q ^ bo r) 0] N 0 O 0 1� lV o 'O . U I 'aD 0 � 0 W 6. U O O u A �y d N O !] N Red u H r�s o 5, 't 0 ~ 0 N v w L) Y y u E v UO ° ° ° 'o o o r. qu 0 0 o 5 I Uo ca'i p U 1r :q O a, '0 -o cw 0 } 04 0 1--I Cd ed 1--i O a ov N Sal 00 O� M 00 E 00 o, M 00 7: u 91 r. s: y O 00 rn r. M 00 0PON ci •^y rA O •U a a Or 8 U uQi W C VILL IL U N c Z a 4) aon a d .r Tn 00 o, M 0000 rA O 7" i • • • • • • • • . • I ► ► ► ► .. ► - ► • _ • • . I ..�.ho;w 00 W 00 0 0 00 a M 00 r s: y M o ca rA N p U a O N A � O ao 0 .� OW .Poy zw� ,o a b W�W�E N^Nw>' rn 00as O� yL>'41 iz o oblD�60 ° rn �60t �1 a,d �Vr°" ° =acon °' 40 601 y o 'r. 0 y•aU a oaw a yoa�ob nc. N .S.i• N y c� d) o c� y� CN y •-- O y A •O � C O U N o���� Pathology (laboratory) $Not available Anesthesia $Not available For unlisted or by -reports procedures, will you approve 80% of usual, customary and reasonable charges, as determined by the City, as the participating physician's maximum allowable charges? If no, please submit your proposal for the pricing of these claims. Sloans Lake Managed Care will determine pricing based on the particular claim. If lab fee reimbursements are not to be based on the 1997-98 St. Anthony's RVS Schedule for Physicians, please describe your proposed reimbursement arrangement. Lab fee reimbursements are based on the 1997-98 St. Anthony's RVS Schedule for Physicians. Hospitals 1. What is the average discount over allowable for Metro Denver area hospitals in aggregate at a minimum, by hospital preferred? Average hospital discounts range from 25-30%. 2. Please complete the following table for McKee Medical Center, Poudre Valley Hospital and North Colorado Medical Center facilities, as applicable. Not available, proprietary information. Name of Hospital: Indicate type and amount of contractual agreements (per diem or DRG preferred): Negotiated Rates: Inpatient• Medical/Surgical ICU/CCU Normal Vaginal Delivery NICU Other (specify) Outpatient: Sloans Lake Managed Care 17 City of Fort Collins July, 98 CONCLUSION Sloans Lake Managed Care is distinguished in the market as a health care solutions company. Through the quality of our service, the caliber of our employees, a commitment to our customers, and the innovation of our products we stand above and beyond our competition. Our partnerships with our providers is key in the success of our operation. Without provider understanding and support, the best benefit strategies are doomed to fail. We continue to improve quality and reduce costs through sharing of information with our providers, profiling and bench marking, which inturn reduces utilization of treatment. Sloans Lake Managed Care looks forward to the opportunity of partnering with the City of Fort Collins to better control your health care needs. No Text Sloans Lake Managed Care 18 City of Fort Collins July, 98 EXHIBIT 'B' YEAR 2000 COMPLIANCE CERTIFICATION AND INDEMNITY Sloans Lake Managed Care hereby represents and warrants that it shall use best efforts to ensure that services and products provided by Sloans Lake which are affected by the year 2000 issue will continue to operate at the same level of functionality as prior to the year 2000 date change. Sloans Lake has budgeted 1,800 hours in 1998 to review and correct any possible year 2000 issues. Section 1. Contractor hereby certifies that all information resources or systems to be provided or used in connection with the performance of this Agreement are "Year 2000 Compliant" shall mean that information resources meet the following criteria: a. Data structures (e.g., databases, data files) provide 4-digit date century recognition. For example, 111996" provides date century recognition; "96" does not. b. Stored data contains date century recognition, including (but not limited to) data stored in databases and hardware/device internal system dates. c. Calculations and programs logic accommodate both same century and multi -century formulas and date values. Calculations and logic include (but are not limited to) sort -algorithms, calendar generation, event recognition and all processing actions that use or produce date values. d. Interfaces (to and from other systems or organizations) prevent non- compliant dates and data from entering any state system. e. User interfaces (i.e., screen; reports; etc.) accurately show 4 digit year. f. Year 2000 is correctly treated as a leap year within all calculations and calendar logic. Section 2. Contractor has identified the following information resources or systems that will be provided or used in connection with the performance of this Agreement that are not, or will not by December 1, 1998, be year 2000 compliant: Section 3. Sloans Lake Managed Care 19 City of Fort Collins July, 98 a. Contractor hereby certifies that the instances of information resources or systems not Year 2000 compliant identified in Section 2, above, will be compliant no later than December 1, 1998 , and that Contractor shall notify the City of the status of Year 2000 Compliance for such resources or systems upon the earlier of the date Year 2000 Compliance is achieved or on June 30, 1999. b. Contractor hereby certifies that the instances of information resources or systems not Year 2000 compliant identified in Section 2, above, as not Year 2000 Compliant, and for which year 2000 Compliance is or will not be achieved by December 1, 1998, are not related to and do not impair the performance by the Contractor of the terms of this agreement, and do not produce new non -compliant information resources or systems. Section 4. Contractor agrees to notify the City immediately of any information resources or systems that are not year 2000 Compliant upon encountering the same in connection with the performance of the Agreement, including without limitation an information resources or systems in use by the Contractor in the performance of the Agreement or information resources or systems of the City regarding which Contractor obtains information in the course of its performance of the agreement Section5. Contractor agrees to permit examination, by the City or agents thereof, of any and all information resources and systems in use in connection with this Agreement, and related Year 2000 Compliance implemented plans, in order to evaluate Year 2000 Compliance and potential implication of the same for the City and for performance of the Agreement. Section 6. The Contractor shall indemnify and hold harmless the City, and its officers, agents and employees, from and against all claims, damages, losses, and expenses, including attorneys fees, arising out of or resulting from the Contractor's failure to disclose instances of information resources or systems that are not year 2000 Compliant, or failure to comply with the terms of this Exhibit C. Sloans Lake Managed Care hereby represents and warrants that it shall use best efforts to ensure that services and products provided by Sloans Lake which are affected by the year 2000 issue will continue to operate at the same level of functionality as prior to the year 2000 date change. Sloans Lake has budgeted 1,800 hours in 1998 to review and correct any possible year 2000 issues. Sloans Lake Managed Care 20 City of Fort Collins July, 98 Rate Quotes Questionnaire Attachment A- Financial Statement Attachment B- Statement of Organizational Resources Attachment C- Marketing Materials Attachment D- Provider Credentialing Plan Attachment E- Quality Program Attachment F- Provider Directory Attachment G- GeoAccess Analysis Utilization Management Questionnaire Requested Attachments Disruption Analysis & Directory Match Attachment A Financial Statement Sloans Lake Management Corp. Consolidated Financial Statements December 1997 Sloans Lake Management Corp. Financial Statements Table of Contents Consolidated Financial Statements Consolidated Comparative Balance Sheet 1-2 Consolidated Income Statement 3 Consolidated Statement of Cash Flow 4 Sloans Lake Management Corp. Comparative Balance Sheet 5-6 Income Statement 7 Statement of Cash Flow g Sloans Lake Health Plan, Inc. Comparative Balance Sheet 9 -10 Income Statement 11 Statement of Cash Flow 12 Other Financial Information Combined Statement of Operations - PPO 13 Combined Statement of Operations - HMO 14 Comparative Statement of Operations - PPO 15 Statement of Operations - Group Health 16 Statement of Operations - Auto Division 17 Statement of Operations - Case Management Is Sloans Lake Management Corp. Consolidated Comparative Balance Sheet December 31, 1997 Current Liabilities Accounts Payable Accrued Salaries and Benefits Deferred Revenue Current Portion of Long -Term Obligations Other Current Liabilities Total Current Liabilities Long Term Liabilities Long -Term Obligations, Less Current Portion Other Long -Term Liabilities Total Long -Term Liabilities Shareholder's Equity Common Stock Retained Earnings Unrealized Holding Gain/(Loss) on Investment Total Shareholder's Equity Total Liabilities and Shareholder's Equity Page 2 Increase Current Jan. 1, 1997 (Decrease) 1,954,553 1,792,726 161,827 2.206,179 1,301.355 904,824 742,122 507,266 234,856 153,504 152,382 1,122 4,044,687 1,936.776 2,107,909 - 9,101,045 5,690,506 3,410,538 44,720 198,224 (153.504) 240,000 1,093,156 (853,156) 284,720 1,291,380 (1,006,660) 12,832,194 10,634,694 2,197,500 (4,268,104) (2,484,390) (1,783,714) 23,238 (3,750) 26,988 8,587,327 8,146,554 440,774 17,973,092 15,128,440 2,844,652 Sloans Lake Management Corp. Consolidated Statement of Cash Flow December 31, 1997 Operating Activities Net Income / (Loss) Adjustments to Reconcile Net Income / (Loss) to Net Cash Provided by Operating Activities: Depreciation Amortization Amortization of Premium (Discount) on Investments (Inerease)/Decrease in Assets: Accounts Receivable Due From Affiliates Other Current Assets Other Assets Increasef(Decrease) in Liabilities: Accounts Payable Other Current Liabilities Total Adjustments Net Cash Provided By/(Used For) Operating Activities Investing Activities Net Additions to Property and Equipment Proceeds from Available -for -Sale Investments Purchase of Available -for -Sale Investments Net Change in Restricted Cash Market Value Adjustment Net Cash Provided By/(Used For) Investing Activities Financing Activities Net Change in Long -Tenn Liabilities Net Dividend Distributions Net Change in Contributed Capital Net Change in Common Stock Net Cash Provided By/(Used For) Financing Activities Net Increase/(Decrease) in Cash and Cash Equivalents Net Increase/(Decrease) in Short -Term Investments Net Increase/(Decrease) in Long -Terre Investments Cash and Cash Equivalents - Beginning of Period Short -Terre Investments - Beginning of Period Long -Term Investments - Beginning of Period Cash and Investments - End of Period Detail of Cash and Investments - End of Period Cash and Cash Equivalents Funds Held in Trust Short -Term Investments Long -Tenn Investments Page 4 Month -To -Date Year -To -Date (556,750) (1,783,714) 104,924 952,567 3,069 36,834 (14,482) (55.749) 5,769 (2,329,436) 0 52,253 (274,010) (761,220) 25,105 (192,597) 143,220 162,237 367.705 3,740,350 361.298 1.605,239 (195.453) (178,476) (369.516) (1,054,436) 0 8.659.589 (45,911) (7,382,738) 1 (0) 29,842 26,987 (385,585) 249,401 50,935 (1,006,660) 0 0 0 0 0 2,197,500 50,935 1,190.840 (530.103) 1,261,765 50,192 (1,029.841) 0 (253,662) 7.615,687 5,823,818 2,017,212 3.097.246 0 253.662 9,152, 991 9,152, 991 7,085,587 0 2,067,404 0 9,152.991 Sloans Lake Management Corp. Comparative Balance Sheet December 31, 1997 Current Liabilities Accounts Payable Accrued Salaries and Benefits Deferred Revenue Current Portion of Long -Tenn Obligations Other Current Liabilities Total Current Liabilities Long -Term Liabilities Long -Term Obligations, Less Current Portion Other Long -Term Liabilities cal Long -Term Liabilities Shareholder's Equity Common Stock Retained Earnings Unrealized Holding Gain on Investment Total Shareholder's Equity Total Liabilities and Shareholder's Equity Page 6 Increase Current Jan. 1, 1997 (Decrease 1,874,106 1,800,137 73,969 2,206,179 1.301,355 904,824 249,968 291,189 (41,221) 153,504 152,382 1,122 1,039,227 1,501,333 (462,107) 5,522,984 5,046,397 476,587 44,720 198,224 (153,504) 240,000 1,093,156 (853,156) 284,720 1,291,380 (1,006,660) 12,832,194 10.634,694 2,197,500 (4,268,103) (2,484,390) (1,783,713) 0 2,855 (2,855) 8,564,091 8.153,159 410,932 14.371,794 14,490,936 (119,140) Sloans Lake Management Corp. Page 6 Statement of Cash Flow December 31, 1997 Operating Activities Net Income / (Loss) Adjustments to Reconcile Net Income / (Loss) to Net Cash Provided by Operating Activities: Depreciation Amortization Amortization of Premium (Discount) on Investments (Increase)[Decrease in Assets: Accounts Receivable Other Current Assets Other Assets Increase/(Decrease) in Liabilities: Accounts Payable Other Current Liabilities Total Adjustments Net Cash Provided By/(Used For) Operating Activities Investing Activities Net Additions to Property and Equipment Proceeds from Available -for -Sale Investments Purchase of Available -for -Sale Investments Investment in Sloans Lake Health Plan, Inc. Market Value Adjustment Net Cash Provided By/(Used For) Investing Activities Financing Activities Net Change in Long -Tenn Liabilities Net Dividend Distributions Net Change in Contributed Capital Net Change in Common Stock Net Cash Provided By/(Used For) Financing Activities Net Increase/(Decrease) in Cash and Cash Equivalents Net increasel(Decrease)in Short -Term Investments Net Increase/(Decrease) in Long -Tenn Investments Cash and Cash Equivalents - Beginning of Period Short -Tenn Investments - Beginning of Period Long -Term Investments - Beginning of Period Cash and Investments - End of Period Detail of Cash and Investments - End of Period Cash and Cash Equivalents Funds Held in Trust Short -Term Investments Long -Term Investments Month -To -Date Year -To -Date (556,750) (1,783,714) 104,924 952.567 3.069 36,834 0 (5,961) 199.980 (280,217) (295,096) (1,069,241) 25,105 (192,597) 155,025 73,969 (117,857) 402.618 75,150 (82,027) (481,600) (1,865,741) (369,516) (1,054,436) 0 259,623 0 0 408.814 1,790.277 0 (2,855) 39,297 992.609 50.935 (1,006.660) 0 0 0 0 0 2,197,500 50,935 1.190,840 (391,367) 317,709 0 0 0 (253.662) 6,015,835 5,306,759 0 0 0 253,662 5.624.458 5,624,468 5.624,468 0 0 0 5.624,468 Sloans Lake Health Plan, Inc. Comparative Balance Sheet December 31, 1997 Current Liabilities Accounts Payable Unpaid Claims Liablilty Deferred Revenue Due to Affiliates - Current Portion Other Current Liabilities Total Current Liabilities Long -Term Liabilities Loans and Notes - Long Term Due to Affiliates Other Long -Term Liabilities Total Long -Term Liabilities Net Worth Capital Stock Paid In Surplus Reserved Surplus Retained Earnings Dividends Paid Unrealized Holding Gain/(Loss) on Investment Total Net Worth Total Liabilities and Net Worth Page 10 Increase Current Jan. 1, 1997 (Decrease) 80,447 44,597 35,850 2,992,947 390,526 2.602,420 492.154 216,077 276,077 1,063,625 114,132 949,493 12,513 45,162 (32,650) 4,641,685 810,495 3.831,190 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,000,000 3,000,000 0 0 0 0 (1,698,756) 91,520 (1,790,277) 0 0 0 23,238 (6,605) 29,843 1,324.481 3,084,915 (1,760,434) 5,966,167 3,895.410 2,070,756 Sloans Lake Health Plan, Inc. Page 12 Statement of Cash Flow December 31, 1997 Operating Activities Net Income / (Loss) Adjustments to Reconcile Net income / (Loss) to Net Cash Provided by Operating Activities: Depreciation Amortization Amortization of Premium (Discount) on Investments (increase)/Decrease in Assets: Premiums Receivable Due From Affiliates Other Current Assets Increase/(Decrease) in Liabilities: Accounts Payable Claims Liability Other Current Liabilities Total Adjustments Net Cash Provided Byl(Used For) Operating Activities Investing Activities Net Additions to Property and Equipment Proceeds from Available -for -Sale Investments Purchase of Available -for -Sale Investments Net Change in Restricted Cash Transfers from/(to) Related Organizations Market Value Adjustment Net Cash Provided By/(Used For) Investing Activities Financing Activities Proceeds from Paid In Capital or Stock Issuance Net Dividend Distributions Other Net Change in Long -Tenn Liabilities Net Cash Provided Byl(Used For) Financing Activities Net increase/(Decrease) in Cash and Cash Equivalents Net Increase/(Decrease) in Short -Term Investments Net Increase/(Decrease) in Long -Term Investments Cash and Cash Equivalents - Beginning of Period Short -Terre Investments - Beginning of Period Long -Tenn Investments - Beginning of Period Cash and Investments - End of Period Detail of Cash and Investments - End of Period Cash and Cash Equivalents Short -Tenn Investments Long -Term Investments Month -To -Date Year -To -Date (408,814) (1,790,277) 0 0 0 0 (14.482) (49.788) (194,211) (2,049,219) 0.00 52,253.00 (15,311) (97,171) (11,805) 36,260 99.431 2,602,422 422,527 1,192,508 286.149 1.687,266 (122,665) (103,011) 0 0 0 8,399,966 (45,911) (7,382,738) 0 0 0 0 29,842 29.842 (16,070) 1,047,070 0 0 0 0 0 0 0 0 (138,734) 944.059 50,192 (1,029,841) 0 0 1,599,852 517,059 2,017.212 3.097,246 0 0 3.523.522 3,528,522 1.461.113 2.067,404 0 3,528.522 Sioans Lake Management Corp. Combined Statement of Operations - HMO For The Period Ending December 31, 1997 Month -To -Date Year -To -Date Page 14 Actual Budget Variance Actual Budget Variance Membership 17,691 18,963 (1,272) 173.151 180,107 (6,956) Premium Revenue PMPM 94.95 111.26 (16.30) .. 110.88 109.05 1.83 Medical Expense PMPM -102.89 90.12 (12.79) 103.27 88.33 (14.93) Medical Loss Ratio 108.4% 81.0% (27.4%) 93.1% 81.0% (12.10%) Marketing Fees % of Premium 2.9% 5.1% 2.2% 3.3% 4.9% 1.6% Revenue Premiums Earned Reinsurance Recoveries Interest Income Total Revenue Expenses Salaries and Wages Employee Benefits Contract Labor )nsulting and Legal Fees . ,dvertising Insurance Travel and Education Meals and Entertainment Lease and Rental Maintenance and Repair Medical Expenses Reinsurance Premium Marketing.Fees Office and Other Expense Bad Debt Expense Interest Depreciation Amortization Total E: penses •• Net Income From Operations 1,679,819 2.109,735 (429,916) 19.198,207 19,640,623 (442,416) 0 0 0 0 0 0 15,604 15,553 51 224.640 184.049 40,591 1,695,423 2,125.288 (429,865) 19,422,847 19,824,673 (401.826) 160,318 184,108 23,790 2,070,037 2,055,226 (14.811) 27,055 46.279 19,224 679.307 522.676 (156,631) 7.908 2.569 (5,339) 96,626 29.383 (67.243) 51,558 32,677 (18,881) 560,085 362,011 (198.074) 23,484 31,885 8.401 339.772 347,202 7.430 5.757 4,451 (1,306) 61,557 50,850 (10.707) 9,710 10.927 1,217 96,239 124,816 28,577 3,731 3,841 110 61.947 43,949 (17.998) 16,892 18,830 1,938 188,157 215,190 27,033 10,731 4,331 (6,400) 82,477 49,500 (32,977) 1,804,401 1,700,762 (103,639) 17,761.373 15,831,705 (1,929.668) 15,864 8,125 (7,739) 120,011 77,200 (42,811) 48,797 106,889 58,092 640,135 971,882 331.747 170,984 64,419 (106,565) 817,419 734.505 (82,914) 0 0 0 0 0 0 264 849 585 4,518 9,740 5,222 13.375 17,367 3,992 141,685 201,918 60.233 0 0 0 0 0 0 2,370,828 2,238,309 (132,519) 23,721.343 21.627,753 (2,093.590) (675.405) (113.021) (562,384) (4.298,496) (1.803,080) (2,495,415) Rate Quotes i s � Sloans Lake Management Corp. Page 16 Statement of Operations - Group Health For The Period Ending December 31, 1997 Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance Revenue Group Health 584,565 711,442 (126,877) 7,007,532 8,002,704 (995,172) Provider Fees 359,911 160,020 199.891 3,367,317 1,800,000 1.567.317 Other PPO Revenues 85,013 75,743 9,270 1,028,222 852,000 176,222 Interest Income 29,349 22,402 6,947 299,382 252,000 47,382 Total Revenue 1,058,838 969,607 89,231 11.702,453 10,906.704 795,749 Expenses Salaries and Wages 477.097 439,881 (37,216) 5,517,698 5,079,033 (438,665) Employee Benefits 70,467 110,357 39,890 1,709,292 1,279,119 (430.173) Contract Labor 34,890 8,615 (26,275) 324,377 98,997 (225,380) Consulting and Legal Fees 88,329 54,607 (33,722) 1,081,373 627,697 (453,676) Advertising 20,661 19,467 (1,194) 265.139 223,763 (41,376) Insurance 15,256 11,408 (3,848) 163,567 131,150 (32,417) Travel and Education 9,694 17,753 8,059 184.839 204,130 19,291 Meals and Entertainment 9,198 4,363 (4,835) 107,776 50,171 (57,605) ,iase and Rental 52,830 50,282 (2,548) 623,481 577,950 (45,531) ,aintenance and Repair 17,030 32,793 15,763 230.313 376,929 146,616 Office and Other Expense 380,131 178,660 (201,471) 2.295,967 2,051,748 (244.219) Management Fee (412,098) (334,063) 78,035 (3,970,720) (3,867,230) 103,490 Bad Debt Expense 104,969 9,874 (95,095) 242,280 102,000 (140,280) Interest 883 2,749 1,866 15,665 31,600 15,935 Depreciation 91,549 74,418 (17,131) 810,883 837,258 26,375 Amortization 2,333 2,666 333 28,000 30,000 2,000 Total Expenses 963,219 683.830 (279,389) 9.629.929 7,834.315 (1,795,614) Net Income From Operations 95,619 285,777 (190,158) 2,072,524 3.072,389 (999,865) Sloans Lake Management Corp. Page 18 Statement of Operations - Case Management For The Period Ending December 31, 1997 Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance Revenue Case Management 264,853 277,285 (12,432) 2,886,641 2,943.576 (56,935) Other Revenue 0 0 0 0 0 0 Total Revenue 264,853 277,285 (12,432) 2,886,641 2,943,576 (56,935) Expenses Salaries and Wages 134,204 148.571 14,367 1,677,517 1,605,873 (71,644) Employee Benefits 21,883 31,198 9,315 235,113 337,232 102,119 Contract Labor 1,977 3,373 1,396 14,099 38,800 24,701 Consulting and Legal Fees 650 902 252 10,647 10,371 (276) Advertising 191 376 185 4,917 4,326 (591) Insurance 0 0 0 0 0 0 Travel and Education 3,193 2,245 (948) 29,360 25,777 (3,583) Meals and Entertainment 214 313 99 3,032 3,600 568 Lease and Rental 4,951 2,946 (2,005) 56,392 33,880 (22,512) Maintenance and Repair 0 69 69 394 784 390 )ffice and Other Expense 15,415 9,731 (5,684) 131,828 111,768 (20.060) Management Fee 108,602 87,886 (20,716) 1,071,608 1,037,615 (33,993) Bad Debt Expense 0 368 368 3,735 4,230 495 Interest 0 0 0 0 0 0 Depreciation 0 0 0 0 0 0 Amortization 736 750 14 8,835 9,000 165 Total Expenses 292,016 288,728 (3,288) 3,247,477 3,223.256 (24,221) Net Income From Operations (27,163) (11.443) (15,720) (360,837) (279,680) (81,157) Attachment B Statement of Organizational Resources • 1' SLOANs LAKE MANAGED CARE 1355 S. Colorado Blvd. Suite 902 • Denver, Colorado 80222 • 303/691-2200 Statement of Organizational Resources Sloans Lake Managed Care has adequate personnel and financial resources to provide the services indicated in this Request for Proposal for the City of Fort Collins. Printed Name: Robert Falkenberiz Signature: Title: Vice President of Marketing & Sales Date: July 27, 1998 Sloans Lake Managed Care u Attachment C Marketing Materials No Text i SWANS LAKE.., _ GROWING WITH COLORADO Since forming in 1978, Sloans Lake has been organization customers. - (PPO) and personal injury protection (PIP) lines of business. We attrbute' our success to the many `trusted relationships developed with providers, payers and other valued customers.We pride ourselves on the development of innovative products to meet our customers' needs and a never- ending commitment to deliver Elie highest level of customer service. attribute bur' ; touch more a company on Elie move, growing into one of the to healll7 Aare urg7uizatiUns in Colorado. Zoday, we Sloans Lake's roots can be traced back to its beginnings as a PPO business, which has now evolved into the state largest and best performing PPO network., providing coverage to more than 450,000 residents. Through the years, our managed care network. Cas continued to grow and consists (if. r Soule 7,300.physieians and nearly 70 hospitals. \ In 199•I, we expanded into auto" managed care by developing a Firs[ -of - its -kind PIP program. As, a result, we have established contracts with many of Elie state'; largest auto insurance carriers to provide access to health care for individuals injured in au[u accidents. With more than l.2 millionColoradd drivers covered by Elie Sloans Lake Managed Care auto network., we have hceonte Elie industry leader. The managed care option has returned as tnuclt as $65 million in one year to state residents through reduced medical care costs and PTT) p;emiu ms. Seeing Elie continuing trend in " eonbumer interest relative to HMOs, we developed Sloans Lake Health Plan in 1995. 'The addition of the HNlO furthers our strategic objective to be a full -service managed care organization to meet the needs of Colorado consumers. And, the health plan allows us to capitalize on our strong provider relationships, broad network, managed care experience and existing prose lice in Elie community. 1) satisfy consumer demand for greater choice and flexibiflity, Sloans Lake IIeallh flan has introduced various innovative product lines. Our point - Perhaps of most interest,, to our customers, we were the first -HMO in the state#o create a comprAensive, , credentialed alternative- care netusOrk for,me1gS`ion info our hiealth, Mans. 4-service plans providis out of rte'lwork. plan benefits in addition to traditional HMO benefits, and our Freedom ,Series plans provide direct access to any Participating physician in the health plan network.. Perhaps of most interest to our customers, we were the first INIO in Elie state to create a comprehensive, credentialed alternati-- care netwock for inclusion into ot�r health plans. SLOANS LAKE... LOCALLY OWNED AND OPERATED I,ik.e you, we ]rave witnessed the ongoing consolidations and mergers that have impacted Elie health care industry in. recent years, and Elie resulting coil - Bern and turmoil experienced by cus- tomers. 'lo solidify our financial future, we felt it was important to partner with a local organization with which we could pursue our goals. 7o that end, Sloans Lahe'was acquirer] in 1991 by Centura Health Systems, the largest not -for -prof- it hospital system in Colorado This relationship strengthens Sloans Lake financially, yet enables us to in twin our own identity. t'nUe publicly uraded companies, our vision is not clouded by a singular focus on lie ho[Lom lino. Sure, wo I11u6L make a profit m 'order to renai❑ in business and serve our cusLomcrs, huL success A � loans LAC will he measured by performance and quality of :are, not by 'ill E1rc01: We also LAC our role as a good corporate citizen very seriously, and we are proud Lo he a leading player in Llrc Coloradu hcallh care industry. Sloaiis Lalze curroidy eniplovs some 400 people and expects to continue �ruwing. c0lupany and its eniployecs are actively iuvolvcd in a variety of community organiralioiis and acLiviLics to riza c Colorado a icllor place in W] ich Lo live. SLOANS LAKE... WHAT COLORADO NEEDS Our goal is to budd[lie company into t Ale 4 the ndLion99�s leadiii� aria naked care organizations. T) ackieve Lhis, Sloan® I_Ae's strategy will focus ou product innovation, performance accountahihty, and a balanced approach to delivering quality, y;ost-effective care. "]'his strafcgy will be supported by an underlying philosophy of simplification r return to old-fashioned -values in' the way we conduct husiness. 14orts Lo huild our managed care presence in Colorado are focused oil the support of existing products and [lie introduction of a variety of new products to fulfill unnleL marLeL needs. in keeping wide our innovative spirit, al ernaLive care will play a pivotal role in future product development. from our point of view, "coolie cutler" benefit ` plans and utilization ni<ana0luciA pro ranis ignore individual (lirferences in healing;patterns, and have served only to reinforce die T'niLcd StaLo ' heap} care sysLem as, "sick, care" rallier than "hcallh care." I\)u;en[ erndics indicate that beLween sixty and ninety percent of all doctors' office visits are sfress-rclaLed, and probably cannot be Lrealed wide the external tolls commonly used by d,c ncdical profa essiou. To will Lherclore place 1grcatcr cnnplyasis oil [lie iLitcradion of Llle mind all(] hodv in Lhc healing process. "Ihis effort will focus oil introducing spirituality into - Lhc healing process, thus placing loans I.Ae at the forefront of Lhc cu.rreul revolution of mind -body medicine We are connuiLLed to providing quality service and will he held accounLable for our performance. We will provide Lankihle proof of our performance by sliarinR our cusLoma' service telephone wait Lime, claims turnaround Lime, and Ill card production time wide all of our SLOANS LAKE... PRODUCTS AND SERVICES, PPO: ■ Sloans Lake Managed Care network -access' ■ Repricing ■ Utilization Review r■ Case Management ■ Coordinated Care Management ■ Baby Talk prenatal program ii Employee Assistance Programs (EAP) ■-Provider Directories ■ Client Reporting l' PIP: i ■- Sloans Lake Managed Care network access ■ Repricing ■ Utilization Review, ■ Case Management HMO:, ■ Sloans Lake Health Plan network ■ Premier Care Program 16 ■ Premier Care Program 15 ■ Tremier Care Program ZO ■ Freedom Series 10 ■ Freedom Series 15 ■ Freedom Series 20 ■ Point of Service option ■ State -mandated Basic and Standard Plans ■ Alterbative Care Services riders ■ Chiropractic Services rider ■ Eye Wear and Eye Care riders ■ Outpatient Prescription Drug'riders cusLomcrs. By makiuk our performance visilnlc, we hope to raise the standards of service provided by managed care „ connpanics in Lhe conunuuiLy. A balanced approach to deliveriq qualify, cost-effective care will be achieved through our business strategy and through our medical manapemenf processes`.- Our business siratcky will i y •�1 yN�.,{}�� nit r.1 yq h 1 ' ' n�l � _ Our focus on quality is unsurpassed. - r' I 1•Jriibodicd within ourbusiness i$ a We will continue to fine-tune a philosophy is a return to old-fashioned , rQut,�n9 �arrtctY�y e physician prof link system and euolve values, which have been lost during the % i`jyti� t" Q!( our outpatient medical management last several years of frantic industry. , �a r ' review process. Our quality . merger and consolidation activity. We w%t ' r rt elr r" { t i ' management program provides for the will strive to restore consumer ,ttt>,' development of quality measures, confidence in the managed care f..� ern �serbar{ x' ite�r collection of data, and implementation industry by providing good service slid a , _ �& i�i�lttti'ijVt�ij�p; of appropriate interventions. the Pf'Or broad product spectrum, and building and HMO lines of business and our . strong, positive relationships with our s' t' n [Itilization Management I3ograln were 'varied customers. We will work to awarded full network, accreditation by develop lie ahth care solutions wlnicb will l + the American Accreditation Healthcare r ultimately improve the quality, of health _ �tcC�iiCYtWitiYl,i#4 Commission/formerly IJRAC. We are in our community. $ ` the f irst.managed care company in Pi r, - 'the -nation to receive full - Oux.website,'at www.sloanslake.com� �y3i F'< accreditation for multiple product. provides general industry information, )IR S. 1 urther, we are committed to Sloans Lake' company and proditet achieving NCQA accreditation for the information, our job line, timely health reflect balance'iri all of our lines of HMO by the year 2000. care and wellness.articles, PPO and business,' including PPO, PIP and . _ HMO provider directories, and a PPO HMO, while'our medical management claim status look -up function for " processes will focus on system improve- ' providers,and payors. Please visit us! ments and the implementation of - p We would be interested in Iznowirig,lurw outcome studies and quality programs. to maize the website work for you. SLOANS LAKE HEALTH PLAN 1355 South Colorado Blvd Suite 902 Denver, CO 80222 303.753.7537 www.sloanslake.com Embod i4 t,'wtthi0 .air bu qi e5S phi% opj? ` 11 IS' a'retrtmitPar'. faAi,t n'J wa%ues, the Z t severah' ars 6' fran`ttc industr� merger ari , consolidation activity,. / SLOANS LAKE MANAGED CARE UTILIZATION MANAGEMENT At Sloans Lake Managed Care, we view Utilization Management (UAI)•as a key element to managed care. We deliver the highest quality, most cost effective medical information and management program available. Our mission is to serve health care consumers by helping to support decisions and behavior that improves health and medical outcomes, thereby improving quality and reducing health costs. Through a patient focused approach, our team of professionals deliver high quality, outcome oriented treatment plans to each patient. UNPARALLELED EXPERIENCE AND DEPTH OF KNOWLEDGE Sloans Lake ensures that patients receive timely, cost effective, quality patient care based upon the expert medical opinions of the Utilization Management staff which includes: • In-house Medical Director • Two supporting Associate Medical Directors in-house • Over 100 certified nurses with both broad based knowledge and specialty expertise • Peer Specialists and Medical Consultant • Established review committees GETTING WHAT YOU PAY FOR When you measure what Sloans Lake Managed Care Coordinators provide, it all adds up to a great value: Individualized, outcome focused care is delivered based upon each patient's specific circumstance • A dedicated team with extensive medical knowledge • Peer performance recognition • All reviewers are licensed medical professionals • All non -authorizations are recommended by on -site peer specialists • Provider performance reports - ' i/utilization managementl.doc THIS FORM MUST BE COMPLETED BY ALL PROPOSERS CITY OF FORT COLL06, COLORADO PROPOSAL FORM COVERAGES QUOTING (Please check all that apply) MEDICAL CARVE -OUT CCA-n PPO ax POS EPO Stop- PRESCRIPTION Network Network TPA UR Loss DRUGS 1. Our proposal is valid for 90 days. 1 16ans l s kc. ' ' q" C.a r e a1 refs. 2. Fee/Rate Guarantee: PPO Network— months POS Network months EPO Network L_ months TPA months UR months Stop -Loss months Carve -Out PPO Prescription Drugs months 3. Standard & Poor's Rating (if applicable): 4. Commissions: Yes No If yes: To whom . /year 5. Contact Name (in case of questions regarding proposal): X4e-a Telephone Number: 3 - 5oLi - S 3 Fax Number: 3p 3 • 564 — 5 1 6. Carrier Name: S� oarls LQ,1 1 chncnack C-Are- 7. Complete the following: 510gcm take. MrNA ed Oare- COMPANY NAME 1 19 D ffl4,;� 111VA SIGNATURE 90og r-_ FQ►kw,b¢ry PRINTED SIGNATUREJ vQ of 7�:=14s l (y6j- 4t r,a TITLE 1S55 S Cola .glad.yr-9—W ADDRESS ii ¢no W , co xosp_aQ CITY. STATE, ZIP CODE blow er COUNTY _tD -2j, - l0:1 1 TELEPHONE NUMBER 25:13 - 5N-1.5�\ FAX NUMBER ANSWERS MUST BE PROVIDED FOR ALL ABOVE QUESTIONS ON THIS FORM. DO NOT REFERENCE ANOTHER SECTION OF THE PROPOSAL FOR YOUR RESPONSE. 5 i WE'VE PASSED THE 2N' OPINION We are proud that for the past three years our program has been extensively reviewed and has been awarded full accreditation approval from The Commission/URAC. Fully accredited Utilization Management translates into: High customer standards • Confidentiality • Continuous Quality Improvement • Formalized appeals process • Preeminent provider, network standards in both contracting and credentialing A COMMITTMENT TO PROVIDER PARTICIPATION The, Utilization Managementleam at Sloan's Lake Managed Care actively collaborates with and educates providers to improve the quality of care in the following ways: • Encourage efficient and accurate communication from one medical professional to another • Attain the'most up-to-date utilization management information • Establish benchmark criteria for treatment based upon best practices, • Ensure high standards of participation and membership in key advisory Committees, including: -Medical Management —>Clinical Quality - 4Appeals WHAT ELSE DOES SLMC UTILIZATION MANAGEMENT OFFER? The Utilization Management Team Provides: • Flexible service and customized authorization standards • System integration of claim authorization • Seamless transitions from Utilization Managbment to Case Management to deliver comprehensive, cost-effective care Sloan Lake Managed Care will provide you with a substantial network savings, aggressive Medical Management, and a comprehensive network of providers to improve quality and reduce costs. FOR FUTHER INFORMATION, PLEASE CONTACT YOUR SLOANS LAKE MANAGED CARE REPRESENTATIVE. , 2 n•.l F.q� rr w' f�..,..,.. rv.4'i^m..ehwy °a y,., �u..>i �. SLOANS LAKE MANAGED CARE MEDICAL CASE MANAGEMENT Our goal is to find the appropriate balance of care, in accordance with standard medical practices, that promotes an improved quality of life for catastrophically or chronically ill members. Pursing a personal approach to case management, we pride ourselves on working with the patient, family, and the care provider to furnish the patient with informed healthcare choices. WHY USE CASE MANAGEMENT? Our program is designed with the patient in mind. Our Case Management (CM) approach considers the needs of the patient first and foremost. Our team's specialized training and flexibility benefits the patient, the plan, and the provider in the following ways: • The patient continues to receive high quality medical care without hospital confinement. • Providers communicate directly with the Case Manager to coordinate alternative care plans for the patient. WHAT ARE THE BENEFITS OF EARLY CASE IDENTIFICATION AND INTERVENTION? Early intervention is essential to properly assess all available resources to meet the patient's needs. Our skilled team of medical professionals: • Identifies high cost cases before they reach catastrophic levels • Provides seamless transitions from Utilization Management to Medical Case Management • Provides comprehensive assessment of patient needs and available resources, including: -*Family Support - +Patient Demographics Discharge Needs -+Available Resources ->Plan Benefit Structure Limitations .WHAT SERVICES ARE PROVIDED BY OUR CASE MANAGERS? Our nurse counselors empower members with medical information and enable them to participate more actively in managing their own health by coordinating the patient's treatment plan, accessing the J. "'i/utilization management1doc j roles of the patient, family and provider, reviewing the patient's medical history, assessing resources - and vendors, negotiating prices with non -participating providers, coordinating community services and performing a cost benefit analysis of an alternative treatment plan WHICH DIAGNOSES MAY BE CONSIDERED APPROPRIATE FOR CASE - MANAGEMENT INTERVENTION? Sloans Lake Managed Care Case Managers are trained to assist those who have been diagnosed with: • Acquired Immune Deficiency Syndrome (AIDS) or other chronic immune -suppressed disorders • Catastrophic injuries • Chemical dependency • Degenerative Neuromuscular disorders • Disorders requiring IV antibiotic and total parenteral nutrition administration • Disorders requiring rehabilitative. services • High risk pregnancy or premature births • Metastatic disease • Multiple fractures or amputations • Organ transplantation • Psychiatric disorders • Renal failure • Selected cardiovascular disease WHAT ARE THE BENEFITS OF WORK TRANSITION PLANS? Our Case Management Department also specializes in providing patients with plans that will expedite their recovey and reduce the time it takes to return to work. Our certified vocational rehabilitation specialists will: • Assess return to work stations Foster the communication between the employer and employee • Provide ergonomic,workstation assessments • Provide on -site job analysis • Identify transferrable skills • Encourage positive work identities as opposed.to negative disabled attitudes • Reduce Loss of Earning -benefits r Sloans Lake has the experience and sensitivity to provide highly sophisticated yet member,fiiendly CM services which balance the need to manage the patients care and recover in a cost-effective manner. 'FOR FUTHER INFORMATION, PLEASE CONTACT YOUR SLOANS LAKE MANAGED CARE REPRESENTATIVE. 2 Sloans Lake Management Corp. Financial Statements Table of Contents Consolidated Financial Statements Consolidated Comparative Balance Sheet 1-2 Consolidated Income Statement 3 Consolidated Statement of Cash Flow 4 Sloans Lake Management Corp. Comparative Balance Sheet 5-6 Income Statement 7 Statement of Cash Flow g Sloans Lake Health Plan, Inc. Comparative Balance Sheet 9 -10 Income Statement 11 Statement of Cash Flow 12 Other Financial Information Combined Statement of Operations - PPO 13 Combined Statement of Operations - HMO 14 Comparative Statement of Operations - PPO 15 Statement of Operations - Group Health 16 Statement of Operations - Auto Division 17 Statement of Operations - Case Management 18 Sioans Lake Management Corp. Consolidated Comparative Balance Sheet December 31, 1997 Current Assets Cash & Cash Equivalents Short-term Investments Gross Accounts Receivable Less: Allowance For Uncollectibles Net Accounts Receivable Prepaid Expenses Current Portion of Long -Term Investments Other Current Assets Total Current Assets Property and Equipment Furniture & Equipment Computers Leasehold Improvements Total Property & Equipment Less: Accumulated Depr. & Amort. Net Property & Equipment Long -Term -Assets Restricted Funds Long -Term Investments, Less Current Portion Unamortized Org/Startup Costs Other Long -Term Assets Total Long-Term.Assets Page 1 Increase Current Jan. 1, 1997 (Decrease) 7.085,587 6,865,416 220.171 2,067,404 2,045,488 21,917 6,557,713 4,063,278 2,494,434 (694,000) (529.000) (165,000) 5,863,713 3,534,278 2,329,434 341,348 220,538 120,809 0 253,662 (253,662) 160,213 16,347 143,866 15,518,265 12,935,730 - 2,582,535 1,303,168 1,217,715 85,453 3,093,347 2,100,253 993,094 310,672 335.771 (25,099) 4,707,187 3,653,739 1,053,449 (2,665,922) (1,714,342) 951,580 2,041,265 1,939,397 101,869 154.758 154,273 484 0 0 0 41,253 78,087 (36,835) 217,552 20,953 196,599 413,562 253,313 160,249 Total Assets 17,973,092 15.128,440 2,844,652 Sloans Lake Management Corp. Consolidated Comparative Balance Sheet December 31, 1997 Current Liabilities Accounts Payable Accrued Salaries and Benefits Deferred Revenue Current Portion of Long Term Obligations Other Current Liabilities Total Current Liabilities Long -Term Liabilities Long -Term Obligations, Less Current Portion Other Long -Term Liabilities Total Long -Term Liabilities Shareholder's Equity Common Stock Retained Earnings Unrealized Holding Gain/(loss) on Investment Total Shareholder's Equity Page 2 Increase Current Jan. 1, 1997 (Decrease) 1,954,553 1.792,726 161,827 2,206,179 1,301.355 904,824 742,122 507,266 234,856 153,504 152,382 1,12-2 4,044,687 1,936,776 2,107.909 9,101,045 5,690,506 3,410,538 44,720 198,224 (153.504) 240.000 1,093,156 (853,156) 284,720 1,291.380 (1,006,660) 12,832.194 10,634.694 2,197,500 (4,268,104) (2,484,390) (1,783,714) 23,238 (3,750) 26,988 8,587,327 8,146,554 440,774 Total Liabilities and Shareholder's Equity 17,973,092 15,128,440 2.844,652 Sloans Lake Management Corp. Page Consolidated Income Statement For The Period Ending December 31, 1997 Revenue PPO Revenues HMO Revenues Interest Income Total Revenue Expenses Salaries and Benefits Purchased Services General and Administrative Medical Expense Bad Debt Expense Interest Depreciation Amortization Total Expenses Net Income From Operations Other Non -Operating (Gain)/Loss Net Income Before Taxes Income Tax Expense Net Income / (Loss) Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance 2,039,898 1,938,656 101,232 22,344.145 21,698,000 646,145 1.632,601 2,069.735 (437,134) 18,734,537 19,160,623 (426,086) 44,953 37,955 6,998 524.023 436,049 87,974 3,717,452 4,046,356 (328.904) 41,602,704 41,294.673 308.031 1,160,892 1,237.810 76,918 14.971,305 14,043,917 (927,388) 239.808 158,553 (81,255) 2,675.202 1,808,458 (866,744) 839,128 589,084 (250,045) 6,613.295 6,484.788 (128,507) 1,820,265 1,708,887 (111,378) 17,881.384 15,908,905 (1,972,479) 104.969 11,135 (93,834) 246,015 116,505 (129,510) 1,147 3,598 2,451 20,182 41,340 21,158 104.924 91,785 (13.139) 952,567 1,039.176 86,609 3,069 .3,416 347 36,834 38,999 2,166 4,274,201 3,804,268 (469,934) _ 43,396,785 39.482,087 (3,914.697) Statement of Shareholder's Equity Balance at January 1, 1997 Net Gain / (Loss) Market Value Adjustment Increase in Common Stock Balance at December 31, 1997 (556,750) 242,088 (798,838) 0 0 0 (1,794,081) 1,812,584 (3,606,664) ^ 0 0 0 (556,750) 242,088 (798,838) (1,794,081) 1.812,584 (3,606,664) 0 95,967 95,967 (10,367) 745,737 756,103 (556,750) 146,121 (702,871) (1,783,714) 1,066,847 (2,850,561) 8,146.554 (1,783,714) 26,988 2,197,500 8,587,327 Sloans Lake Management Corp. Page 4 Consolidated Statement of Cash Flow December 31,1997 Operating Activities Net Income / (Loss) Adjustments to Reconcile Net Income / (Loss) to Net Cash Provided by Operating Activities: Depreciation Amortization Amortization of Premium (Discount) on Investments (Increase)/Decrease in Assets: Accounts Receivable Due From Affiliates Other Current Assets Other Assets Increase/(Decrease) in Liabilities: Accounts Payable Other Current Liabilities Total Adjustments Net Cash Provided By/(Used For) Operating Activities Investing Activities Net Additions to Property and Equipment Proceeds from Available -for -Safe Investments Purchase of Available -for -Sale Investments Net Change in Restricted Cash Market Value Adjustment Net Cash Provided By/(Used For) Investing Activities Financing Activities Net Change in Long -Tenn Liabilities Net Dividend Distributions Net Change in Contributed Capital Net Change in Common Stock Net Cash Provided By/(Used For) Financing Activities Net Increase/(Decrease) in Cash and Cash Equivalents Net Increase/(Decrease) in Short -Term Investments Net Increase/(Decrease) in Long -Term Investments Cash and Cash Equivalents - Beginning of Period Short -Term Investments - Beginning of Period Long -Term Investments - Beginning of Period Cash and Investments - End of Period Detail of Cash and Investments - End of Period Cash and Cash Equivalents Funds Held in Trust Short -Term Investments Long -Tenn Investments Month -To -Date Year -To -Date (556.750) (1,783,714) 104,924 952.567 3,069 36,834 (14.482) (55.749) 5,769 (2,329,436) 0 52,253 (274,010) (761,220) 25,105 (192,597) 143,220 162,237 367,705 3,740,350 361,298 1,605,239 (195.453) (178,476) (369,516) (1,054,436) 0 8,659.589 (45,911) (7,382.738) 1 (0) 29,842 26,987 (385,585) 249,401 50,935 (1,006,660) 0 0 0 0 0 2,197.500 50,935 1,190,840 (530.103) 1,261,765 50,192 (1,029,841) 0 (253,662) 7,615,687 5,823.818 2.017.212 3,097,246 0 253,662 9,152.991 9.152, 991 7,085,587 0 2.067,404 0 9,152,991 Sioans Lake Management Corp. Comparative Balance Sheet December 31, 1997 Current Assets Cash & Cash Equivalents Gross Accounts Receivable Less: Allowance For Uncollectibles Net Accounts Receivable Prepaid Expenses Long -Term Investments, Current Portion Other Current Assets Total Current Assets Property and Equipment Furniture & Equipment Computers Leasehold Improvements Total Property & Equipment Less: Accumulated Depr. & Amon Net Property & Equipment Long -Term Assets Investment in Sloans Lake Health Plan Long -Term Investments, Less Current Portion Unamortized Org/Startup Costs Other Long -Term Assets Total Long -Term Assets Total Assets Page 5 Increase Current Jan. 1, 1997 (Decrease) 5,624,468 5,306,759 317,709 4,433,746 3,988.529 445.217 (694,000) (529,000) (165,000) 3,739.746 3,459,529 280,217 341,348 220,538 120,809 0 253,662 (253,662) 1,064,919 120,489 944,429 10,770,480 9,360,978 1,409,503 1,303,168 1,217,715 85,453 3,093,347 2,100,253 993.094 310,672 335,771 (25.099) 4,707,187 3,653,739 1,053.449 (2,665,922) (1,714,342) 951,580 2,041,265 1,939,397 101.869 1,301,244 3,091,520 (1,790,277) 0 0 0 41,253 78,087 (36,835) 217,552 20,953 196,599 1,560,048 3.190,561 (1,630,512) 14,371,794 14,490,936 (119,140) Sloans Lake Management Corp. Page 6 Comparative Balance Sheet December 31, 1997 Current Liabilities Accounts Payable Accrued Salaries and Benefits Deferred Revenue Current Portion of Long -Term Obligations Other Current Liabilities Total Current Liabilities Long -Term Liabilities Long -Term Obligations, Less Current Portion Other Long -Term Liabilities tal Long -Term Liabilities Shareholder's Equity Common Stock Retained Earnings Unrealized Holding Gain on Investment Total Shareholder's Equity Total Liabilities and Shareholder's Equity Increase Current Jan. 1, 1997 (Decrease) 1,874,106 1,800,137 73,969 2,206,179 1,301.355 904.824 249,968 291,189 (41,221) 153,504 152,382 1,122 1,039,227 1,501,333 (462,107) 5,522,984 5.046.397 476,587 44,720 198,224 (153,504) 240,000 1,093.156 (853,156) 284,720 1,291,380 (1,006,660) 12,832,194 10,634,694 2,197,500 (4,268,103) (2,484.390) (1,783,713) 0 2,855 (2,855) 8,564,091 8,153,159 410,932 14,371,794 14.490,936 (119,140) MEDICAL MANAGED CARE PLANS (PPO. POS & EPO) FEE QUOTATIONS Please provide your fee quotation with regard to the services described in this section. Your fee quotation should be presented in the following format. Additional Charges: ID Cards/Enrollment Start -Up Fees Other (detail) For purposes of your quote, please assume 605 eligibles in the PPO plans. ©/EPf3l�ieork.dnlp 1Vlonthly Charges per:Eligtble POS Access Fee $ Capitation Fee $ $� Incentive $ $ a Additional Charges: ID Cards/Enrollment $ $ O Start -Up Fees $ $ O Other (detail) 1 $ $ For purposes of your quote, please assume 80 eligibles in the POS plan and 585 in the EPO plan. How do the above charges differ assuming you are selected as the network provider for all plans? NO 17 Sloans Lake Management Corp. Page 7 Income Statement For The Period Ending December 31, 1997 Revenue Group Health Auto Division Case Management Provider Fees Other PPO Revenues HMO Administrative Fee Other HMO Revenues Interest Income Total Revenue Expenses Salaries and Wages Employee Benefits Contract Labor Consulting and Legal Fees Advertising Insurance Traveland Education Meals and Entertainment Lease and Rental Maintenance and Repair Office and Other Expense Bad Debt Expense Interest Depreciation Amortization Total Expenses Net Income From Operations Other Non -Operating (Gain)/Loss Net Income Before Taxes Income Tax Expense Net Income I (Loss) Month -To -Date Year -To -Date . Actual Budget Variance Actual Budget Variance 584,565 711,442 (126,877) 745.556 714.176 31,380 264,853 277,285 (12,432) 359.911 160,020 199.891 85,013 75,743 9,270 235,175 295,361 (60,186) 0 0 0 29.349 22,402 6,947 7.007,532 8,002,704 (995,172) 8,054,433 8,099,720 (45,287) 2,886.641 2,943,576 (56,935) 3,367.317 1,800,000 1.567,317 1,028.222 852,000 176,222 2,689.293 2.749,687 (60.394) 0 0 0 299.382 252,000 47,382 2,304,422 2.256,429 47,993 25.332.820 24,699,687 633,133 1,044,404 1,034,242 (10,162) 163,707 243,568 79,861 44,775 15,046 (29,729) 167,272 106,185 (61,087) 43,032 52,899 9,867 21,013 15,859 (5,154) 28,025 36,346 8,321 14,461 9,666 (4,795) 88,405 87,442 (963) 27,761 37,322 9,561 595,394 279,983 (315,411) 104,969 11,134 (93,835) 1,147 3,597 2,450 104,924 91,785 (13,139) 3,070 3,416 347 2,452,358 2,028,490 (423,867) (147,936) 227,939 (375,874) 12,326,876 11,744,867 (582,009) 3,108,099 2,779,050 (329,049) 448,425 172,782 (275,643) 1,910.624 1,206,963 (703.661) 613,274 588,760 (24,514) 225.124 182,000 (43.124) 339,352 416,996 77,644 ^ 184,015 110,924 (73.091) 1,022,026 1,003,856 (18,170) 316.153 428,713 112,560 3.576,689 3,210.370 (366,319) 246,015 116,505 (129,510) 20.182 41,340 21.158 952.567 1,039,176 86,609 36,835 39.000 2,165 25.326,257 23,081.302 (2,244.955) 6,563 1,618,385 (1,611,822) 408,814 (8,632) (417,446) 1,790,278 (118,462) (1,908,738) (556.750) 236,571 (793,321) (1,783,714) 1,736,847 (3,520,561) 0 90,450 90,450 0 670,000 670,000 (556,750) 146,121 (702,871) (1,783,714) 1.066,847 (2,850,561) Sloans Lake Management Corp. Page 8 Statement of Cash Flow December 31, 1997 Operating Activities Net Income / (Loss) Adjustments to Reconcile Net Income / (Loss) to Net Cash Provided by Operating Activities: Depreciation Amortization Amortization of Premium (Discount) on Investments (Increase)/Decrease in Assets: Accounts Receivable Other Current Assets Other Assets Increase/(Decrease) in Liabilities: Accounts Payable Other Current Liabilities Total Adjustments Net Cash Provided By/(Used For) Operating Activities Investing Activities Net Additions to Property and Equipment Proceeds from Available -for -Sale Investments Purchase of Available -for -Sale Investments Investment in Sloans Lake Health Plan, Inc. Market Value Adjustment Net Cash Provided By/(Used For) Investing Activities Financing Activities Net Change in Long -Term Liabilities Net Dividend Distributions Net Change in Contributed Capital Net Change in Common Stock Net Cash Provided By/(Used For) Financing Activities Net Increase/(Decrease) in Cash and Cash Equivalents Net Increase/(Decrease) in Short -Tenn Investments Net Increase/(Decrease) in Long -Tenn Investments Cash and Cash Equivalents - Beginning of Period Short -Term Investments - Beginning of Period Long -Term Investments - Beginning of Period Cash and Investments - End of Period Detail of Cash and Investments - End of Period Cash and Cash Equivalents Funds Held in Trust Short -Term Investments Long -Term Investments Month -To -Date Year -To -Date (556,750) (1,783,714) 104,924 952,567 3,069 36,834 0 (5,961) 199,980 (280.217) (295,096) (1,069,241) 25,105 (192.597) 155.025 73,969 (117.857) 402,618 75,150 (82,027) (481.600) (1,865,741) (369,516) (1,054,436) 0 259.623 0 0 408,814 1.790,277 0 (2,855) 39.297 992,609 50,935 (1,006,660) 0 0 0 0 0 2,197.500 50,935 1,190,840 (391,367) 317,709 0 0 0 (253.662) 6,015,835 5,306.759 0 0 0 253,662 5.624.458 5,624,458 5.624,468 0 0 0 5.624,468 Sloans Lake Health Plan, Inc. Page 9 Comparative Balance Sheet December 31,1997 Current Assets Cash & Cash Equivalents Short-term Investments Accounts Receivable - Medical Care Accounts Receivable - Other Due From Affiliates Other Current Assets Total Current Assets Property and Equipment Furniture & Equipment Computers Leasehold Improvements Total Property & Equipment Less: Accumulated Depr. & Amort. Net Property & Equipment Long -Term Assets Statutory Deposit Restricted Funds Long -Term Investments Other Long -Term Assets Total Long -Term Assets Total Assets Increase Current Jan.1, 1997 (Decrease) 1,461,118 1,558,657 (97,538) 2,067,404 2,045,488 21,917 2,123,967 74,749 2,049,218 0 0 0 0 0 0 158.919 62,243 96,676 5,811.409 3,741,137 2,070,272 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 154,758 154,273 484 0 0 0 0 0 0 0 0 0 154,758 154,273 484 5,966,167 3,895,410 2,070,756 Sloans Lake Health Plan, Inc. Page 10 Comparative Balance Sheet December 31, 1997 Current Liabilities Accounts Payable Unpaid Claims Liablilty Deferred Revenue Due to Affiliates - Current Portion Other Current Liabilities Total Current Liabilities Long -Term Liabilities Loans and Notes - Long Term Due to Affiliates Other Long -Term Liabilities Total Long -Term Liabilities Net Worth Capital Stock Paid In Surplus Reserved Surplus Retained Earnings Dividends Paid Unrealized Holding Gain/(Loss) on Investment Total Net Worth Total Liabilities and Net Worth Increase Current Jan. 1, 1997 (Decrease) 80,447 44,597 35,850 2,992,947 390,526 2,602,420 492,154 216,077 276,077 1,063,625 114,132 949,493 12,513 45,162 (32,650) 4,641,685 810.495 3,831,190 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,000,000 3,000,000 0 0 0 0 (1,698,756) 91,520 (1,790,277) 0 0 0 23,238 (6,605) 29,843 1,324,481 3,084,915 (1,760,434) 5,966,167 3,895,410 2,070,756 Sloans Lake Health Plan, Inc. Page 11 Income Statement For The Period Ending December 31, 1997 Month -To -Date Year -To -Date - Actual Budget Variance Actual Budget Variance Revenue Premiums Earned 1,679,819 2,109,735 (429,916) 19,198,20 19,640.623 (442,416) Interest Income 15,604 15,553 51 224,640 184,050 40,590 Other Revenue 0 0 0 0 0 0 Total Revenue 1,695,423 2,125,288 (429,865) 19,422,847 19,824,673 (401,826) Expenses . Medical Care Physician Services Other Professional Services Emergency Room and Out of Area Inpatient Expenses Outpatient Expenses Prescription Drugs Other Medical Expenses Total Claims Incurred Reinsurance Recoveries COB and Subrogation Incentive Pool Adjustment Reinsurance Premium Total Medical Care Adminstration Administrative Fee Marketing Fees Other General and Administrative Depreciation Amortization Total Administration Total Expenses Income / (Loss) Less Loss Carry -Forward Taxable Income Provision for Taxes Net Income / (Loss) 920,495 724,433 (196,062) 105,221 65,165 (40,056) 25,993 30,296 4,303 198,976 342.782 143.806 234.976 289,049 54,073 259,225 191.493 (67,732) 63,003 57,543 (5,460) 1,807,889 1,700,761 (107,128) 0 0 0 (3,488) 0 3,488 0 0 0 15,864 8,125 (7,739) 1,820,265 1,708.886 (111,379) 235,175 295,363 60,188 48,797 106,889 58,092 (0) 0 0 0 0 0 0 0 0 283,971 402,252 118,281 2,104,236 2,111,138 6,902 (408,814) 14,151 (422,964) 0 0 0 (408,814) 14,151 (422,964) 0 5,519 5.519 (408,814) 8,632 (417,445) 7,904.002 6,743,462 (1,160,540) 1,269,687 606.592 (663.095) 205,983 282,012 76,029 2,637,256 3.190,818 553,562 2,930,190 2,690.645 (239,545) 2,554,924 1.782,530 (772,394) 389,596 535,646 146,050 17,891,638 15,831,704 (2,059,933) 0 0 0 (139,381) 0 139,381 0 0 0 129,128 77,200 (51,928) 17,881,384 15.908,904 (1,972.479) 2,689,293 2,749.687 60,394 640,135 971,882 331.747 12,679 0 (12,679) 0 0 0 0 0 0 3.342.107 3,721,569 379,462 21,223,492 19,630.473 (1,593,018) (1,800,645) 194.200 (1,994,844) 0 0 0 (1,800,645) 194,200 (1,994,844) (10,368) 75,738 86,106 (1,790,277) 118,462 (1,908,738) Sloans Lake Health Plan, Inc. Page 12 Statement of Cash Flow December 31, 1997 Operating Activities Net Income / (Loss) Adjustments to Reconcile Net Income / (Loss) to Net Cash Provided by Operating Activities: Depreciation Amortization Amortization of Premium (Discount) on Investments (Increase)/Decrease in Assets: Premiums Receivable Due From Affiliates Other Current Assets Increase/(Decrease) in Liabilities: Accounts Payable Claims Liability Other Current Liabilities Total Adjustments Net Cash Provided By/(Used For) Operating Activities Investing Activities Net Additions to Property and Equipment Proceeds from Available -for -Sale Investments Purchase of Available -for -Sale Investments Net Change in Restricted Cash Transfers from/(to) Related Organizations Market Value Adjustment Net Cash Provided By/(Used For) Investing Activities Financing Activities Proceeds from Paid In Capital or Stock Issuance Net Dividend Distributions Other Net Change in Long -Term Liabilities Net Cash Provided Byl(Used For) Financing Activities Net Increase/(Decrease) in Cash and Cash Equivalents Net Increase/(Decrease) in Short -Term Investments Net Increase/(Decrease) in Long -Term Investments Cash and Cash Equivalents - Beginning of Period Short -Tenn Investments - Beginning of Period Long -Term Investments - Beginning of Period Cash and Investments - End of Period Detail of Cash and Investments - End of Period Cash and Cash Equivalents Short -Term Investments Long -Term Investments Month -To -Date Year -To -Date (408,814) (1,790,277) 0 0 0 0 (14,482) (49,788) (194,211) (2,049,219) 0.00 52.253.00 (15,311) (97,171) (11,805) 36,260 99,431 2,602,422 422,527 1,192.508 286,149 1,687,266 (122,665) (103,011) 0 0 0 8,399,966 (45,911) (7,382,738) 0 0 0 0 29,842 29,842 (16,070) 1.047,070 0 0 0 0 0 0 0 0 (138,734) 944.059 50,192 (1,029,841) 0 0 1,599.852 517,059 2,017.212 3.097,246 0 0 3, 528, 522 3.528, 522 1,461,113 2.067.404 0 3.528.522 Sloans Lake Management Corp. Page 13 Combined Statement of Operations - PPO For The Period Ending December 31, 1997 Revenue Group Health Auto Division Case Management Provider Fees Other PPO Revenues Interest Income Total Revenue Expenses - Salaries and Wages Employee Benefits Contract Labor Consulting and Legal Fees Advertising Insurance Travel and Education Meals and Entertainment Lease and Rental Maintenance and Repair Office and Other Expense Bad Debt Expense Interest Depreciation Amortization Total Expenses Net Income From Operations Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance 584,565 711,442 (126,877) 7,007,532 8,002.704 (995,172) 745,556 714,176 31,380 8,054,433 8,099,720 (45,287) 264,853 277,285 (12,432) 2,886,641 2,943,576 (56,931 ) 359,911 160,020 199,891 3,367,317 1,800,000 1,567.317 85,013 75,743 9,270 1,028,222 852,000 176,222 29,349 22,402 6,947 299.382 252,000 47,382 2,069,247 1.961,068 108,179 22,643,527 21,950,000 693.527 884,086 850,134 (33,952) 10,256,839 9,689,641 (567,198) 136,652 197,289 60,637 2,428,792 2,256.374 (172,418) 36,867 12,477 (24,390) 351,799 143,399 (208.400) 115,714 73,508 (42,206) 1,350,539 844,952 (505,587) 19,548 21,014 1,466 273,502 241,558 (31,944) 15,256 11,408 (3,848) 163,567 131,150 (32,417) 18,315 25,419 7,104 243.114 292.180 49,066 10,730 5,825 (4,905) 122,069 66,975 (55,094) 71,513 68,612 (2,901) 833,869 788,666 (45,203) 17,030 32,991 15,961 233,676 379.213 145,537 424,412 215,564 (208,848) 2,771.950 2,475,865 (296,085) 104,969 11,135 (93,834) 246.015 116,505 (129,510) 883 2,749 1,866 15,665 31,600 15,935 91,549 74,418 (17,131) 810,883 837,258 26,375 3,070 3,416 346 36,835 39,000 2,165 1,950,592 1.605.959 (344,633) 20,139,112 18,334,336 (1,804,776) 118,655 355,109 (236,454) 2,504,415 3.615.664 (1,111,249) Sloans Lake Management Corp. Page 14 Combined Statement of Operations - HMO For The Period Ending December 31, 1997 Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance Membership 17,691 18,963 (1,272) 173,151 180,107 (6,956) Premium Revenue PMPM 94.95 111.26 (16.30) .. 110.88 109.05 1.83 Medical Expense PMPM - 102.89 90.12 (12.79) 103.27 88.33 (14.93) Medical Loss Ratio 108.4% 81.0% (27.4%) 93.1% 81.0% (12.1%) Marketing Fees % of Premium 2.9% 5.1% 2.2% 3.3% 4.9% 1.6% Revenue Premiums Earned 1,679,819 2,109.735 (429,916) 19,198.207 19,640,623 (442,416) Reinsurance Recoveries 0 0 0 0 0 0 Interest Income 15.604 15,553 51 224,640 184.049 40.591 Total Revenue 1,695,423 2,125,288 (429,865) 19,422,847 19,824,673 (401,826) Expenses Salaries and Wages 160,318 184,108 23,790 2.070,037 2,055,226 (14.811) Employee Benefits 27,055 46.279 19,224 679,307 522,676 (156,631) Contract Labor 7,908 2.569 (5,339) 96,626 29,383 (67.243) insulting and Legal Fees 51.558 32,677 (18,881) 560,085 362,011 (198.074) ,dvertising 23,484 31,885 8.401 339.772 347,202 7.430 Insurance 5,757 4,451 (1,306) 61,557 50,850 (10.707) Travel and Education 9,710 10,927 1,217 96,239 124,816 28,577 Meals and Entertainment 3.731 3,841 110 61,947 43,949 (17,998) Lease and Rental 16.892 18,830 1,938 188,157 215,190 27,033 Maintenance and Repair 10,731 4,331 (6,400) 82,477 49,500 (32,977) Medical Expenses 1,804,401 1,700.762 (103,639) 17,761,373 15.831,705 (1,929,668) Reinsurance Premium 15,864 8,125 (7,739) 120.011 77.200 (42,811) Marketing.Fees 48.797 106,889 58,092 640,135 971,882 331,747 Office and Other Expense 170.984 64,419 (106,565) 817,419 734,505 (82,914) Bad Debt Expense 0 0 0 0 0 0 Interest 264 849 585 4,518 9.740 5,222 Depreciation 13,375 17.367 3.992 141,685 201,918 60,233 Amortization 0 0 0 0 0 0 Total Expenses • 2,370,828 2,238.309 (132,519) 23,721,343 21,627,753 (2,093,590) Net Income From Operations (675,405) (113.021) (562,384) (4.298,496) (1,803,080) (2,495,415) Sloans Lake Management Corp. Page 15 Comparative Statement of Operations - PPO For The Period Ending December 31, 1997 n Year -To -Date Group Auto Case Total Health Division Management PPO Revenue Group Health 7,007,532 0 0 7,007,532 Auto Division 0 8,054,433 0 8,054,433 Case Management 0 0 2,886.641 2,886,641 Provider Fees 3,367,317 0 0 3,367,317 Other PPO Revenues 1,028,222 0 0 1,028,222 Interest Income 299,382 0 0 299,382 Total Revenue 11.702.453 8,054,433 2,886,641 22,643,527 Expenses Salaries and Wages 5,517,698 3.061,624 1,677.517 10,256,839 Employee Benefits 1,709,292 484,387 235,113 2,428.792 Contract Labor 324,377 13,323 14,099 351,799 Consulting and Legal Fees 1,081,373 258,519 10,647 1.350,539 ' Advertising 265.139 3,445 4,917 273,502 Insurance 163,567 0 0 163,567 Travel and Education 184,839 28,915 29,360 243,114 Meals and Entertainment 107,776 11,261 3,032 122,069 'Lease and Rental 623,481 153,996 56,392 833,869 Maintenance and Repair 230,313 2,970 394 131,828 233.676 2,771.950 Office and Other Expense 2,295,967 344.154 (0) Management Fee (3,970,720) 2,899,111 1,071,608 Bad Debt Expense 242,280 0 3,735 246.015 Interest 15,665 0 0 15,665 Depreciation 810,883 0 0 810,883 Amortization 28,000 0 8,835 36,835 Total Expenses 9,629,929 7,261.705 3,247,477 20,139.112 Net Income From Operations 2,072,524 792,728 (360,837) 2.504,415 Sfoans Lake Management Corp. Page 16 Statement of Operations - Group Health For The Period Ending December 31, 1997 Revenue Group Health Provider Fees Other PPO Revenues Interest Income Total Revenue Expenses Salaries and Wages Employee Benefits Contract Labor Consulting and Legal Fees Advertising Insurance Travel and Education Meals and Entertainment -iase and Rental ,aintenance and Repair Office and Other Expense Management Fee Bad Debt Expense Interest Depreciation Amortization Total Expenses Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance 584,565 711,442 (126,877) 7,007,532 8,002,704 (995,172) 359,911 160,020 199.891 3,367,317 1,800,000 1,567,317 85,013 75,743 9,270 1.028,222 852,000 176,222 29,349 22,402 6,947 299,382 252,000 47,382 1.058,838 969,607 89,231 11.702,453 10,906,704 795,749 477,097 439,881 (37.216) 5,517,698 5,079,033 (438,665) 70,467 110,357 39,890 1,709,292 1,279,119 (430,173) 34,890 8,615 (26,275) 324,377_ 98,997 (225,380) 88,329 54,607 (33,722) 1.081,373 627,697 (453,676) 20,661 19,467 (1,194) 265.139 223,763 (41,376) 15,256 11,408 (3,848) 163,567 131,150 (32,417) 9,694 17,753 8,059 184,839 204,130 19,291 9,198 4,363 (4,835) 107,776 50,171 (57.605) 52,830 50,282 (2,548) 623,481 577,950 (45,531) 17,030 32,793 15,763 230.313 376,929 146,616 380.131 178,660 (201,471) 2,295,967 2,051,748 (244,219) (412,098) (334,063) 78,035 (3,970,720) (3,867,230) 103.490 104.969 9,874 (95,095) 242,280 102.000 (140,280) 883 2,749 1,866 15,665 31,600 15,935 91,549 74,418 (17.131) 810,883 837,258 26,375 2,333 2,666 333 28,000 30,000 2,000 963,219 683,830 (279,389) 9,629,929 7,834,315 (1,795,614) Net Income From Operations 95,619 285,777 (190,158) 2,072,524 3,072,389 (999.865) FEE QUOTATION SECTION Please provide your fee quotations to provide the cost management services requested. Your quotatio n should be in the following format. Monthly Fee Umf ger Per Case PPO Plan§ Drily Eligible Employee Charges 1. Pre-Admission/Concurrent .0�p Utilization Review 2. Psychiatric/Substance Abuse Review (if separate from #1 above) Full Package (1 and 2 above)a �e 3. Case Managerned') 100. Other Charges 1. Start-Up/Implementation Fee 2. Basic Communication C7 Package (brochure, stickers, and letters) Note: Excludes Medicare Retirees. (" Indicate hourly rate if this is your standard arrangement. For purposes of your quote, please assume 600 eligibles in the PPO plans. 39 Sloans Lake Management Corp. Page 17 Statement of Operations - Auto Division For The Period Ending December 31, 1997 Month -To -Date Year -To -Date Actual Budget Variance Actual Budget Variance Revenue Medical Management Fees 593,286 578,465 14,821 6,240.545 6,560,520 (319,975) Provider Fees 152,270 135,711 16,559 1,813.888 1,539,200 274,688 Other Revenue 0 0 0 0 0 0 Total Revenue 745,556 714.176 31,380 8,054.433 8,099,720 (45,287) Expenses Salaries and Wages 272,784 261,682 (11,102) 3,061,624 3,004,735 (56,889) Employee Benefits 44,302 55,734 11,432 484,387 640,023 155.636 Contract Labor 0 489 489 13,323 5,602 (7,721) Consulting and Legal Fees 26,735 17,999 (8,736) 258,519 206,884 (51,635) Advertising (1,304) 1,171 2,475 3,445 13,469 10,024 Insurance 0 0 0 0 0 0 Travel and Education 5,428 5,421 (7) 28,915 62,273 33,358 Meals and Entertainment 1,318 1,149 (169) 11,261 13,204 1,943 Lease and Rental 13,732 15,384 1,652 153,996 176.836 22,840 Maintenance and Repair 0 129 129 2,970 1,500 (1,470) Office and Other Expense 28,865 27,173 (1,692) 344,154 312.349 (31,805) Management Fee 303.495 246.177 (57,318) 2,899,111 2,829.615 (69.496) Bad Debt Expense 0 893 893 0 10,275 10,275 Interest 0 0 0 0 0 0 0 0 Depreciation 0 0 0 0 0 0 0 Amortization 0 0 0 Total Expenses 695.357 633,401 (61,956) 7.261,705 7,276,765 15,060 Net Income Ffom Operations 50199 80,775 (30,576) 792,728 822,955 (30,227) Provider Credentialing Plan 0 r` •� SLOANS LAKE MANAGED CARE 1355 S. Colorado Blvd. Suite 902 • Denver, Colorado 80222 • 303/691-2200 PROVIDER CREDENTIALING PLAN SLOANS LAKE MANAGED CARE, INC. I. INITIAL APPLICATION A. Request for Application Applications for participation on the Sloans Lake Managed Care, Inc. provider panels, (i.e. HMO, PPO, PIP and/or Worker's Compensation panels) are available by request from Sloans Lake Managed Care, Inc. Sloans Lake Managed Care, Inc. may deny a request for application if no need exists for certain provider services on the respective panel(s). A copy of this policy shall accompany all applications sent to providers. Providers to be credentialed include: MD, DO, DDS, DPM, DC, AHP, NP, PT, OT and Speech Therapist. Applicants acceptances are accomplished without regard to age, sex, race, color, religion, national origin, or disability. The completed application shall be submitted to the Medical Director responsible for the respective provider panel. B. Application content Each provider must furnish complete information regarding the following: Professional training - schools attended, degrees obtained and board certifications obtained (includes internship, residency and fellowship training) (Copies of all certificates of all Board Certification must be attached.) 2. Professional licensure or certification (all states in which a current license or certification is held) (Copies of all licenses to be attached.) 3. DEA registration with issued and expiration dates (copy to be attached.) Sloans Lake Managed Care 1 Provider Credentialing Plan 4. Clinical area of practice (Attach statement from primary admitting or practice facility stating date of last appointment, scope of privileges and restrictions, and statement of good standing.) Any mental or physical condition which interferes with the ability of the provider to perform the essential functions of the clinical area of expertise. 6. Current professional liability insurance coverage. For all participating providers, the coverage shall be at least $1 million/$3 million. Provider shall contact all carriers for the past five (5) years, and request proof of coverage and claims history be mailed to Sloans Lake Credentialing Division. Sloans Lake's credentialing department will request this as well. In addition, provider shall furnish information regarding malpractice actions (including pending claims) for the last five (5) years. (A copy of the current policy, including any coverage limitations or exclusions, to be attached.) 7. Any pending investigation or any final adverse action by: a. Any state board of medical examiners or other state licensing agency; b. DEA; C. Medicare/Medicaid; d. Malpractice carrier; or e. Any hospital at which Applicant has or had privileges within the last five (5) years. C. Agreements Associated with the Application The applicant must sign the application and in so -doing: 1. Attests to the correctness and completeness of all information and acknowledges that failure to submit a complete and accurate application may be cause for immediate rejection of the application or automatic termination of provider's participation on the provider panel. A provider who is terminated for this reason is not entitled to a hearing or review under the Fair Hearing Policy. 2. Agrees to notify Sloans Lake Managed Care of any changes in the information contained in the application, including any changes in hospital privileges held, in malpractice carrier, in good standing with licensing agencies or in office location. 3. Releases from liability those who, in good faith and absence of malice, review or act on any information included in the application. Sloans Lake Managed Care 2 Provider Credentialing Plan 4. Agrees to participate in quality assurance, credentialing, and utilization management activities of the MCO. 5. Authorizes the MCO to obtain credentialing and peer review information from third parties, including hospitals at which provider practices. D. Upon receipt of a completed application, the Medical Director or Credentialing Committee shall ensure that the following additional provider information is obtained: 1. Primary verification of license(s), training and board certification; 2. Statement from the National Provider Data Bank; 3. Verification of good standing with the Medicare/Medicaid programs; 4. Verification of malpractice coverage and information regarding claims against the provider over the last five (5) years; 5. QI/UR information from primary admitting facility; 6. QI/UR information maintained by Sloans Lake Managed Care, Inc.; and 7. Visit to the office of the provider (applies to all primary care providers, and Ob/Gyns. E. The Credentials Committee 1. Committee Membership The Credentials Committee shall consist of five (5) participating providers who shall be appointed by the Medical Director. All committee members will sign a confidentiality statement and abstain from giving opinion when there is a conflict of interest. It shall be multi -disciplinary in nature. The Committee shall consult with appropriate specialists as necessary to credential various types of providers. 2. Meetings The Credentials Committee shall meet as needed but no less frequently than every other month. All provider applications and reapplications completed prior to each meeting are to be considered by the committee. The Medical Director shall be the committee chairperson and shall be responsible for the meeting agenda, including the applications to be considered for participation. 3. Committee Responsibilities The Credentials Committee shall be responsible for the following: Sloans Lake Managed Care 3 Provider Credentialing Plan a. Verifying that all applications and reapplications are complete; b. Evaluating each provider's qualifications, scope of practice, and quality of practice; C. Making recommendations to the Quality Council regarding acceptance or denial of applications; and d. Annually reviewing all credentialing policies and procedures, revising them as necessary for approval by the Quality Council. e. Evaluates and reports on the overall effectiveness of the Credentialing Program. 4. Committee Recommendations The Credentials Committee may make a favorable or unfavorable recommendation regarding an application to the Quality Council, or may table an application pending receipt of further requested information. Any negative recommendation to the Quality Council must be accompanied by written findings supporting such recommendation. F. Quality Council Final Action The Quality Council is the governing body of the MCO and, as such, has the sole discretion to take final action regarding applications for participation on the provider panel. The Council may approve, disapprove or return a provider's application to the Credentialing Committee for additional information. The decision of the Quality Council shall be final, and a provider shall not be entitled to a hearing or review under the Fair Hearing Policy. II. REAPPLICATION PROCEDURES All participating providers shall be required to submit an updated application every two (2) years for continued participation on the provider panel. Applications shall be sent to participating providers 120 days prior to the every other anniversary date of the contractual arrangement between the provider and the MCO. The provider shall have thirty (30) days to return the completed application. A. Content of the Application The application will include all the information in Article I(B) of this policy. B. Additional Information Sloans Lake Managed Care 4 Provider Credentialing Plan The reapplication process may include review of all additional information in Article I(D) of the policy as well as the following provider information: 1. Sloans Lake Managed Care QI information (outcome studies, indicators, etc.) 2. Patient, provider and internal complaints; 3. Utilization management results; and 4. Patient satisfaction surveys. C. Recommendations and Final Action All reapplications will be subject to the same procedures as initial applications, including review and recommendation by Credentials Committee and final action by the Quality Council, except that a recommendation to terminate the participation of the provider may be subject to the Fair Hearing Policy. G: \forms W ppl icationInstr.doc Sloans Lake Managed Care 5 Provider Credentialing Plan Quality Program 1997 QUALITY PROGRAM SLOANS LAKE MANAGED CARE, INC. STATEMENT OF PURPOSE The purpose of the Sloans Lake Managed Care, Inc. ("SLMC") quality improvement program ("the Program") is to provide a system to monitor and evaluate the quality of care delivered to members of Sloans Lake Health Plan, Inc. ("HMO"), and the payers of SLMC PPO, PIP programs. This is accomplished through the credentialing of providers and facilities, through medical management and through quality review and studies. The Program emphasizes education of members and all payers and providers in order to develop a quality, efficient health care delivery system. The Program utilizes preventive quality indicators, as well as critical clinical pathways to evaluate the care rendered by providers. In addition, the Program analyzes member, payer and provider satisfaction information. The Program is implemented through comprehensive policies and a committee structure which has been approved by the respective Boards of Directors of Sloans Lake Health Plan, Inc. and Sloans Lake PPO, Inc., as well as the Board of Directors of Sloans Lake Managed Care, Inc. 1. To continuously define and identify quality of member care and services as well as work to maintain and improve on previously established quality projects on an ongoing basis. 2. To establish, implement, and monitor corrective action plans as appropriate. 3. To establish an ongoing monitoring system to detect trends and/or patterns in health care delivery and evaluate their impact on outcomes and satisfaction on the membership as a whole. 4. To identify opportunities for service enhancements, improved health status and administrative effectiveness for providers, members, community and Plan staff and implement appropriate communication/educational/training programs to meet those needs. 5. To continuously improve the quality of care and service by documenting accurate quality management information and utilizing this information in the credentialing and recredentialingof health care providers. AUTHORITY AND ACCOUNTABILITY The Boards of Directors of Sloans Lake Health Plan, Inc. and Sloans Lake PPO, Inc., as well as the Board of Directors of Sloans Lake Managed Care, Inc., has the ultimate authority and accountability for ensuring quality of care and service provided to members of Sloans Lake Managed Care. These Boards of Directors have delegated this authority to the Quality Council of Sloans Lake. The Quality Council, comprised of executive staff, has the responsibility for oversight of the planning, designing, implementing and coordinating the clinical and service quality activities including provider performance monitoring, credentialing, utilization management, processing of member appeals, grievances and complaints. The Chief Medical Officer holds the responsibility for ensuring that direct oversight occurs. The Director of Quality and the department staff hold the responsibility for the day to day planning, creating, implementation and coordination of quality activities for the quality program. SCOPE The scope of quality review will reflect the health care delivery system, including quality of clinical care (including medical and mental health), quality of services provided by the Plan, and the organizational administrative systems. Quality activities will reflect the Plan's membership population in terms of age groups, disease management programs and identified high risk areas. The scope of services include, but are not limited to services provided in institutional/hospital care, outpatient care, home care/DME/pharmacy settings, and members interactions, communications and transactions with the Plan. I. A. The OuaIity Council The Quality Council is a subcommittee of the Sloans Lake Managed Care, Inc., Sloans Lake Health Plan, Inc. and Sloans Lake PPO, Inc., Board of Directors. Each of these Boards of Directors has delegated its authority to act on all matters of quality to the Quality Council. Membership on this committee shall consist of two members from the Board of Directors, the Chief Executive Officer of the HMO and the PPO, all Medical Directors, the Vice President of Network Relations, the Director of Quality, the Director of Medical Management, the Director of Customer Services and a designated member at large. The Chief Medical Officer shall be the chairperson. Meetinas T rR sFRVICES FEE QUOTATION SECTION (continued) 1. Pre-Admission/Concurrent Utilization Review 2. Psychiatric/Substance Abuse Review (if separate from #1 above) Full Package (1 and 2 above) 3. Case Managemenf" •7 ". 1. Start-Up/Implementation Fee 2. Basic Communication Package (brochure, stickers. and letters ..1 POS N jA Fee Unit Per Case. rolovee ' C)arges EPO POS EPO NCR N/R I ,Vote: Excludes lVedieare Retirees. (1) Indicate hourly rate if this is your standard arrangement. For purposes of your quote, please assume 80 eligibles in the POS plan and 585 in the EPO plan. How do the above charges differ assuming you are selected to provide utilization review for all plans? N a 40 The Quality Council shall meet as necessary but no less frequently than every other month. The chairperson shall be responsible for preparation of an agenda for each meeting. 2. Council Responsibilities The Quality Council shall have the following responsibilities: a. The Quality Council oversees the implementation of the Quality Program by review of data analysis, reports, and minutes of the Clinical Quality Subcommittee, the Provider Contracts & Services Quality Subcommittee, and the Customer Service Quality Subcommittee. The Quality Council annually reviews and approves the Quality Program, the Quality Program's annual evaluation and the annual Quality work plan. b. Act on behalf of the Boards of Directors on any recommendations from the above committees. C. Direct the Subcommittees to address any areas of quality the Council deems necessary. d. Make the final decisions regarding all areas of credentialing and discipline. e. Review and approve the annual evaluations and workplan updates from the Clinical Quality Subcommittee, the Customer Service Quality Subcommittee, the Provider Contracts & Services Quality Subcommittee, the Credentials Committee, the Medical Management Committee and the Pharmacy and Therapeutics Committee. B. Ouality Subcommittees There are three quality subcommittees dedicated to the review and analysis of specific issues affecting health care delivery to our members and service provided to Plan Network physicians and facilities. By reviewing specific issues for trends and patterns, the Plan will have the ability to create a positive impact on areas identified as needing improvement: 1. THE CLINICAL QUALITY SUBCOMMITTEE There shall be a Clinical Quality Subcommittee (CQC) for HMO, PPO, and PIP. The CQC is a multi-discilinary committee responsible for review of clinical data and developing quality initiatives concerning clinical issues. The CQC coordinates clinical improvement action plans resulting from outliers identified from physician profiling, specific cases identified as potentially gross and flagrant deviations from the standards of care, as well as the actions from its subcommittees as outlined below. The Committee shall consist of six (6) participatingproviders, the Chief Medical Officer, the Director of Quality and Quality Department staff, the Director of Medical Management, the Director of Network Relations, the Director of Customer Services and a representative from Information Technology. The Director of Quality shall be the committee chairperson. All actions of the Clinical Quality Subcommittee shall be reported to the Quality Council. Meetings The Clinical Quality Subcommittee shall meet as necessary, but no less frequently than every other month. The chairperson shall be responsible for the preparation of an agenda for each meeting. Overall Committee Responsibilities The overall responsibilities of the Clinical Quality Subcommittee shall be as follows: a. Quality review - review and analysis of indicators, preventive medicine studies, and outcome studies. Identify overall trends in the care provided by participatingproviders. b. Review and analysis of complaints involving issues of quality of care, lack of qualifications or quality of services. C. Review and analysis of medical management statistics and patterns. d. Performance of quality studies. Evaluation of patient satisfaction. Physician profiling. Recommendations to the Quality Council regarding measures to monitor and quality of care improvement initiatives. h. Review appropriateness of summary suspensions. The Clinical Quality Subcommittee may appoint subcommittees and workgroups to perform any studies it deems necessary. All results shall be reported to the Quality Council. Specific Activities of the Clinical Quality Subcommittee a. HEDIS 3.0 Data (HMO only) HEDIS 3.0 data will be collected, analyzed and reported to the CQC.. Emphasis will be placed on review of effectiveness of care indicators and evaluation of customer service, as well as overall plan stability, with the intent to develop benchmarks. In conjunction with provider profiling, HEDIS reporting will allow individual physicians to receive their performance results, average performances for all physicians in their peer group, and benchmarks developed by the CQC. Periodic re - measurements of HEDIS Specifications will occur in order to determine progress made toward reaching established benchmarks. Individual physician profile data will be placed in that physician's credentials file for evaluation at the time of recredentialing. HEDIS 3.0 results will also provide the Plan with the ability to develop quality improvement initiatives based on areas identified as requiring member education for preventive healthcare measures. b. Commonly Encountered Diagnoses The committee will identify the most common diagnoses in frequency, cost and high risk. Cost -quality analysis of these DRG's will be performed using both inpatient and outpatient information. Staff supported and physician based workgroups will evaluate data specific to physician specialties and will develop pathways for high quality/low cost delivery of patient care. These pathways will be shared with all appropriate participating providers for their input and approval following which they will be implemented. Follow-up re - measurement and analysis will determine the effectiveness of these pathways. C. Medical Management The Medical Management Committee is responsible for utilization management/review(see Medical Management Committee outlined in detail in this program). d. Outcome Studies The CQC will evaluate the results of and complicationsof various forms of patient treatment. The CQC, or its subcommittees, will identify the pathways taken by those participating providers obtaining the best results and will share these pathways with all appropriate participating providers. These pathways will be further reconciled with national guidelines. It is anticipated that these actions will produce quality improvements for all participating providers and best practices will be developed and communicated to all Network providers. MOM Data Data obtained from physician office visits performed by Medical Quality Measurement, Inc. will be analyzed. Trends will be identified and reported to physicians. Individual profiling data will be placed in physicians' credentials files. f. Patient Satisfaction The CQC shall coordinate its activities with the Director of Member Services to develop patient satisfaction surveys. The CQC will assist in analyzing the results of these surveys and in recommending strategies to improve identified areas of concern. This information will be given to the participatingproviders. Additional information obtained from the Customer Service and Inquiry Module (CSIM) will be analyzed jointly with the Customer Service Quality Subcommittee in order to determine the major areas of member complaints. Strategies to improve these areas of concern will be developed and recommended to participatingproviders. g. Provider Satisfaction The CQC shall coordinate its activities with the Provider Contracts & Services Quality Subcommittee to develop provider satisfaction surveys. The two committees will analyze the results of these surveys and use them to help attain internal quality improvements. Results also will be forwarded to participating providers. 4. Timelines for Review The CQC shall develop timelines for all quality review and surveys. It shall be the responsibility of the Director of Quality to produce a yearly listing of these timelines and present this listing to the CQC in order to facilitate the Committee's activities. This timeline will serve the purpose of the Quality Work Plan. 5. Annual Evaluation The CQC shall perform an annual evaluation of its activities which will include a summary of all reviews and guideline development and their impact on the quality of care. Unsuccessful activities will be analyzed with an emphasisplaced on determining the factors responsible for the lack of success. Finally, plans for the next year's activities will be developed. The chairperson of the CQC will compile a report of these activities and forward the report to the Quality Council for its approval. The following Committees report into the Clinical Quality Subcommittee and provide regular reporting on the status of their individual areas: 1. The Credentials Committee All credentialing for the HMO, PPO, and PIP programs shall be performed by a single committee, which shall be representative of the providers in these programs. The Committee is responsible for credentialing and recredentialingproviders and contracted services for the organization. Credentialing and recredentialing decisions are based upon application criteria and individual performance standards. The membership of the committee shall include seven (7) participatingproviders, a Medical Director, the Director of Medical Management, the Credentials Manager and the Director of Quality. The Medical Director shall serve as the chairperson of the committee. All actions of the Credentials Committee shall be reported to the Clinical Quality Subcommittee. Meetings The Credentials Committee shall meet as necessary, but no less frequently than every month. The chairperson shall be responsible for the preparation of an agenda for each meeting. Committee Responsibilities The Credentials Committee is responsible for all credentialing and recredentialing. The method by which this is accomplished is outlined in the Provider Credentialing Policies. The Credentials Committee shall report its findings and recommendations to the Clinical Quality Subcommittee for final action. 2. The Pharmacy and Therapeutics Committee There shall be one Pharmacy and Therapeutics Committee for the HMO, PPO, and PIP programs. The committee shall consist of four (4) participating providers from any of the programs; one Medical Director, the Director of Quality, a member of the Medical Management Committee and a Pharmacist. One of the providers shall chair the committee. All actions of the Pharmacy and Therapeutics Committee shall be reported to the Clinical Quality Subcommittee. Meetings The Pharmacy and Therapeutics Committee shall meet as necessary, but at least every three (3) months. The chairperson is responsible for the agenda at each meeting. Committee Responsibilities The Pharmacy and Therapeutics Committee has the following responsibilities: a. Review and update the formulary annually. b. Evaluate the need for adding newly released drugs to the formulary. C. Evaluate requests for drugs to be added to the formulary. d. Perform specific quality studies on drug use (diabetes, hypertension, etc.). e. Consult with the Medical Management Committee on drug utilization data. f. Report results to the Clinical Quality Subcommittee. 3. The Medical Management Committee There shall be one Medical Management Committee for the HMO, PPO, and PIP programs. It shall consist of three (3) participating providers from any of these programs; the Chief Medical Officer, the Medical Director for Auto Programs, the Director of Medical Management, the Director of Quality, the Director of Case Management, the Director of Claims and Distribution, the Director of Business Integration Technology, the Director of Network Relations, the Manager of Group Health, PPO, & HMO, the Clinical Manager of Case Management, Risk Management staff, and a member of the Pharmacy and Therapeutics Committee. The Director of Medical Management shall serve as the chairperson of this committee. All actions of the Medical Management Committee shall be reported to the Clinical Quality Subcommittee. Meetings The Medical Management Committee shall meet as needed, but no less frequently than monthly. The chairperson is responsible for the agenda at each meeting. Committee Responsibilities The Medical Management Committee has the following responsibilities: a. Evaluate UM/UR performed for the HMO, PPO, and PIP programs; identify utilization patterns. b. Oversee the medical management which has been delegated. C. Review UM/UR plans annually. d. Share drug utilization data with the Pharmacy and Therapeutics Committee. e. Coordinate and act on provider and member requests for reconsideration and/or appeal of UM decisions. f. Report results involving quality of care, lack of qualification or unprofessional conduct to the Clinical Quality Subcommittee. g. Evaluate and approve requests from providers for new technology h. Evaluate and approve research studies. 4. The Internal Quality Committee There shall be an Internal Quality Committee for HMO, PPO, and PIP. It shall consist of all Medical Directors, the Director of Quality, the Director of Medical Management, the Vice -President of Case Management, all Managers of Credentialing, UM, and Case Management, a representative from Marketing, and a representative from IT. A Medical Director shall serve as the chairperson of the committee. All actions of the Internal Quality Committee shall be reported to the Clinical Quality Subcommittee. Meetings The Internal Quality Committee shall meet as often as necessary but no less frequently than every other month. The chairperson is responsible for developing the agenda for each meeting. Committee Responsibilities 9 The committee's responsibilitiesare as follows: a. Serve as a training center for Sloans Lake employees to learn principles of Quality Improvement. b. Develop internal quality improvement/process improvement projects which will allow the company to better serve its customers. c. Teach employees of Sloans Lake the techniques of critical data analysis. 5. Accreditation Committee SLMC shall have a Committee comprised of multi-disiplinary interdepartmental staff for the purpose of providing linkage and communication regarding the Accreditation process. The Committee shall consist of a Medical Director, the Vice -President of Case Management, the Director of Quality, the Director of Medical Management, the Managers of Group Health and PIP for Medical Management, the Director of Contracts and Network Relations and the two designated Managers, the Manager of Credentialing, the Director of Customer Service, the Manager of Customer Service, the Director of Business Technology Integration, the Manager of Enrollment, a customer service representative and representativesfrom the claims department and sales and marketing. The Director of Quality shall be the Chairperson. All actions of the Accreditation Committee shall be reported to the Clinical Quality Subcommittee. Meetings The Accreditation Committee shall meet as necessary but no less frequently than once a month. The chairperson shall be responsible for the preparation of the agenda for each meeting. Committee Responsibilities The Committee's responsibilitiesare as follows: a. Review standards for the National Committee for Quality Assurance (NCQA) and AAHCC/URAC to provide a forum in which multi - departmental discussioncan occur to promote smooth functioning and communication between departments. b. Standardize organizational functions. C. Develop policies and procedures when the need is identified. 10 2. THE CUSTOMER SERVICE QUALITY SUBCOMMITTEE There shall be a Customer Service Quality Subcommittee (CSQC) for HMO, PPO and PIP. The CSQC is a multi -disciplinary, cross functional committee responsible for reviewing customer service issues and indicators, including analysis of trends in member complaints, appeals and grievances, and satisfaction surveys, access and developing quality initiatives concerning customer service and responsiveness. The committee shall consist of the Director of Customer Service, the Director of Quality, the Manager of Customer Service, the Compliance Manager, the Enrollment Manager, a representative from Information Technology, and a representative of Network Relations. The Director of Customer Service shall be the chairperson. All information from the committee shall be reported to the Quality Council. Meetings The Customer Service Quality Subcommittee shall meet as necessary but no less frequently than every two months. The chairperson shall be responsible for the preparation of the agenda for each meeting. Committee Responsibilities The committee's responsibilities are as follows: a. Review and categorize HMO member complaints. b. Develop action plans to respond to member complaints. c. Perform customer/member surveys for HMO and PPO and analyze the results of these surveys in order to recommend strategies to improve identified areas of concern. d. Work with the Clinical Quality Subcommittee to use survey information to improve customer/memberservice. e. Review actions of HMO Member Appeals Committee. The following Committee reports into the Customer Service Quality Subcommittee 1. The HMO Member Anneals Committee There shall be an HMO Member Appeals Committee. It shall consist of the Director of Customer Service, the Medical Director for HMO, the Vice - President for Provider Networks, the Manager of Customer Service, and the Compliance Manager for HMO. The Director of Customer Service shall serve 3. as chairperson. All actions of the HMO Member Appeals Committee shall be reported to the Customer Service Quality Subcommittee. Meetings The HMO Member Appeals Committee shall meet when it is required by the HMO Member Appeals Policy. The chairperson is responsible for distributing all pertinent information to the committee members and notifying the member of the time and place of the meeting. The chairperson is also responsible for meeting all of the reporting timelines set forth in the HMO Member Appeals Policy. Committee Responsibilities The committee has the following responsibilities: a. Review content of the member appeal and all pertinent information relative to the appeal. b. Interview the member ( if member requests to be present). C. Decide on a course of action and notify the member. d. Fulfill any additional requirements set forth in the Member Appeals Policy. -- There shall be a Provider Contracts and Services Quality Subcommittee (PCSQC) for HMO, PPO and PIP. This committee is a multi-disciplinary,cross functional committee responsible for reviewing provider servicing issues and indicators including Network provider concerns. The committee shall consist of the Vice -President for Provider Networks, the Director of Contracts and Network Relations, the Director of Quality, a designated Medical Director, the Director of Mountain and Rural Network Development, the Managers of Contracts and Network Relations, a representative from Information Technology, and a representative from Customer Services. The Vice -President of Network Relations shall be the chairperson. All information from the committee shall be reported to the Quality Council. Meetings 12 Questionnaire The committee shall meet as necessary but no less frequently than every two months. The chairperson shall be responsible for the preparation of the agenda for each meeting. Committee Responsibilities The committee's responsibilitiesare as follows: a. Review the actions of the Provider Appeals Committee and the Provider Action Committee. b. Review provider contracts on a regular basis. c. Ensure adequate provider access and availability to HMO members and members of PPO customers. d. Work with the Clinical Quality Subcommittee to develop and analyze providerprofiling information. e. Share (d) above with participating providers. The following Committees report into the Provider Contracts and Services Quality Subcommittee: 1. ProviderAction Committee There shall be a Provider Action Committee for HMO, PPO and PIP. It shall consist of the Vice-Presidentfor ProviderNetworks, the Medical Directors, the Director of Medical Management, Director of Network Relations, and the Manager of Network Relations. The Director of Network Relations shall be the chairperson. All actions of the Provider Action Committee shall be reported to the Provider Contracts and Services Quality Subcommittee. Meetinj?s The Provider Action Committee shall meet as necessary but no less frequently than every other month. The chairperson shall be responsible for the agenda and all pertinent materials for each meeting. Committee Responsibilities The committee's responsibilitiesare as follows: a. Review action forms on individual providers demonstrating repetitive patterns. 13 b. Develop plans for eliminating problems with individual providers (education, referral to Clinical Quality Subcommittee). c. Identify and solve problems related to the entire provider group. 2. Provider Appeals Committee There shall be a ProviderAppeals Committee for HMO, PPO, and PIP. It shall consist of the Director of Network Relations, the Vice -President for Provider Networks, the Medical Director, and other individuals deemed necessary by the chairperson. The chairperson shall be the Director of Network Relations. All actions of the ProviderAppeals Committee shall be reported to the Provider Contracts and Services Quality Subcommittee. Meetinss The Provider Appeals Committee shall meet whenever it is required by the ProviderAppeals Policy. The chairperson shall be responsible for distributing all pertinent information to the committee members and for notifying the provider of the time and location of the meeting. The chairperson is also responsible for assuring that all timelines and communications are performed according to the guidelines in the Provider Appeals Policy. Committee Responsibilities The committee's responsibilitiesare as follows: a. Listen to and act on provider appeals. b. Notify the provider of the action in the appropriate time frame. II. QUALITY IMPROVEMENT PERSONNEL 1. CHIEF MEDICAL OFFICER a. Reports directly to the Chief Executive Officer. b. Delegated the authority by the Board of Directors the oversight responsibility of planning, designing, implementing, and monitoring the Quality Program for all lines of business. c. Chairs the Quality Council, the Credential Committee, and Internal Quality Committee. Participant of the Clinical Quality Subcommittee, Pharmacy and 14 Therapeutics Committee, Medical Management Committee, Accreditation Committee, HMO Member Appeals Committee, Provider Contracts and Services Quality Subcommittee, Provider Action Committee, and the Provider Appeals Committee. 2. DIRECTOR OF QUALITY a. Reports to the Chief Medical Officer. b. Responsible for planning, directing, implementing, monitoring and ongoing management of all quality activities with an emphasis on continuous improvementprocess for both internal and external customers. c. Chairs the Clinical Quality Subcommittee and the Accreditation Committee. Participant of the Quality Council, Credentials Committee, Pharmacy and Therapeutics Committee, Medical Management Committee, Internal Quality Committee, Customer Service Quality Subcommittee, and the Provider Contracts and Services Quality Subcommittee 3. QUALITY NURSE SPECIALIST a. Reports to the Director of Quality. b. Responsible for the daily maintenance of Quality Department activities, studies and projects, specifically HEDIS data collection and analysis. c. Participant on Committees and Subcommittees as designated by Director of Quality 4. QUALITY DEPARTMENT ADMINISTRATIVEASSISTANT a. Reports to the Director of Quality. b. Responsible for administrative support to the Director of Quality and the Quality Nurse Specialist. c. Attends meetings in which the Director of Quality is the designated chair in order to take minutes and coordinate the preparation of the meeting. III. COMPLAINTS AND INVESTIGATIONS A. Sources 15 1. QI Committee activities/studies 2. HMO members 3. PPO payers 4. Other providers 5. Institutions in which the provider practices 6. Other sources B. Quality of Care/Lack of Oualifications/Oualityof Service All complaints regarding quality of care/service issues (including certain medical management issues) shall be submitted in writing and investigated by the CQC. These issues may include professional competency or qualifications, quality of service to members, or availability. In order to evaluate these issues completely, the CQC may need to review a provider's claims, encounter forms, and/or medical records. The Committee also may chose to interview the complainant(s) and/or the provider. If the CQC determines that no problem exists, this determination shall be forwarded to the provider and a copy of the CQC determination will be placed in the provider's credentialing file. When it is determined that a quality of care/service or lack of qualification issue does exist with respect to the care or practice of a specific provider, the issue shall be assigned a level of severity as follows: Level 0 - a minor problem of documentation, service or clinical judgment causing no harm to patients Level 1- a significant problem where a repetitive pattern exists or where a clinical action could potentially have caused harm to a patient Level 2 - a serious problem where a patient is harmed or where a provider's care falls below the standard of practice in the community. The reporting of these issues will be conducted follows: Level 0 issues shall be recorded in the provider's credentialing file, and the provider shall be notified of this action. The CQC shall forward the record of this action to the Quality Council "for information only". 2. Level 1 and 2 issues shall be thoroughly reviewed by the CQC and recommendations for a plan of corrective action, follow-up evaluation and monitoring, probation, suspension or termination of participation in the HMO, PPO, and/or PIP providerpanels with respect to any Sloans Lake Managed Care program shall be 16 formulated. If the recommendation is adverse to the provider, written notice of the recommendation shall be forwarded to the provider, and the provider shall have such right to a hearing or review as set forth in the Fair Hearing Policy. C. Unprofessional Conduct All complaints regarding unprofessional conduct, including disruptive or impaired behavior, shall be investigated by an Ad Hoc Investigative Committee appointed by the Medical Director. This Committee shall interview the provider and other witnesses, review and examine appropriate evidence and documents and prepare written findings and recommendations. If the Ad Hoc Investigative Committee finds that no disruptive or impaired behavior has occurred, no further action is required, and the committee report shall be placed in the provider's credentialing file. 2. If the Committee finds that disruptive or impaired behavior has occurred, the Committee shall send written notice of the recommendationsto the provider, and the provider shall have such right to a hearing or review as set forth in the Fair Hearing Policy. D. Final Disposition If the provider accepts the recommendationof the CQC or Ad Hoc Investigative Committee and does not exercise his/her rights under the Fair Hearing Policy, the CQC or the Ad Hoc Investigative Committee shall forward the recommendationto the Quality Council for final action. Recommendations regarding a corrective action plan or practice restrictions shall include a clear statement of the problem, what corrective actions or practice restrictions should be imposed, and the dates of follow-up reviews. The Quality Council may accept or reject the committee recommendations or request further information from the committee. When a decision of the Quality Council results in the imposition of a corrective action plan, a follow-up evaluation, monitoring, or probation, it shall be the responsibility of the Medical Director to review and approve the plan to accomplish such a task. The Director of Quality shall be responsible for assuring that monitoring occurs, that corrective action plans are implemented, and that follow-up reviews and evaluations occur on their appointed dates. All follow-up reporting and evaluations are to occur in the Clinical Quality Subcommittee. Progress reports and recommendations following completion of the process are referred to the Quality Council for final determination. 17 Any final action taken by the Quality Council which is adverse to the provider shall be reported to the appropriate state licensing agency and the National PractitionerData Bank in accordance with applicable state and federal law. IV. SUMMARYACTIONS A. Summary Suspension 1. A recommendationfor summary suspension from participation as provider in the HMO, PPO, and/or PIP provider panels may be made whenever the conduct of a provider requires that immediate action be taken to protect the life or safety of any patient or to reduce the substantial likelihood of immediate damage to the health or safety of any patient. 2. The Chief Executive Officer and/or the Medical Director shall have the authority to summarily suspend a provider from the HMO, PPO, and/or PIP providerpanels. Written notice of summary suspension shall be given to the provider by personal delivery to the office of the provider, along with a statement of the reason(s) for such action. As of the date of receipt of the notice and for as long as it shall remain in effect, the provider shall cease providing medical services to HMO members or on behalf of PPO payers and shall be ineligible for claim payment or other compensation. The HMO provider shall assign all HMO members for whom he/she is actively providing care to a substitute participating provider for the period of the suspension. If the provider fails to do so, the appropriate Medical Director shall assign the HMO members to other providers. The CQC shall investigate the circumstances leading to the summary suspension in accordance with the procedures set forth in Article II herein, and shall, within ten (10) days, prepare findings and a recommendation for the continuation or termination of the summary suspension and/or any other appropriate corrective action. a. If the CQC recommends that the summary suspension be terminated without any further corrective action, such recommendation shall be forwarded to the Quality Council for final disposition. The Quality Council may affirm, reject or modify the recommendation of the CQC. The final decision of the Quality Council shall be delivered to the provider. If the final decision of the Quality Council is adverse to the provider 18 with respect to participation on the HMO, PPO, and/or PIP provider panels, the provider shall be entitled to a hearing or review as set forth in the Fair Hearing Policy. If the provider does not request a hearing or review, the final decision of the Quality Council shall stand. b. If the CQC recommends that the summary suspension of the provider should be continued or has another recommendation that is adverse to the provider with respect to participation on the HMO, PPO, and/or PIP provider panels, written notice of such recommendation shall be delivered to the provider and the provider shall be entitled to such hearing or review as set forth in the Fair Hearing Policy. If the provider determines to accept the recommendationof the CQC, the recommendations of the CQC shall: be forwarded to the Quality Council. The Quality Council shall render a final decision and, in doing so, may affirm, reject or modify the recommendationsof the CQC or may request further investigationby the CQC or hearing panel. As soon as practicable after receipt of all information, the Quality Council shall take final action. The provider shall have no further right of appeal. c. The summary suspension of a provider for a period of greater than thirty (3 0) days shall be reported to the appropriate state licensing agency and the National Provider Data Bank in accordance with applicable state and federal law. B. Automatic Contract Termination The following events may result in automatic termination of participation on the HMO, PPO, and PIP provider panels: I . Revocation or suspension of a provider's license, certification, or other legal credential authorizing him/her to practice in this State. 2. Revocation or suspension of DEA certificate. Loss of the required medical malpractice insurance coverage. 4. The furnishing of incomplete or inaccurate information on an applicationor reapplication. Revocation or suspension of provider's privileges at the primary admitting or practice facility. 19 The provider shall not have any right to a hearing or review as a result of termination for any of the above reasons. V. CONFIDENTIALITY All quality individual member specific case review documentation, and individual provider profiling results shall remain confidential information and protected from discovery by the state statutes governing the quality review process. All meeting minutes which contain information regarding individual members and provider identification. are considered confidential. All staff and committee members will respect this confidentiality and shall not release any information without the consent of the member and/or legal counsel. A Confidentiality Statement will be signed by all persons having access to this material. VI. CONFLICT OF INTEREST No individual may participate in the review process, evaluation of, or final adjudication of any issue in which he/she has been professionally involved or where judgment may be compromised. VII. ANNUAL REVIEW The Quality Program and its effectiveness including improvements and enhancements shall be reviewed, evaluated and revised at least annually. Results of the annual evaluation of the effectiveness of the Program, the revised Quality Program, and annual Quality Workplan of activities will be submitted to the Quality Council and the Sloans Lake Managed Care Board of Directors for approval. Effective Date: 11/8/95 Revision Date(s): 2/5/97 Committee 8/15/97 Vice President's Council 9/3/97 President's Council Approval Date: 9/4/97 20 SLOANS LAKE MANAGED CARE 1997 QUALITY PROGRAM APPROVAL APPROVAL Henry Cleve d, M.D. Chairpers , Sloans Lake Managed Care, Inc., Board of Directors Neil Wal on -Chief Executive Officer Sloans Lake Managed Care, Inc. Robert Faraci, M.D. Chief Medical Officer Sloans Lake Managed Care, Inc. fqwec� fz41L Andrea Fortney, RN., HQ Director of Quality Sloans Lake Managed Care, Inc. 21 DATE 9-V-`i7 -y-97 9-N-`l7 i N (0 a) a) a c aD 0 o Q U E NQ E O cn .o U m U Z d a` E as E w o U U N L O h ai U = U a ca to Gy`m o m A caa etz d 'm m a d in E E- 0 �U o lo- n (gyp V � v � d Q Z n EO — t`A � QU s C d 3 EOn) � t: C a Q a) G ia y 3 R 4 , L h m Q 4 Q m m E h co h m m m ( co m U to E coW WA UF= Q03 N Z � Q M Q J rn E ca) ma' od cd v, Eo m°' �E�' my C7- U CE vcm vE E y O a7 EE O O 0 0 U O a) U a U U U Q U c T N 7 E E ti N O U U c � L C 7 O> � U 3 N 0� C o ca .y m o a, o a c a, aNi N aGi �. o� a m 4` co w °ate' o a m m �� co cnc7a 2 Ua Uv> Una