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Welcome to Health Plan of Nevada-Northern Nevada Check Up_ We

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Welcome to Health Plan of Nevada-Northern Nevada Check Up_ We Powered By Docstoc
					  Welcome to Health Plan of Nevada-Northern Nevada Check Up! We would like to
 thank you for choosing us to arrange the quality care your child deserves. We think
you will find that we can provide your child with programs, which exceed the services
                your child would receive on a commercial insurance plan.

 The following information will provide important features of HPN-Northern Nevada
  Check Up. It will also help you decide when and how to get appropriate medical
                                  care for your child.
                     Please keep this document in a safe place.

 Oral interpretation services in languages other than English are available through
          our Member Services Department. Please call 702-242-7317 or
                               1-800-962-8074 for help.

    Hearing impaired members may call our TTY/TTD line at 1-702-242-9214 or
                          1-800-349-3538 for help.

     Visually impaired members may call our Member Services Department at
   702-242-7317 or 1-800-962-8074 for help. We can also give you documents in
                         larger print for easier reading.


 Please visit our website at www.hpnmedicaidnvcheckup.com for more information
                                about our program.




        This handbook is not a Certificate of Insurance and shall not be
         construed or interpreted as evidence of insurance coverage
                       between the HMO and member.
                 This Member Handbook has important information
                        about your child’s health benefits.

•   When you have a question, look for the answer in this handbook.
    If you still have questions, call our Member Services Department between 8 a.m. and 5 p.m., Monday
    through Friday.


    The phone numbers are:           242-7317 in Las Vegas
                                     1-800-962-8074 outside of the Las Vegas area


•   If your child needs to see a doctor, call the doctor’s office.
    You will need to choose a doctor to be your child’s primary care physician. You can do that by calling
    our Member Services Department at 1-800-962-8074.

    For your reference write your child’s doctor’s name, office location and phone number here.

       The doctor is:______________________________________________

       Location:_________________________________________________

       Telephone:________________________________________________


•   If you need an answer to a medical problem, call your doctor during regular office hours. Or call our
    Telephone Advice Nurse at 1-800-288-2264 anytime, 24 hours a day, 7 days a week.

•   If your child needs medical treatment “after hours” (for a problem that should not wait until your
    doctor can see you), go to an Urgent Care Center in our Provider Directory.

•   If your child has a medical emergency (you need help immediately for a very serious problem), go to
    the nearest hospital emergency room. Or call 911 for any life-threatening situation, such as major
    injuries from an accident, severe chest pain, unconsciousness or difficulty breathing.




                                                     2
                 Welcome! Thank you for choosing
         Health Plan of Nevada-Northern Nevada Check Up.
    With your help we will do our best to keep your child healthy and give him/her quality medical care.

Table of Contents                                                                                          Page
What HPN-Northern Nevada Check Up does for your child                                                         4
  What is HPN-Northern Nevada Check Up?
  Do I need to bring a member card to the doctor’s office?
About your primary care physician (PCP)                                                                     4-5
  What your child’s PCP does for him/her
  How to help your doctor take care of your child
How to choose or change your child’s primary care physician (PCP)                                           5-6
How to get health care services                                                                             6-8
  When your child needs to see a doctor
  Getting your child’s prescriptions filled
  When your child needs a specialist or a hospital
In an emergency or when your child needs urgent care                                                        8-9
  When should your child to use the emergency room
  If your child needs care right away or after hours
While you are away from the HPN-Northern Nevada Check Up service area                                      9
Telephone Advice Nurses                                                                                    9
Your child’s basic medical benefits                                                                    10-17
A special note about family planning services                                                             17
Special benefits for HPN-Northern Nevada Check Up members                                              17-18
  Special programs to help your child stay healthy
  Support services for HPN-Northern Nevada Check Up members
If your child is pregnant                                                                              18-19
  Who will take care of your child during her pregnancy?
  Who will deliver your child’s baby?
  A healthy start for your child’s new baby
Keeping your children healthy                                                                          19-21
  Choosing your child’s doctor
  Regular checkups for your child
  Shots to protect your child against getting sick
  Special checkups for children from the Healthy Kids program
  If your child has asthma
Services you receive directly through HPN-Northern Nevada Check Up                                           21
Services that are not covered by HPN-Northern Nevada Check Up                                                21
A special note about mental health benefits                                                                  22
Your child’s rights and responsibilities                                                                     22
  Your child has the right
  Your responsibilities as a parent/guardian are
When your 18 year old child can’t make his/her own health care decisions                                  23
When you should contact us                                                                             24-25
  And when we might contact you
What to do if you have an appeal or a grievance                                                           25
Appeals                                                                                                25-27
Grievances                                                                                                27
If you no longer want your child to be a member of HPN-Northern Nevada                                    28
Check Up
If your child is no longer on HPN-Northern Nevada Check Up                                                   28




                                                     3
What HPN-Northern Nevada Check Up does for your child

What is HPN-Northern Nevada Check Up?
HPN-Northern Nevada Check Up was created by Health Plan of Nevada, Inc. (HPN), the largest and most
experienced health maintenance organization (HMO) in Nevada. An HMO works with doctors, nurses,
hospitals and other healthcare workers and medical facilities. Our goal is to help your child stay healthy and
provide your child with the best care possible when he/she becomes ill.

HPN is a managed care company. This means that:
• Your child has a personal doctor, a primary care physician (PCP), whom he/she sees when healthcare is
  needed.
• You should make appointments for regular checkups with your child’s doctor, so he/she can get to know
  your child and help your child stay well.
• If your child needs any extra care, your child’s doctor arrange it through our network of doctors,
  hospitals and other healthcare facilities.

While your child is on the plan, he/she must see the PCP before:
• going to a hospital;
• seeing a specialist;
• having tests done; or
• getting most other special healthcare services.

Your child’s doctor must give you a written referral before he/she can use these services. If you take your
child to a hospital or get other special services without a referral, they may not be covered under the plan. It
is your responsibility to make sure the provider your child is seeing is in the HPN-Northern Nevada Check
Up Provider Directory.

In an emergency you can take your child straight to the emergency room. If your child is outside the Washoe
County he/she may get emergency medical services from any emergency room, if necessary.

Do I need to bring my child’s Nevada Check Up card to the doctor’s office?
Yes, you should always take your child’s Nevada Check Up card to medical appointments. You will receive
a card for each of your children who are enrolled with Nevada Check Up from the Division of Health Care
Financing and Policy.


About the primary care physician (PCP)

As an HPN-Northern Nevada Check Up member your child can receive care from a doctor listed in the
HPN-Northern Nevada Check Up Provider Directory. This doctor is called a primary care physician or PCP,
and he/she is your child’s personal doctor.

Your child’s PCP will coordinate all his/her medical needs. The PCP will refer your child to a specialist
when medically needed.

When you signed up for HPN-Northern Nevada Check Up, you chose a doctor’s office where you will take
your child to receive care. If you did not pick a doctor, we will help you choose one. Call Member Services,
1-800-962-8074 for help and to let us know your PCP choice.



                                                       4
About the primary care physician (PCP) - continued

What your child’s PCP does for him/her
One of the first things you should do is make an appointment for your child to see his/her doctor. During this
first checkup, the PCP finds out about your child’s health needs. He/she will help you plan routine checkups,
shots and tests to help your child stay well.

If your child needs lab tests or x-rays, or needs to see a special doctor or to go to the hospital, the PCP
arranges that. You will get a referral form to take with you to the doctor, lab or hospital. Your child’s PCP
works with this health care team to help plan your child’s care. Your child may only get care from doctors
and hospitals listed in the HPN-Northern Nevada Check Up Provider Directory. If your child needs
emergency medical treatment, he/she may get medical services from any emergency room you choose.

How to help your doctor take care of your child:
• Choose a PCP your child likes and wants to stay with.
• Plan ahead so you can learn as much as possible during every doctor visit.
• Listen to your child’s PCP. Follow his/her instructions to help your child get well and stay healthy.


How to choose or change your child’s primary care physician (PCP)

Each of your children enrolled in HPN-Northern Nevada Check Up can choose a PCP from the Provider
Directory that is included in this packet of information. PCPs work in one of these areas:
• General or family practice;
• Internal medicine;
• Gynecology;
• Pediatrics;
• Obstetrics.

If you feel your child needs care from any other type of doctor, or any other type of special care, you must
take your child to the PCP first. Your child’s PCP will check out the problem, and if your child needs special
care he/she will help you get it from a specialist listed in the HPN-Northern Nevada Check Up Provider
Directory.

Under HPN-Northern Nevada Check Up, you can choose a different PCP for each of your children. If you
have young children, we suggest you choose a pediatrician to be their PCP. Usually, you can find a
pediatrician for your younger children and a family practice doctor for your older children in the same
doctor’s office. Some PCPs will take care of people of all ages, from babies through adulthood. If your
child’s PCP does, and you want all of your children to have the same PCP that’s fine. The choice is up to
you.

If your child is pregnant, you will choose an obstetrician to take care of your child during the pregnancy until
after the baby is born.

When you choose a primary care physician (PCP)
Try to choose a doctor who:
• has an office that is easy for you to get to;
• has office hours when you can arrange to get there;


                                                       5
How to choose or change your child’s primary care physician (PCP) - continued

•   you can talk to easily, speaks your language and will listen to you.

You received a Provider Directory, which lists doctors you can choose as your child’s PCP with this
handbook. If the doctor your child is seeing now is on the list, your child can stay with him/her. If you want
more information about any of the doctors in the Provider Directory, call our Member Services staff at
1-800-962-8074. You may also visit our website, www.hpnmedicaidnvcheckup.com for an updated provider
directory each month.

If you want to change your child’s PCP, you may call us at any time. Before you take your child to a
different doctor, please call us and tell us who you would like the new PCP to be. Usually, the PCP change
will be effective the 1st of the next month. Just call Member Services at 1-800-962-8074.


How to get healthcare services

When your child needs to see a doctor
  Unless it is an emergency, you should call your child’s doctor for an appointment. If your child gets sick
  when the doctor’s office is closed, you can call the Telephone Advice Nurse at 1-800-288-2264 or go to
  an Urgent Care Center listed in the provider directory anytime, 24 hours a day, 7 days a week.
    When you call your child’s PCP, you should get a medical appointment in the following time frames:

    •   Routine appointments within 2 weeks;
    •   Urgent appointments within 2 calendar days;
    •   Emergent appointments same day.

    When you call your child’s specialist, you should get an appointment in the following time frames:

    •   Routine appointments within 30 calendar days of referral;
    •   Urgent appointments within 3 calendar days of referral;
    •   Same day, medically necessary appointments within 24 hours of referral.

    If your child is pregnant, she should get an obstetrical appointment in the following time frames:

    •   Within 7 calendar days of the first request for women in their first or second trimesters;
    •   Within 3 calendar days of the first request for women in their third trimester;
    •   Within 3 calendar days of identification of a high-risk pregnancy; or
    •   Immediately for emergency conditions.

    Expect not to wait more than one hour from your scheduled appointment time to see your child’s PCP,
    unless the PCP has an emergency. In the case of an emergency, you may need to wait longer than one
    hour while the PCP takes care of the patient with an emergency. Remember that if your child has an
    emergency, the PCP will give you the same prompt service.

    If you have trouble getting an appointment or wait in the office longer than one hour, call Member
    Services at 1-800-962-8074. We’ll be happy to help you.



                                                        6
How to get healthcare services - continued

On the day of your child’s appointment :
• Arrive 15 minutes before the scheduled appointment. If you are going to be late or cannot keep your
   child’s appointment, call the doctor’s office.
• Always bring your child’s current Nevada Check Up card with you.
• Before you talk with the doctor, write some notes about what you want to tell him/her.
• While you are talking with the doctor, write notes about what you need to do once you leave. These notes
   might tell you:
   - how and where to get any medication your child needs;
   - how and when to take the medication;
   - where and when to go for lab tests or x-rays;
   - what food to eat or exercises to do.
• If your child needs to come back for another visit, make the appointment before you leave.

Getting your child’s prescription filled
Your child’s doctor may give your child a prescription for medicine. Ask the doctor if you have any
questions about the medicine or how to take it. You can also ask the pharmacist where you get the medicine.
HPN-Northern Nevada Check Up has a preferred list of drugs for your child to use. The preferred drug list is
on our website, www.hpnmedicaidnvcheckup.com. Ask the doctor if the medicine he/she is prescribing for
your child is on the HPN Preferred Drug List. If the medicine is not on the list, HPN-Northern Nevada Check
Up may not pay for the medicine, or the medicine may require prior approval. If it does, your doctor may call
our Pharmacy Services Department at 1-800-962-8074 for approval.

As an HPN-Northern Nevada Check Up member, your child’s prescriptions may be filled at any Kmart,
Wal-Mart, Sav-On, Albertsons, Vons, Smiths, Rite-Aid or Walgreen’s stores. If you need help finding a
drug store or pharmacy, ask at the doctor’s office or call Member Services at 1-800-962-8074.

When your child needs to see a specialist or go to the hospital
There are times when your child’s doctor may feel your child needs to see a specialist. The doctor will help
you choose one from the HPN-Northern Nevada Check Up Provider Directory and give you a referral form.
The provider directory may be found on our website, www.hpnmedicaidnvcheckup.com. Take this form with
you when you see the specialist. If the specialist needs to see you more often, he will need to get prior
authorization by calling our Utilization Management Department at 1-800-288-2264.

Prior Authorization Requirements
There are some medical services that need approval before you can get the services. Your doctor will ask
HPN-Northern Nevada Check Up for the approval first and then help you get the care you need. Before you
seek the services ordered by your child’s doctor ask the doctor if HPN-Northern Nevada Check Up has
approved the services. HPN-Northern Nevada Check Up may not pay for services you get that are not
approved. If you are not sure, ask your doctor to call our Member Services Department at 702-242-7317 or
1-800-962-8074. The doctor may also check the status of a prior authorization request electronically at
www.healthplanofnevada.com using the link to HPN @YourService.

Services that require authorization may include:
• Hospital admissions
• Outpatient surgeries
• Procedures, lab tests, x-rays and services that cost more than $200


                                                     7
How to get healthcare services - continued

•    Medical equipment & supplies
•    Specialist care
•    Physical, occupational and speech therapy
•    Some medications

If the doctor feels your child needs to go to the hospital, he/she will make the arrangements. The doctor will
call our Utilization Management Department for approval. The only time you should take your child to a
hospital without the doctor’s approval is in an emergency. In that case, go to the nearest hospital emergency
room.


In an emergency or when your child needs urgent care

When should your child use the emergency room?
When your child is feeling sick, or has an injury, ask your child: Are you in very severe pain? Ask yourself:
Could my child lose a limb, or eyesight or hearing? Could my child die if he/she doesn’t get treatment within
the next 24 hours? Is my child likely to hurt himself or someone else if I don’t take him/her to a doctor
quickly?

                           If your answer is “yes,” to any of these questions,
take your child to the nearest hospital emergency room even if the emergency room is not listed in the
                         HPN-Northern Nevada Check Up Provider Directory
                                              or call 911.

Tell the desk clerk in the emergency room that your child is an HPN-Northern Nevada Check Up member.

As soon as you can, or the next day, call your child’s doctor’s office. Tell the office staff about your child’s
emergency room visit.

 If your child needs care right away or “after hours”
 (not an emergency, but something that should be taken care of quickly):

 •    Call your child’s doctor during regular office hours. The office staff will arrange for your child to get
      care as quickly as possible.
 •    After office hours you can call our Telephone Advice Nurse hotline at 1-800-288-2264. The nurse will
      help you decide the best place to get help for your child.
 •    If your child’s doctor cannot see him/her right away, go to an Urgent Care Center listed in the Provider
      Directory. They have evening and weekend hours. You do not need to make an appointment.

When a doctor sees your child in the emergency room and he/she gets medical services for an emergency
medical condition, your child will also receive post stabilization services as a benefit. Post stabilization care
means covered services, related to an emergency medical condition that are given after your child is
stabilized to keep him/her stabilized, or to improve or resolve your child’s condition. These emergency
services and post stabilization services are covered even if they are not provided by a doctor or hospital
listed in the HPN-Northern Nevada Check Up Provider Directory.




                                                        8
Use this chart to help you decide the best place to get care:
 Emergency care is necessary       Call your child’s PCP during        Call the 24-hour Telephone
 only if your child’s health       regular office hours when your      Advice Nurse at 1-800-288-2264
 might be in serious danger.       child just doesn’t feel well or for when your child’s doctor’s office
 This includes situations like:    situations like:                    is closed and your child has:
 • Serious accidents               • Colds or sore throats             • Colds or sore throats
 • Severe cuts or burns            • Tension headaches                 • Tension headaches
 • Chest pain                      • Back pain                         • Back pain
 • Vomiting blood                  • Frequent urination                • Frequent urination
 • Severe bleeding                 • Rashes                            • Rashes
 • Severe shortness of breath      • Earaches                          • Earaches
 • Emergency labor and             • Low-grade fever                   • Low-grade fever
     delivery
 • Any other situation that        • Strains or sprains                • Sprains or strains
     could endanger your child’s
     life or places the health of
     your child in serious
     jeopardy
 If you take your child to the
 emergency room and it is not
 an emergency, you may have
 to wait longer than you would
 if you saw your child’s PCP or
 used an Urgent Care Center.
   If your child’s doctor or the Telephone Advice Nurse cannot help him/her right away, go to one of
      the Urgent Care Centers listed in the Provider Directory or to the nearest emergency room, if
                                                 necessary.


While you are away from the HPN-Northern Nevada Check Up service area

The HPN-Northern Nevada Check Up service area is Washoe County. When you are out of the service area,
your child should only get healthcare in an emergency at the nearest hospital emergency room or urgent care
center. Make sure you tell them your child is an HPN-Northern Nevada Check Up member. Also, tell your
child’s doctor he/she went to an emergency room while you were away.

If your child is being treated for a medical problem and is going to be away for more than a few days, let
your doctor know. If you have any questions while you are away, call Member Services at 1-800-962-8074.

Telephone Advice Nurses

If you need help deciding what you should do, call one of the 24-Hour Telephone Advice Nurses. This free
service is available 24 hours a day, 7 days a week. The nurse can answer most basic health questions and
can help you decide if your child needs to see the doctor. The 24-hour phone number is 1-800-288-2264.




                                                     9
Your child’s basic medical

Basic health benefits
As an HPN-Northern Nevada Check Up member, your child gets all of the medically necessary covered
services at no cost to you. Your child’s doctor will arrange his/her care. Your child will need to use an HPN-
Northern Nevada Check Up approved healthcare facility for most of these services, including:

Allergy Testing
- Covered with medically recognized allergic reactions

Ambulance Services (for emergency services only)
- Medically necessary ground or air ambulance
- EXCLUDES: Non-emergency medical transportation

Ambulatory Surgery Centers

Case Management Services

Chiropractors
- Treatment covered for members if referred by an EPSDT screening.

Cochlear Implants
- Covered services include hearing evaluations, surgical implantation of the device, rehabilitation and
   postoperative follow-up evaluations every six-months for the first two years and then annually or as
   needed.
- Equipment-covers supplies, repairs, adjustments and replacement for the effective use of the implanted
   device.
- Damage or loss insurance covers one replacement of implant.
- Replacement parts are limited to the following:
   - Cochlear device-one time purchase
   - Battery charger including 2 rechargeable batteries-$150/one year
   - Rechargeable batteries (3)-$90 set/year
   - Earhook-$15/year
   - Cables-$25 each/2 years
   - Headset including cables, earhook, magnet, and microphone-$450/year
   - Insurance-$250/year
   - External speech processor-Invoice cost/year

Diabetic Services
- Diabetic outpatient self-management training for Type I and Type II Diabetes includes blood glucose
   self-monitoring, diet and exercise planning, individual and group training.
- Supplies limited to:
   - Lancets                    200/month
   - Alcohol swabs              200/month
   - Battery                   1/year
   - Blood Glucose Monitor 1/lifetime
   - Blood glucose strips       200/month
   - Insulin Syringes          100/month
   - Keto-stix                 100/month
   - Control Solution           1/month


                                                     10
Your child’s basic medical - continued

Durable Medical Equipment
- Covers equipment that can be used repeatedly for a medical condition or injury.
  Examples: respiratory therapy equipment including oxygen and related supplies, walkers, canes,
  crutches, hospital beds, apnea monitors, commodes, traction equipment, wheelchairs for non-walking
  patients and power wheelchairs for quadriplegics.
- Small volume nebulizer
- Blood pressure cuffs up to $50 for purchase
- ABI Vest Airway Clearance for children at least 2 years of age with Cystic Fibrosis
EXCLUDES: motorized scooters, liquid oxygen

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Annual exam available for members
- Laboratory tests
- Initial Screening or re-screening once in each age group
- Childhood immunizations
- Vision test, including eyeglasses (one exam every 2 years and eyeglasses once every 2 years, repairs and
   replacement for damaged eyeglasses, as necessary, lenses limited to standard plastic or glass material,
   lightweight lenses are excluded unless prescription is vastly different in each eye or there is blindness in
   one eye)
- Hearing tests
- Other medically necessary services

Emergency Room Services (plan and out-of-plan)
- Hospital and physician services for stabilization of medical emergency
- Post-stabilization services for medical emergency
- Hospital and physician services for screening, triage and testing for non-emergency services received in
  an emergency room

End Stage Renal Disease Facilities

Family Planning Services and Supplies
- Physician, Certified Nurse Midwives, Nurse Practitioners and Physician Assistant services
- Counseling
- Physical Exams
- Birth control devices and supplies including intrauterine contraceptive devices, pills, condoms,
    diaphragms, spermicidal foams, vaginal suppositories and gels, Norplant and injectable medications
- Missed abortions
EXCLUDES: infertility studies, procedures or treatments (that are meant to help a participant have a baby),
including reversals of sterilization and re-sterilizations; abortions unless the mother’s life is in danger if the
fetus is carried to term or the pregnancy resulted from rape or incest.

Gunshot Wounds
- Covered for victim and felon, if felon not in prison at time of incident
- Necessary physician, hospital and related medial services




                                                       11
Your child’s basic medical - continued

Hearing Services
- Hearing exam as part of the EPSDT exam
- Hearing aid(s)
- Hearing loss of at least 20 decibels for a frequency range of 500-2000 Hz
- Hearing aid repairs once each year
- Batteries: one package per aid per month
- Replacement of lost of damaged earmold(s)
EXCLUDES: eyeglass-hearing aid unit combined, replacement of lost/broken hearing aid(s) if replacement
is not covered by insurance purchased with original aid(s).

Home Health Care
- Intermittent skilled nursing visits, physical therapy visits, occupational therapy visits, speech therapy
   visits, respiratory therapy visits, registered dietician visits, when ordered by a physician to a homebound
   patient
- Intermittent home health aide services for personal care when a skilled service is also ordered by a
   physician
- 24-hour care available for a maximum of 5 days/calendar year due to the absence of the primary care-
   giver because of the medical needs of the caregiver or family member and no other legally responsible
   adult or caregiver is available
- Limitations: Skilled nursing services for wound care is limited to a 21-day period
EXCLUDES: respite, homemaker, companion, master of social work visits or sitter services, routine
supplies (alcohol swabs, prep pads, adhesive and paper tape, non-sterile cotton applicators, tongue
depressors, non-sterile gloves, aprons, masks, gowns, thermometers, probe covers and cotton balls) and
routine personal hygiene supplies

Hyperbaric Oxygen Therapy Outpatient

Immunizations
- All childhood immunizations covered under EPSDT including Varicella, DPT, Flu, Hepatitis A&B,
  MMR, Pneumonia, Polio, Prevnar

Inpatient Hospital Services
- Acute care admissions including all necessary physician care, including surgery and anesthesia
- Free-standing medical (rehabilitation and specialty) hospital admissions
- Care at skilled or intermediate levels in a Medicare certified swing-bed hospital (i.e., temporary use of an
   acute bed to provide skilled nursing or intermediate care)
EXCLUDES: swing bed stays over 45 days

Inpatient and Outpatient Rehabilitation Services
- Initial physical, occupational or speech evaluations prescribed by physician
- Medically necessary physical, occupational, respiratory, audiological or speech therapy, no maximum as
   long as there is measurable improvement toward the goals
- Audiological evaluation (see hearing services)
EXCLUDES: palliative, maintenance or restorative therapy

Laboratory Services
- Includes all medically necessary diagnostic tests
- As part of EPSDT



                                                      12
Your child’s basic medical - continued

-   urine dipstick, hemoglobin and hematocrit test, PKU for children under 1, sickle cell anemia test for
    African-American children

Medical Supplies
- Throw away medical supplies for the treatment of a medical condition including diabetic syringes and
   needles, dressings, pads, diapers for members over age 3 (limited to 300 items/34 day supply), catheter
   and irrigation items, ostomy supplies, saline, sterile and non-sterile gloves
EXCLUDES: sanitary napkins, band-aides, cosmetics, dentrifice items, personal hygiene items, astringents,
emollients, rubbing alcohol, merthiolate, hydrogen peroxide, Neosporin and other topical preparations.

Mental Health and Substance Abuse Services
- Inpatient Psychiatric and Rehabilitation Services:
   - Up to five hospital days for detoxification
   - Up to 28 hospital days for substance abuse treatment (limited to once in a lifetime unless referred by
      EPSDT screening)
- Methadone therapy
- Rehabilitative services for members deemed SED/SMI
- Outpatient Counseling (Psychiatric and Psychological Services)
- Individual psychological therapy to a maximum of 24 medically necessary sessions per calendar year
- Psychological testing and/or evaluation prescribed by a physician
- Mental health outpatient case management services
- Mental health rehabilitative treatment services
EXCLUDES: bed day rate paid for by the DHCFP for residential treatment centers (RTC); family and
marriage counseling; maintenance therapy

Nursing Facility Care
- Care in a nursing facility, free-standing or hospital-based, at skilled or intermediate levels of care
  limited to first 45 days
EXCLUDES: mental health services

Nutritional Supplements or Replacements
- When used for total nutrition by tube feeding

Ocular Care
- Exam and prescription by ophthalmologist (MD) or optometrist (OD); eyeglasses once every 2 years;
    repairs and replacement for damaged eyeglasses, as necessary; lightweight lenses for blindness or great
    difference in vision between the eyes
- Prescription eyeglasses
- Trifocals for previous wearer only
- Bifocals with a dual diagnosis
- Double segments if required by employment
- Tints no darker than White or Cruxite A-AX
EXCLUDES: sunglasses or cosmetic lenses; contact lenses unless required to correct legal blindness or
following cataract surgery; eyeglasses for minimal correction; charges for lens tints darker than white or
Cruxite A-AX; blended or progressive lenses; faceted lenses; scratch proof coatings, ultra lightweight
plastic lenses, cost of an extended warranty to repair/replace glasses; radial keratotomy or any surgical
procedure to improve vision.



                                                       13
Your child’s basic medical - continued

Orthotics
- Appliances necessary for straightening or correction of a deformity including, but not limited to, braces,
    orthopedic shoes, elastic stockings, back support/corsets, splints, cervical collars, and burn garments
- Adjustments and repairs of orthotics require prior authorization
EXCLUDES: Replacement of lost or stolen orthotics, unless the member can prove by a police report that
he/she was not at fault for stolen orthotics.

Other Diagnostic and Therapeutic Services
- Chemotherapy
- Dialysis
- Therapeutic Radiology
- Appropriate Therapies and other treatments
- Complex diagnostic imaging services including nuclear medicine, CAT Scans, cardiac ultrasonography,
   MRI, and arthrography
- Complex neurological diagnostic tests
- Complex cardiovascular tests
- Complex pulmonary tests
- Treatment of TMJ

Outpatient Hospital Services

Oxygen Therapy
- Oxygen and equipment including oxygen concentrator, compressed oxygen tank, regulators, carts,
  tubing, masks, cannulas and humidifiers
EXCLUDES: liquid oxygen and related equipment

Parenteral Therapy
- Intravenous feedings daily with certain diagnoses
EXCLUDES: therapy for less severe conditions such as nutritional supplement, infants with allergies who
can tolerate soy formula, diabetic diets, supplements to ulcer diets.

Physician, Physician Assistant, Nurse Anesthetist and Nurse Practitioner Services and Consultations
(surgical and non-surgical)
- Primary Care Office Visits
- Specialist Visits when referred by PCP
- Inpatient/Outpatient services
- Services covered for the diagnosing and treating an illness or injury
- Preventative services covered under EPSDT
- Hyalgan & Synvisc for treatment of osteoarthritis
- Biofeedback Therapy
EXCLUDES: intestinal bypass, transvenous pulmonary embolectomy, fabric wrapping of abdominal
aneurysm, silastic gel implant, psychosurgery, refractive keratoplasty, non-FDA approved implants,
ballistocardiogram, icterus index, ligation internal mammary arteries for angina, protein bound iodine, hair
analysis, gastric freezing, cochloestomy with neuro-vascular transplant for Menier’s Disease, failed
appointments, well child care except for EPSDT, routine physical check ups, precamp or preathletic
physicals, colonic irrigation, diathermy or ultrasound for pulmonary conditions, cellular therapy,
thermogenic therapy, prolotherapy, electrosleep, sclering agent injection of ligamentous structures,
intravenous histamine therapy, oxygen/carbon dioxide treatment of inner ear disease, low intensity direct


                                                     14
Your child’s basic medical - continued

current treatment of ischemic skin ulcers, acupuncture, treatment of motor function disorder with electric
nerve stimulation, biofeedback for muscle tension and psychosomatic illness, UV-light therapy and topical
application of oxygen, hysterectomy for purpose of sterilization, abortions unless mother’s life is in danger
or pregnancy was the result of rape or incest; experimental or Investigational procedures

Podiatry
- Treatment if referred by an EPSDT screening

Prenatal/Obstetrical and Postnatal Care by Obstetrician or Certified Nurse Midwife
- Prenatal care includes OB office visits, ultrasounds, lab work
- Postpartum care includes OB postpartum office visits Perinatology services when referred by OB
   provider
- Delivery

Prescription Drugs (generic substitutes required unless physician requests a brand name)
- HPN 2-Tier Drug List
- Includes family planning items such as condoms, diaphragms, oral contraceptives, Norplant, foams and
    jellies
- Prenatal vitamin/mineral supplements, intended for prenatal care
- Schedule V anti-diarrheal and cough preparations and other OTC drugs with a prescription
- Self-injectable medications subject to prior authorization
- Transdermal patches (clonidine, Estrogen, Nicotine (12 week supply), Nitroglycerin, Scopolamine)
- Tetanus (injury related)
- 100-day supply of maintenance medications
- 34-day supply of other drugs maximum quantity supply
EXCLUDES: experimental, investigative or ineffective drugs or services except as covered by Northern
Nevada Check Up, anorectics, amphetamine combinations, radiographic agents, drugs used for cosmetic
purposes or hair growth, fertility drugs, yohimbine, replacement of lost or stolen medications without a
police report
EXCEPTIONS: the following are covered with prior authorization:
Amphetamine (Dexedrine, Adderal), HCG, Dipyridamole, Erythropoietin (Epogen, Procrit), Lupron,
Zoladex, Growth Hormone, Interferon, IV antibiotic therapy, Ritalin, non-legend pharmaceuticals,
nutritional supplements or replacements, Cylert, Pulmozyme, vitamins, vitamin/mineral combinations or
hematinics

Preventive Care Services
- Well-child exams for EPSDT
- Routine physical exams
- Annual gynecological exam and pap smear
EXCLUDES: sports and school physicals

Prostheses, and Prosthetic Supplies
- Artificial appliance necessary to replace missing body parts including, but not limited to, artificial limbs
   and eyes
- Initial prosthetic and adjustments
- Repairs, replacement of parts or entire prosthetic device subject to prior authorization for reasonableness
   of cost and frequency


                                                      15
Your child’s basic medical - continued

Radiology and Non-Invasive Diagnostic Center Services
- Includes all medically necessary radiology services
- Bone Mineral Density every two years when medically indicated

Residential Treatment Services
- Limited to medical and dental services as medically needed while member is living in RTC.
- Daily room rate paid for by the Division of Health Care Financing and Policy

Respigam
- Infants and children under age 2 with Broncopulmonary Dysplasia

Rural Health Clinics and Federally Qualified Healthcare Centers’ Medical Services

Special Clinics
- Special Children’s Clinic
- First Step Program
- Happy Step Program

Surgical Services
- Inpatient/Outpatient/Ambulatory facility services
- Physician services
- Surgical Assistant Services
- Anesthesia Services including nurse anesthetist
- Laser Prostatectomy for BPH
- Gastric Bypass Surgery for Morbid Obesity
- Circumcisions for newborns and for non-newborns when authorized
- Medically necessary cosmetic surgery to correct birth defects in newborns; to restore physical function
   after an injury; breast reconstructive surgery begun within three years following a mastectomy (breast
   removal or partial removal); or any other cosmetic surgery mandated by Nevada Medicaid
- Total Ankle Arthroplasty
- Medically necessary surgeries
EXCLUDES: medically unnecessary cosmetic procedures (performed only to improve the way a participant
looks or feels about him/herself) except as outlined above.

Terbutaline Infusion Pump Therapy
- To prevent preterm labor

Transportation
- Emergency transportation only to medical services(refer to Ambulance services)
EXCLUDES: non-emergency transportation to medical services within or outside the service area,
transportation to non-covered services, cost of meals and lodging when traveling to and from medical
services or while receiving medical care, travel to visit a hospitalized patient, transport of a deceased
person, transports between facilities, and cost of a car rental.

Transplants
-     Limited to corneal, kidney, liver and bone marrow transplants
   - Hospital and physician services for medically necessary, approved organ transplants



                                                       16
Your child’s basic medical – continued

    -EXCLUDES: heart, heart/lung, heart/liver or pancreas transplants and all associated costs of the
     non-covered organ transplants, experimental organ transplants, organ transplants that will not make
     a difference in the patient’s health, unsafe organ transplants due to the patient’s age and prognosis
- Familial and unrelated bone marrow donor search and match services
- Organ donor search and harvest is limited to $10,000 per member
EXCLUDES: transportation, meals and lodging to and from and while receiving medical services

This is just a basic list of the covered medical services your child may receive from HPN-Northern Nevada
Check Up. Remember that your child must have approval from the PCP or and HPN-Northern Nevada
Check Up before your child receives most health services. These include specialist visits and hospital
stays. Your child’s PCP or our Member Services staff at 1-800-962-8074 can answer questions you have
about these services.


A special note about family planning services

Family planning services help people of child-bearing age who do not want to get pregnant. These
services include:
• Counseling
• Various kinds of birth control, including over-the-counter products and prescription birth control supplies

Your child can get family planning services:
• From his/her PCP
• From any doctor, clinic or family planning center that takes HPN-Northern Nevada Check Up patients
• Your child does not have to get family planning services from a health care facility in the HPN-Northern
   Nevada Check Up Provider Directory. You do not need a referral from your child’s PCP, but please
   bring your child’s Northern Nevada Check Up card with you. Always have your child tell his/her PCP
   when he/she is using birth control pills or other family planning methods.

Special benefits for HPN-Northern Nevada Check Up members
Special programs to help your child stay healthy
• Rewards for staying healthy: When your child participates in some of the HPN-Northern Nevada
   Check Up programs, he/she can earn special gifts and prizes for following the program.

•   Health education classes: We believe that if you know how to stay healthy, you are less likely to get
    sick. As an HPN-Northern Nevada Check Up member, your child can take special classes to help
    him/her learn good health habits. We also have the following classes to help people with health problems
    take better care of themselves so they can stay as active as possible:

    -   The Puff Stops Here -- stop smoking
    -   The Balancing Act -- for people with diabetes
    -   One Small Breath at a Time -- for children with asthma
    -   Healthy Pregnancy--for pregnant women




                                                     17
Special benefits for HPN-Northern Nevada Check Up members - continued

If your child wants to take a class, talk it over with the doctor. If your child’s doctor agrees, he/she will give
you a referral that will allow your child to take the class at no cost to you. You may find more information
about these programs on our website, www.hpnmedicaidnvcheckup.com. Use the, “A Guide to Services”
link and then click on, “Health Education and Wellness” or call 1-800-720-7253.

•   Programs for parents and children: First-time moms and dads often need help to learn how to be good
    parents. The health education staff works closely with several groups that teach parenting and child care
    skills. They can help your child get into the classes and group programs he/she needs.

Support Services for HPN-Northern Nevada Check Up members
• Member Services phone number: 1-800-962-8074. Our friendly staff will help with any question you
   have about your child’s benefits. They can help if you have a problem getting health care for your child.
   You should also tell them about any suggestions or grievances you have.
• 24-hour Telephone Advice Nurse: 1-800-288-2264. Having a sick child can be very frightening in the
   middle of the night. But as an HPN-Northern Nevada Check Up member, you have someone you can
   call -- our Telephone Advice Nurse. The nurse can tell you what you need to do for your child’s problem
   and whether you need to follow up with your child’s PCP. Also, you can call the nurse with questions
   that you don’t think are serious enough to ask your child’s doctor.


If your child is pregnant

Your child’s unborn baby is very special. We are here to help your child during her pregnancy and after the
baby is born so both mom and baby will be strong and healthy.

Who will take care of your child during her pregnancy?
Tell your child’s doctor if she is pregnant. If you think your child might be pregnant but are not sure, the
doctor can give your child a quick, easy test to find out.

If your child is pregnant, we will help her choose an obstetrician. These doctors are specially trained to care
for pregnant women and to deliver babies. You should make an appointment to see your child’s obstetrician
right away for a complete checkup. He/she will tell your child what to expect during her pregnancy and how
to take care of herself and her unborn baby. The obstetrician will check to see if your child’s unborn baby
might need special care. He/she also stays in touch with your child’s PCP in case she has other health needs.

Who will deliver your child’s baby?
Your child will probably have the baby in the hospital. The obstetrician or another doctor he/she works with
usually delivers the baby. Some mothers want to have a certified nurse-midwife deliver the baby. If your
child wants her baby to be delivered this way, ask the obstetrician to help you find a certified nurse-midwife,
who is in the HPN-Northern Nevada Check Up Provider Directory. A monthly updated version of the
provider directory may be found on our website, www.hpnmedicaidnvcheckup.com.

A healthy start for your/your child’s new baby
Your child’s baby may become an HPN-Northern Nevada Check Up member from the date of birth if the
pregnancy is reported to both the DHCFP’s Nevada Check Up office and HPN-Northern Nevada Check Up
prior to and within 14 days of the baby’s birth. If this notification is not provided to both offices, the baby
will not be a member as of the date of birth. Instead, the baby may become a member the first day of


                                                        18
If your child is pregnant - continued

the next month following the birth. Make sure your child calls our Member Services Department at
1-800-962-8074 and the Nevada Check Up office at 1-800-360-6044 to report the pregnancy and birth
of the child.

If you are pregnant and have other children on HPN-Northern Nevada Check Up, you need to inform the
Northern Nevada Check Up Office that you are pregnant. Call 1-800-360-6044. If you have other health
insurance, your baby will be covered under that health insurance for the first month of life. Your baby will
be covered by HPN-Northern Nevada Check Up after the first month. If you do not have other health
insurance, your baby will be covered by HPN-Northern Nevada Check Up from the date of birth, but only if
you inform the office of your pregnancy prior to the birth of the baby.

One of the most important things you will need to do right after childbirth is to choose a doctor for your/your
child’s baby. The baby should receive a checkup within the first week after birth and circumcisions for baby
boys are usually a part of this visit. If you need help choosing a doctor for the baby, call Member Services at
1-800-962-8074 or visit our website, www.hpnmedicaidnvcheckup.com. The staff will help you find a doctor
for the baby at or near your child’s PCP’s office. You’ll learn more about choosing a doctor for your/your
child’s baby in the next section.


Keeping your children healthy

One of the most important things you can do to keep your children healthy is to make sure they get the
regular checkups and shots they need. Your child’s doctor will help you arrange the checkups and shots that
are right for each child’s age group.

Choosing your child’s doctor
Every child enrolled in HPN-Northern Nevada Check Up needs to have a doctor. We suggest you choose a
pediatrician as your child’s doctor. Pediatricians are specially trained to take care of children’s health.

Most doctors’offices and clinics in the HPN-Northern Nevada Check Up Provider Directory have
pediatricians on their staff. If you need help choosing a pediatrician, call Member Services at
1-800-962-8074.

Some family practice doctors will take care of children. If the doctor you choose does and you want all of
your children to go to the same doctor that’s fine.




                                                      19
Keeping your children healthy - continued

Regular medical checkups for your child
Your child’s pediatrician is your partner in keeping your child healthy. But the only way the doctor can help
is if you bring your child in for regular checkups. This schedule will help you remember when you should
bring your child in for a regular checkup:

Child’s name _______________________ Date of birth:____________________

                                   Date my child is due for checkup
 Checkup schedule                  (write day for each checkup below)         Date my child saw the doctor

 Within 2 weeks of birth
 1 month
 2 months
 4 months
 6 months
 9 months
 12 months
 18 months
 24 months
 Once a year thereafter

Shots to protect your children against getting sick
Your children should receive all required shots by the time they are 18 months old. If you are taking your
children in for regular checkups, their doctor will see that they get their shots when they are supposed to.
Your children probably don’t like getting shots, but these shots, called immunizations or vaccinations, can
protect them from illnesses such as:
• Diphtheria
• Tetanus
• Whooping cough (Pertussis)
• Measles
• Polio
• Mumps
• Chicken pox
• Hepatitis B
• Hepatitis A
• Chronic ear infections
• Spinal Meningitis

Special checkups for children from the Healthy Kids program
Your children will receive special health screenings and physical exams once a year after they have been
enrolled with HPN-Northern Nevada Check Up. These tests are offered to help your children stay healthy
and to catch and treat health problems early. If the tests show your children need special treatment, your
doctor will arrange it.




                                                      20
Keeping your children healthy - continued

It is very important that you bring your children in to see the doctor when they are due for this special
testing. HPN-Northern Nevada Check Up will let you know when your children need to come in for these
screenings. You will receive a post card in the mail as a reminder.

If your child has asthma
HPN-Northern Nevada Check Up has a special program to help children with asthma and their families. This
program is called “One Small Breath at a Time.” It includes classes and special gifts for children who
follow the program. If your child has asthma, be sure to ask your doctor about this program.


Services you receive directly through Northern Nevada Check Up

Some services that Nevada Check Up pays for are not part of your HPN-Northern Nevada Check Up benefit
package. You do not have to see your child’s doctor first.

Some services you get directly through Nevada Check Up are:
• Non-emergency medical transportation- you will need to call the Logisticare to get transportation to
   medical care when it is not an emergency. Call 1-888-737-0833.
• Indian Health Services and Tribal Clinics.
• The cost of care in a special facility- like an institution for people who are mentally retarded or a
   residential treatment facility for alcoholism or drug abuse.
• Services for people who need long term care- like staying in a nursing home longer than 45 days.

If you have questions about these services, please contact Nevada Check Up at 1-800-360-6044.


Services that are not covered by HPN-Northern Nevada Check Up

Some services are not covered by HPN-Northern Nevada Check Up. Some examples of these services are:
• Experimental, investigative or ineffective drugs or services except as covered by Nevada Check Up
• Some prescription drugs (call Member Services if you have any questions about this)
• Medically unnecessary cosmetic procedures (performed only to improve the way your child looks or
   feels about himself/herself)
• Certain infertility procedures or treatments, including reversals of sterilization and re-sterilization
• Abortions, unless
   - The mother’s life is in danger if the fetus is carried to term or
   - The pregnancy results from rape or incest
• Ecological or environmental medicine
• Contact lenses, tints, lightweight lenses and some other vision services.
• Sitters, homemakers or chore services
• Services provided before you signed up your children for HPN-Northern Nevada Check Up or after you
   leave HPN-Northern Nevada Check Up.
• Genetic testing for parents of HPN-Northern Nevada Check Up members




                                                     21
A special note about mental health benefits

Basic mental health benefits as required by Nevada Check Up are available to HPN-Northern Nevada Check
Up members when they need this kind of help. Some people who have very serious mental illness will
continue on the HPN-Northern Nevada Check Up plan. They will receive all of their mental health services
through HPN-Northern Nevada Check Up

There is a special process to identify and care for seriously emotionally disturbed (SED) children. The HPN-
Northern Nevada Check Up staff, our doctors and other health care providers will help these members
through the process.

If have questions about your mental health benefits, please call Member Services at 1-800-962-8074.

Your child’s rights and responsibilities

To be an active partner in your child’s healthcare, you should know your child’s rights and take
responsibility for his/her good health.

Your child has the right:
• to be treated with respect, to be listened to and to be a part of decisions that affect his/her healthcare;
• to be treated with consideration for his/her dignity and privacy;
• to get the information on available treatment options and alternatives presented in an easily understood
  manner;
• to refuse care from doctors, and other healthcare workers your child does not like;
• to be able to make a grievance or appeal that is listened to and promptly responded to;
• to tell us in advance how your 18 year old child would like to be cared for if he/she is terminally ill or
  injured (see next page);
• to request and receive a copy of his/her medical records and ask that they be amended or corrected;
• to have all information about his/her health and medical care kept private. The only times we release this
  information are:
  - when it needs to be shared with others for important medical or legal reasons;
  - to help us improve the quality and cost-effectiveness of the care we give your child;
  - when you tell us in writing we can give it to someone else.
• to choose a PCP for your child from the HPN-Northern Nevada Check Up Directory, who speaks your
  language and understands your culture, whenever possible;
• to get a second opinion from a qualified, contracted provider
• to get timely services from a non-contracted provider, if the services are not available from a contracted
  provider.

Your responsibilities as a parent/guardian are:
• to tell HPN-Northern Nevada Check Up, and the doctors, and other healthcare providers, things we need
  to know to give your child good health care;
• to make an appointment when your child needs routine care;
• to keep your child’s medical appointments;
• to be on time for your child’s appointments;
• to ask questions about your child’s health and if you don’t understand the doctor’s instructions;
• to follow your child’s doctor’s advice about taking care of your child;
• to follow directions about taking medications and what to do when your child is sick; and
• to get a referral from your child’s PCP before getting any health services, unless
  - it is an emergency or,
  - your child is getting certain kinds of services like family planning.


                                                     22
When your 18 year old child can’t make his/her own healthcare decisions

Nevada law says you have the right to make decisions about your health care if you are 18 years of age
and older as long as you are able to do so. If your child becomes sick, his/her doctor will tell you what is
wrong with your child, the types of treatment your child can choose and what might happen if your child
does not get care. Your child age 18 has the right to refuse care, even if his/her doctor feels he/she needs it in
order to save his/her life.

Sometimes when people get very sick they are not able to make decisions or tell doctors what they want. For
example, if there is no hope that they will get well again, some people don’t want the doctor to keep them
alive by feeding them through a tube or putting them on machines. If your child feels this way, it is very
important that he/she tells the doctor and family what his/her alternative is while he/she is still healthy
and able to tell them. This is done by a written “advance directive.”

There are two main types of advance directives:

•   A “Living Will” (also called a “Declaration”) tells the doctor and your family what kind of health care
    your child wants, or does not want, if he/she becomes unable to tell them.

•   A “Durable Power of Attorney for Health Care” names someone your child chooses to make health
    care decisions for him/her if he/she cannot make their own decisions.

An advance directive must be in writing and your child must sign it. It must also be signed by a notary
public or by two other people as witnesses. Make sure your family and your child’s PCP have copies so they
will know how to help your child.

Your child may change his/her advance directive at any time. Put the change in writing in the same way
your child did the first time. Make sure your child’s doctor and family knows about the change. Make sure
the date is on it so others will know which directive is the most recent.

If your child needs to, he/she can have both types of advance directives. And if he/she chooses, he/she does
not have to have an advance directive -- it is totally up to him/her.

We want to know what kind of medical care your child wants. If your child wants to make an advance
directive, a lawyer can write one for him/her. If your child can’t see a lawyer, the people in the PCP’s office
have forms and can help him/her. Or, you can call our Member Services staff at 1-800-962-8074.

Northern Nevada Check Up requires that we keep information in your medical file telling us whether
or not your child has an advance directive. We are including a form with this handbook that you will need
to fill out. You should fold it in half, seal it shut and send it in to HPN-Northern Nevada Check Up (the
address is pre-printed on the form). You do not need to put a stamp on it.

If you have a complaint about the Advance Directive information please call the Division of Health Care
Financing & Policy at 1-800-360-6044.

Health Plan of Nevada, Inc., and the HPN-Northern Nevada Check Up plan does not discriminate on
the basis of whether members have or do not have advance directives.




                                                        23
When you should contact us

As you look through this handbook, you will probably notice that we urge you to call us or your child’s
doctor often. We are better able to help you when you stay in touch with us. Every year you may ask us for:
- a provider list
- your rights and responsibilities as a member of HPN-Northern Nevada Check Up
- information on grievances and appeals
- benefits including how to get them
- prior authorization requirements
- family planning services
- after-hours and emergency services information including, how, where and when to get services
- referral to specialists
- post-stabilization services
- how to get Medical benefits that are not available through HPN-Northern Nevada Check Up
- information on the structure and operations of our health plan
- information on quality performance indicators
- member satisfaction survey information
- physician incentive plans

Here are some examples of when you should contact us:
Call Member Services at 1-800-962-8074
• with any questions about the HPN-Northern Nevada Check Up benefits;
• if you want to change your child’s PCP;
• whenever you move, even if you still live within the HPN-Northern Nevada Check Up service area. Let
   us know if you plan to leave the service area for more than a month, or move away;
• if your phone number changes;
• if your child is pregnant, or has a baby;
• if your child is covered by any health benefits, in addition to HPN-Northern Nevada Check Up. For
   example, tell us:
   - if you have a health insurance policy for your child
   - if you got a settlement for you child after being in an accident
• if you have a problem getting the health care your child needs;
• with an issue or concern about HPN-Northern Nevada Check Up or one of our doctors, or other health
   care providers;
• if you think you want to leave the HPN-Northern Nevada Check Up plan; or
• if you have a suggestion you think would improve HPN-Northern Nevada Check Up’s services or
   programs.

And when we might contact you
From time to time, we will send you important information that you should keep with this handbook -- like
news about:
• changes to the HPN-Northern Nevada Check Up benefits or plan;
• changes to the list of doctors and network of providers your child can use; or
• information about our special programs and benefits.

We may also call you or send you a survey form to ask how you like the HPN-Northern Nevada Check Up
plan and what you think of your child’s doctor and other health services. What you think is very important to
us.


                                                     24
When you should contact us - continued

We may also send you a letter if your child is hurt in a motor vehicle accident or injured through no fault of
his/her own. This letter will ask you to call us and let us know if there is another insurance company that
might help pay for your medical care. We call this situation, Third Party Liability. All we ask is that you call
us and let us know if there is another insurance company, we will contact them. If there isn’t, we will pay for
the medical care. You are not responsible for the cost of this care.

What to do if you have an appeal or a grievance

How Member Services can help you
Call and talk to a Member Services staff member whenever you have a problem of any kind with HPN-
Northern Nevada Check Up or any of our doctors, providers or services. The phone numbers are:

                                     242-7317 in the Las Vegas area
                                1-800-962-8074 outside the Las Vegas area

Our Member Services people are here to help you. They will listen to your concerns and try their best to
solve your problems. If after that you feel your problem has not been solved, you may have the right to file
an appeal or grievance.


Appeals

You have the right to file an appeal within 90 days of receiving a notice for any of the following issues:
- the services you requested were denied or limited
- the services your child was receiving are reduced, suspended or stopped
- part or all of the payment for a service your child received is denied
- your request for services was not responded to timely
- HPN-Northern Nevada Check Up does not resolve your grievance or appeal timely

There Are Two Kinds of Appeals You Can File:

Standard (30 days) You can ask for a standard appeal. We will send you a letter letting you know we
received your appeal within three calendar days. We must give you a written decision no later than 30 days
after we get your appeal. (We may extend this time by up to 14 days if you request an extension, or if we
need additional information and the extension benefits you.)

Expedited (72 hour review) You may ask for an expedited appeal if your doctor believes that your child’s
health could be seriously harmed by waiting too long for a decision and is willing to support this.

We must decide on an expedited appeal no later than 72 hours, three working days after we get your appeal.
(We may extend this time by up to 14 days if you request an extension, or if we request an extension from
the DHCFP, in order to obtain additional information, and the extension benefits you.) We will call you
whenever possible to let you know the decision. If we are unable to contact you, you will receive written
notice of our decision within 2 days of making the decision.




                                                       25
Appeals - continued

If we decide your request for an expedited appeal does not meet the criteria, we will change it to a standard
appeal. We will let you know verbally, whenever possible and send you written notice within two calendar
days.

If any doctor asks for an expedited appeal for you, or supports you in asking for one, and the doctor indicates
that waiting for 30 days could seriously harm your child’s health, we will automatically give you an
expedited appeal.

What Do I Include With My Appeal?
You should include your child’s name, address, Member ID number, reasons for appealing, and any evidence
you wish to attach. You may send in supporting medical records, doctors’ letters, or other information that
explains why we should provide the service. Call your doctor if you need this information to help you with
your appeal. You may send in this information or present this information in person if you wish or you may
authorize another adult to do so on your child’s behalf.

How to file a Standard Appeal: You or your authorized representative should mail or deliver your signed
appeal request to the address below:
       Health Plan of Nevada, Inc.
       2720 North Tenaya Way
       P.O. Box 15645
       Las Vegas, NV 89114-5645

Standard appeals may be filed by calling our Member Services Department at 702-242-7317 or 1-800-962-
8074, but must be followed by a written, signed appeal.

How to file an Expedited Appeal: You or your child’s doctor acting on your behalf or authorized
representative should contact us by telephone or fax:
       Fax # (702) 242-6462
       Phone # (702) 242-7317
       Toll Free: (800) 962-8074
       TTY/TDD (702) 242-9214
       TTY/TDD (800) 349-3538

State Fair Hearing: If you still do not agree with our decision, after HPN’s appeal process has been
completed, you can ask for a State Fair Hearing by contacting the Nevada Medicaid Hearings Unit at 1-800-
992-0900, extension 43602 or 1100 East William Street, Suite 204, Carson City, NV 89701. You must ask
for this hearing within 90 days of receiving the final Appeal Notice from HPN. You may also request a State
Fair Hearing if we fail to make our decision in a timely manner. That is, within the time frames described in
this section.

If you need information or help, call the State Medicaid Office at:

       Las Vegas:   (702) 486-3000, extension, 43602 or
                    1-800-992-0900, extension 43602
       Carson City: 1-800-992-0900, extension 43602

If you need legal assistance, call the Legal Services Program in Washoe County (775) 329-2727.


                                                      26
Appeals - continued
If you need information or help, call us at:

       Phone #         (702) 242-7317
       Toll free       (800) 962-8074
       TTY/TDD         (702) 242-9214
       TTY/TTD         (800) 349-3538

We can help you through the grievance and appeals process. Interpreter services are available. We are
available from 8:00 a.m. to 5:00 p.m., Monday through Friday. You have a right to review your case file,
including medical records and any other documents and records used during the appeals process.

Continuation of Benefits: If you ask for an appeal, you can ask that your benefits continue while your
appeal is being considered. You must ask for this within 10 days of the date of the letter HPN-Northern
Nevada Check Up sends you about the reduction, suspension or termination of the services you are getting if
there is still time left in the authorization period.

If your services are continued and any of the services you requested are still denied following your appeal,
you may be asked to pay HPN-Northern Nevada Check Up back for those services.

Grievances
You have the right to file a grievance if you have an issue with:
- services you received through HPN-Northern Nevada Check Up
- the care or services you received from one of our doctors or other health care providers
- you need to file your grievance within 90 days
- you may file a grievance in two ways:
   - call us at 702-242-7317 or 1-800-962-8074, or
   - write to us at: Health Plan of Nevada
                       PO Box 15645
                       Las Vegas, NV 89114

We take your grievance seriously and will try to get it settled to your satisfaction. If you need help filing a
grievance, just call our Member Services Department at 702-242-7317 or 1-800-962-8074. Our
representatives will be happy to help you. Oral interpreter services are also available. Once we receive your
grievance the following will occur:
- You will receive a letter from us within three calendar days telling you we have received your
    grievance. Our staff may also contact you to make sure they understand the situation.

-   Within 90 days of the day we receive your grievance, we will send you a letter letting you know the
    outcome. We may extend this time up to 14 calendar days if additional information is needed and the
    extension will benefit you.




                                                      27
If you no longer want your child to be a member in HPN-Northern Nevada
Check Up

As a member of HPN-Northern Nevada Check Up, your child may disenroll at any time for any reason. You
must inform the Division of Health Care Financing and Policy’s Nevada Check Up office of your request to
disenroll your child from HPN-Northern Nevada Check Up by calling 1-800-360-6044. Your child will be
disenrolled no later than the 1st day of the second month following the request.

We hope you will want to stay with HPN-Northern Nevada Check Up as long as you are eligible for the
                program, and that you will let us know how we can serve you better.

If your child is no longer on Nevada Check Up

Your child must be on Nevada Check Up to be enrolled in the HPN-Northern Nevada Check Up plan. If your
child loses his/her coverage, the Nevada Check Up office will let us know. Premium payments are due on the
first day of each quarter, January 1, April 1, July 1, and October 1. Failure to pay the quarterly premium will
result in loss of insurance coverage under Nevada Check Up.

If your child loses his/her Northern Nevada Check Up coverage for a short time and gets back on Nevada
Check Up within the year, your child will again be an HPN-Northern Nevada Check Up member unless you
choose another health plan for your child.

                                              Remember:
                        Bring your child’s HPN-Northern Nevada Check Up card
                                    whenever he/she gets health care.




                                                      28
HPN-Northern Nevada Check Up
    Health Plan of Nevada, Inc,
  PO Box 15645 Las Vegas, NV 89114-5645
          Form No. 21.NV.HPN.03.586




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